Wrist/Hand

The Effectiveness of Manual Therapy on Pain, Physical Function, and Nerve Conduction Studies in Carpal Tunnel Syndrome Patients: a Systematic Review and Meta-Analysis

Author Names

Jimenez-del-Barrio, S; Cadellans-Arroniz, A; Ceballos-Laita,L; Esteban-de-Miguel, E; Lopez-de-Celis, C; Bueno-Garcia,E; Perez-Bellmunt, A

Reviewer Name

Semat Adekoya, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Aim of the study Systematic review and meta-analysis to assess the effectiveness of manual therapy in improving carpal tunnel syndrome (CTS) symptoms, physical function, and nerve conduction studies. Method MEDLINE, Web of Science, SCOPUS, Cochrane Library, TRIP database, and PEDro databases were searched from the inception to September 2021. PICO search strategy was used to identify randomized controlled trials applying manual therapy on patients with CTS. Eligible studies and data extraction were conducted independently by two reviewers. Methodology quality and risk of bias were assessed by PEDro scale. Outcomes assessed were pain intensity, physical func- tion, and nerve conduction studies. Results Eighty-one potential studies were identified and six studies involving 401 patients were finally included. Pain inten- sity immediately after treatment showed a pooled standard mean difference (SMD) of − 2.13 with 95% confidence interval (CI) (− 2.39, − 1.86). Physical function with Boston Carpal Tunnel Syndrome Questionnaire (BCTS-Q) showed a pooled SMD of − 1.67 with 95% CI (− 1.92, − 1.43) on symptoms severity, and a SMD of − 0.89 with 95% CI (− 1.08, − 0.70) on functional status. Nerve conduction studies showed a SMD of − 0.19 with 95% CI (− 0.40, − 0.02) on motor conduction and a SMD of − 1.15 with 95% CI (− 1.36, − 0.93) on sensory conduction. Conclusions This study highlights the effectiveness of manual therapy techniques based on soft tissue and neurodynamic mobilizations, in isolation, on pain, physical function, and nerve conduction studies in patients with CTS.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Key Finding #1

Conservative treatment based on manual therapy is effective for reducing pain intensity, improving function, and nerve conduction compared to control or sham in patients with Carpal Tunnel Syndrome.

Key Finding #2

There is a statistical difference between diacutaneous fibrolysis techniques to sham or control.

Key Finding #3

There is a statistical difference between glide and tension neurodynamic techniques compared to sham on symptom function and nerve conduction studies.

Please provide your summary of the paper

This aim of this study was to analyze the effectiveness of manual therapy in patients with carpal tunnel syndrome (CTS). CTS is considered one of the most common upper extremity neuropathies, often resulting in pain, paresthesia, sensory disturbances, and a decrease in quality of life in patients with this diagnosis. Clinical guidelines recommend conservative treatment to help manage symptoms, primarily focusing on splinting, steroid injections, electrotherapy, and manual therapy. As previously mentioned, this analysis focuses on the effects of manual therapy. 81 studies were identified to be used, 6 studies were included following inclusion criteria. Researchers focused on the impacts on pain intensity, function and nerve conduction. The analysis found that manual therapy is effective in reducing pain intensity as well as improving function and nerve conduction.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study can impact clinical practice by increasing awareness of manual therapy techniques in patients with CTS, but can also be expanded to other upper extremity neuropathies (Cubital, Ulnar, etc). This is also beneficial as patients may be able to use manual therapy techniques prior to resorting to other conservative treatment such as injections which may cause additional financial burden.

A Manual Therapy Intervention Improves Symptoms in Patients with Carpal Tunnel Syndrome: A Pilot Study

Author Names

Bongi,S., Signorini,M., Bassetti,M., Del Rosso, A., Orlandi, M., De Scisciolo, G.

Reviewer Name

Jessika Barnes, LPTA, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

In carpal tunnel syndrome (CTS), manual therapy interventions (MTI) reduce tissue adhesion and increase wrist mobility. We evaluated the efficacy of a MTI in relieving CTS signs and symptoms. Twenty-two CTS patients (pts) (41 hands) were treated with a MTI, consisting in 6 treatments (2/week for 3 weeks) of soft tissues of wrist and hands and of carpal bones. Pts were assessed for hand sensitivity, paresthesia, hand strength, hand and forearm pain, night awakening; Phalen test, thenar eminence hypotrophy and Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) and Functional Status Scale (FSS). Median nerve was studied by sensory nerve conduction velocity (SNCV) and distal motor latency (DML). CTS was scored as minimal, mild, medium, severe and extreme. We considered as control group the same pts assessed before treatment: at baseline (T0a) and after 12 weeks (T0b). Pts were evaluated at the end of treatment (T1) and after 24-week (T2) follow-up. At T0b, versus T0a, forearm pain and Phalen test positivity were increased and hand strength reduced (p < 0.05). BCTQ–SSS and BCTQ–FSS scores improved at T1 versus T0b (p < 0.05) with the amelioration maintained at T2. At T1, the number of pts with paresthesia, night awakening, hypoesthesia, Phalen test, hand strength reduction and hand sensitivity was reduced with the lacking of symptoms maintained at T2 (p < 0.05). No changes in SNCV, DML and CTS scoring were shown. MTI improved CTS signs and symptoms, with benefits maintained at follow-up. Thus, it may be valid as a conservative therapy.

NIH Risk of Bias Tool

Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group

Was the study question or objective clearly stated?

Were eligibility/selection criteria for the study population prespecified and clearly described?

Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?

Were all eligible participants that met the prespecified entry criteria enrolled?

Was the sample size sufficiently large to provide confidence in the findings?

Was the test/service/intervention clearly described and delivered consistently across the study population?

Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?

Cannot Determine, Not Reported, Not Applicable

Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

Key Finding #1

Patients improved significantly in hand symptoms and function, as assessed by Boston Carpal Tunnel Questionnaire and by the reductions in the prevalence of paresthesias, hand pain and sensitivity, and night awakening.

Key Finding #2

The treatment did not improve Nerve Conduction Studies nor change neurophysiological grading of CTS.

Key Finding #3

Conservative management should be the first-step treatment, to be preferred for early and supposedly transient cases of CTS, such as those associated with pregnancy or short-term overuse. For other cases, it might be used for reducing the symptoms of CTS while awaiting surgery.

Please provide your summary of the paper

This pilot study looked at the effects of a manual therapy intervention on CTS symptoms and hand function. Twenty-two carpel tunnel patients were treated with manual therapy interventions, consisting in 6 treatments (2/week for 3 weeks) of soft tissues of wrist and hands and of carpal bones. Pts were assessed for hand sensitivity, paresthesia, hand strength, hand and forearm pain, night awakening by using the Phalen’s test, thenar eminence hypotrophy and Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) and Functional Status Scale (FSS). The manual interventions in this study included: In the first session (duration, 10 min), the most thickened tissues of hand palmar surface and wrist and forearm volar side were treated by deep transverse massage (cyriax), in order to improve tissue elasticity by detachment maneuvers performed in the cranio-caudal direction. In the second and third sessions (duration, 15 min), performed with the hand maintained in traction, passive mobilizations of the radio-carpal and radio-ulnar joints, and opening of the palmar surface of metacarpal–phalangeal joints were added. In the following (4th to 6th) sessions (duration, 15 min) The wrist, maintained in traction, was treated with passive flexo-extension and transversal movements in order to improve the range of movement of the joints and the elasticity of flexo-extensor and prono-supinator muscles. Also, the palmar aponeurosis and the pollical and the first palmar interosseous muscles were treated, working on the hand that was maintained open and extended. This study considered the control group the same pts assessed before treatment: at baseline (T0a) and after 12 weeks (T0b). Pts were evaluated at the end of treatment (T1) and after 24-week (T2) follow-up. The results of this study concluded that patients improved significantly in hand symptoms and function, as assessed by Boston Carpal Tunnel Questionnaire and by the reductions in the prevalence of paresthesias, hand pain and sensitivity, and night awakening.The manual therapy treatment did not improve Nerve Conduction Studies nor change neurophysiological grading of Carpel Tunnel Syndrome.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

My clinical interpretation of this paper is that manual therapy would be beneficial for patients dealing with the acute affects of carpel tunnel syndrome. More non-conservative measures may be taken into consideration if this is a chronic issue.

Manual Therapy Intervention in the Treatment of Patients with Carpal Tunnel Syndrome: Median Nerve Mobilization Versus Medical Treatment

Author Names

Mohamed, F. I., Hassan, A. A., Abdel-Magied, R. A., & Wageh, R. N.

Reviewer Name

Juan Carlos Chavez Casiano

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Median nerve mobilization is a manual therapy intervention used for treating CTS. Aim The aim of the present study was to investigate the effectiveness of median nerve mobilization in relieving manifestations of CTS when compared with conventional medical treatment. Patients and methods A total of 28 CTS patients were divided into two groups: patients in group I (n = 18) underwent median nerve mobilization, and those in group II (n = 10) underwent conventional medical treatment. Median nerve mobilization consisted of 18 treatments (three/week for 6 weeks). Patients were assessed for hand sensitivity, paresthesia, strength, pain, night awakening, thenar eminence atrophy, and were subjected to Phalen’s test, Tinel’s sign, Boston Carpal Tunnel Questionnaire’s Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS), and sensory and motor conduction studies for median nerve at baseline and at 6 weeks after treatment. Results At baseline versus at 6 weeks, pain, sensation, paresthesia, tingling, Tinel’s signs, and Phalen’s test outcomes were significantly improved in both groups; wrist flexion and extension improved only in group I. The difference between group I and group II after 6 weeks was significant as regards tingling, pain, wrist flexion, and extension. BCTQ-SSS and BCTQ-FSS scores improved after 6 weeks compared with baseline in patients in group I, whereas in group II the improvement was observed in BCTQ-FSS; the difference between the groups was significant. Sensory nerve conduction velocity, sensory distal latency, sensory amplitude, distal motor latency, and motor amplitude were significantly improved after 6 weeks in group I. In addition, there was a change in the grade of CTS, whereas in group II there was improvement only in sensory nerve conduction velocity; the difference between the groups was not significant. Conclusion CTS improves after median nerve mobilization, which is better than conventional medical treatment. It provides support for the use of manual therapy in conservative management of CTS with satisfactory results.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

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?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Cannot Determine, Not Reported, or Not Applicable

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?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

Patients who underwent median nerve mobilization treated had a significant improvement in symptoms of carpal tunnel syndrome when compared to the conventional medical treatment.

Key Finding #2

Sensory nerve conduction velocity, sensory distal latency, sensory amplitude, distal motor latency, and motor amplitude improved significantly in patients who received median nerve mobilization compared to medical treatment.

Key Finding #3

Comparted to the conventional medical treatemnt group the patients that received the median nercer mobalilization were the onlys one to show an improvement in wrist flextion and extension.

Please provide your summary of the paper

This study compared the effects of median nerve mobilization versus conventual medical treatment on patients with carpal tunnel syndrome. This study took a total of 28 patients and split them into two groups; group 1 patients were treated with neurodynamic mobilization technique (median nerve mobilization) and group 2 patients underwent conventional medical treatment (NSAIDs, diclofenac 150 mg/day for 2 weeks and 1500 μg vitamin B12 per day for 6 weeks). All patients were assessed using the Boston Carpal Tunnel Questionnaire, Functional Status Scale, hand sensitivity, paresthesia, strength, pain, night awakening, thenar eminence atrophy, Phalen’s test, and Tinel’s sign. The results showed a significant improvement in patients who received median nerve mobilization when compared to conventual medical treatment.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study supports the use of Manuel therapy treatment with patients that have carpal tunnel syndrome. As a future clinician I want to be someone that uses evidence based practice in my clinic, so finding more articles that support my treatment style or not are necessary to do so. Along with the conventional medical treatment, manual therapy can help the patient see dramatic results.

Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial

Author Names

Fernández-de-Las-Peñas C, Arias-Buría JL, Cleland JA, Pareja JA, Plaza-Manzano G, Ortega-Santiago R

Reviewer Name

Erin Dennis, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: No study to our knowledge has investigated the effects longer than 1 year of manual therapy in carpal tunnel syndrome (CTS). The purpose of this study was to investigate the effects of manual therapy versus surgery at 4-year follow-up and to compare the post-study surgery rate in CTS. Methods: This randomized controlled trial was conducted in a tertiary public hospital and included 120 women with CTS who were randomly allocated to manual therapy or surgery. The participants received 3 sessions of physical therapy, including desensitization maneuvers of the central nervous system or carpal tunnel release combined with a tendon/nerve gliding exercise program at home. Primary outcome was pain intensity (mean and the worst pain). Secondary outcomes included functional status, symptom severity, and self-perceived improvement measured using a global rating of change scale. Outcomes for this analysis were assessed at baseline, 1 year, and 4 years. The rate of surgical intervention received by each group was assessed throughout the study. Results: At 4 years, 97 (81%) women completed the study. Between-group changes for all outcomes were not significantly different at 1 year (mean pain: mean difference [MD] = -0.3, 95% CI = -0.9 to 0.3; worst pain: MD = -1.2, 95% CI = -3.6 to 1.2; function: MD = -0.1, 95% CI = -0.4 to 0.2; symptom severity: MD = -0.1, 95% CI = -0.3 to 0.1) and 4 years (mean pain: MD = 0.1, 95% CI = -0.2 to 0.4; worst pain: MD = 0.2, 95% CI = -0.8 to 1.2; function: MD = 0.1, 95% CI = -0.1 to 0.3; symptom severity: MD = 0.2, 95% CI = -0.2 to 0.6). Self-perceived improvement was also similar in both groups. No between-group differences (15% physical therapy vs 13% surgery) in surgery rate were observed during the 4 years. Conclusions: In the long term, manual therapy, including desensitization maneuvers of the central nervous system, resulted in similar outcomes and similar surgery rates compared with surgery in women with CTS. Both interventions were combined with a tendon/nerve gliding exercise program at home. Impact: This is the first study to our knowledge to report clinical outcomes and surgical rates during a 4-year follow-up and will inform decisions regarding surgical versus conservative management of CTS. Lay summary: Women with CTS may receive similar benefit from a more conservative treatment-manual therapy-as they would from surgery. Trial registration: ClinicalTrials.gov NCT01789645. Keywords: Carpal Tunnel; Physical Therapy; Surgery.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

There were no significant differences between those who received manual therapy versus surgery in mean pain, worst pain, and self-perception of improvement at 1- and 4-years post-intervention.

Key Finding #2

Only 15% of women who received manual therapy required surgery 4 years post-intervention compared to previous findings suggesting a surgery rate of 60% after localized conservative treatment.

Key Finding #3

The proposed manual therapy approach including soft tissue mobilizations and nerve/tendon gliding techniques directed at the entire upper extremity may be more effective than localized interventions targeting only the hand and/or wrist in the CTS population based on current nociceptive theories on CTS.

Please provide your summary of the paper

The results of this study revealed similar outcomes 4 years post-treatment in women with carpal tunnel syndrome who received manual therapy consisting of desensitization maneuvers of the central nervous system versus those who received surgery combined with a tendon and nerve gliding home exercise program. Data on mean pain, worst pain, functional status, and self-perceived improvements were collected at baseline, 1, 3, and 6 months, and 1 and 4 years after treatment. The authors found no significant differences in these outcomes at the 1- and 4-year follow-ups. While only the manual therapy group received soft tissue mobilization, both the manual therapy group and the surgical intervention group were instructed in a tendon/nerve gliding exercise program, which could influence the 1- and 4-year follow-up outcomes. Other limitations of this study include the lack of accounting for psychological variables, such as mood disorders or sleep disturbances, the fact that patients nor clinicians were blinded to the treatment intervention due to the nature of the treatments, and the lack of reassessing provocative tests (i.e. Phalen or Tinel test) nor electromyography at any period, which could also elucidate potential between-group differences. The authors discussed a need for future research to identify what types of patients may benefit from conservative management as the first therapeutic option compared to those who would best benefit from surgery.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The results of this study can assist clinicians with patient education and advocating for conservative therapy as the first therapeutic intervention in women with carpal tunnel syndrome. Since the outcomes were similar in the manual therapy and surgical groups at 1 and 4 years post-intervention, conservative therapy should be advocated for in this patient population to avoid the higher risk of complications that may come with surgery. The authors found that only 15% of the women who received manual therapy required surgery 4 years after the intervention, which is contrary to previous findings suggesting a surgery rate of 60% after localized conservative treatment. These results should guide clinicians to utilize similar manual therapy techniques, which included soft tissue mobilizations and nerve/tendon gliding techniques directed at the entire upper extremity according to more current nociceptive theories on CTS compared to previous more localized therapeutic approaches targeting solely the hand and/or wrist.

The Effectiveness of A Manual Therapy and Exercise Protocol in Patients with Thumb Carpometacarpal Osteoarthritis: A Randomized Controlled Trial

Author Names

Villafaña. J, Cleland. J, Fernandez-de-las-peñas. C

Reviewer Name

Jaydee Dillon, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study design: Double-blind, randomized controlled trial. Objective: To examine the effectiveness of a manual therapy and exercise approach relative to a placebo intervention in individuals with carpometacarpal (CMC) joint osteoarthritis (OA). Background: Recent studies have reported the outcomes of exercise, joint mobilization, and neural mobilization interventions used in isolation in patients with CMC joint OA. However, it is not known if using a combination of these interventions as a multimodal approach to treatment would further improve outcomes in this patient population. Methods: Sixty patients, 90% female (mean ± SD age, 82 ± 6 years), with CMC joint OA were randomly assigned to receive a multimodal manual treatment approach that included joint mobilization, neural mobilization, and exercise, or a sham intervention, for 12 sessions over 4 weeks. The primary outcome measure was pain. Secondary outcome measures included pressure pain threshold over the first CMC joint, scaphoid, and hamate, as well as pinch and strength measurements. All outcome measures were collected at baseline, immediately following the intervention, and at 1 and 2 months following the end of the intervention. Mixed-model analyses of variance were used to examine the effects of the interventions on each outcome, with group as the between-subject variable and time as the within-subject variable. Results: The mixed-model analysis of variance revealed a group-by-time interaction (F = 47.58, P<.001) for pain intensity, with the patients receiving the multimodal intervention experiencing a greater reduction in pain compared to those receiving the placebo intervention at the end of the intervention, as well as at 1 and 2 months after the intervention (P<.001; all group differences greater than 3.0 cm, which is greater than the minimal clinically important difference of 2.0 cm). A significant group-by-time interaction (F = 3.19, P = .025) was found for pressure pain threshold over the hamate bone immediately after the intervention; however, the interaction was no longer significant at 1 and 2 months postintervention. Conclusion: This clinical trial provides evidence that a combination of joint mobilization, neural mobilization, and exercise is more beneficial in treating pain than a sham intervention in patients with CMC joint OA. However, the treatment approach has limited value in improving pressure pain thresholds, as well as pinch and grip strength. Future studies should include several therapists, a measure of function, and long-term outcomes. Trial registration: Current Controlled Trials ISRCTN37143779.Level of evidence: Therapy, level 1b

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Cannot Determine, Not Reported, Not Applicable

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

4-6 session of joint mobilizations over a 2-week period resulted in significantly greater improvements in pressure pain thresholds measured over the first CMC joint and scaphoid bone than nontherapeutic ultrasound.

Key Finding #2

Grade 3 posterior/anterior glide with distraction technique to the first CMC joint was used.

Key Finding #3

Results indicated that patients receiving a multimodal intervention of manual therapy and exercise exhibited significantly greater improvements in pain compared to those who received a placebo intervention.

Please provide your summary of the paper

The purpose of this study was to analyze the effectiveness of manual therapy and exercise on individuals with carpometacarpal (CMC) joint osteoarthritis. Manual therapy interventions consisted of grade 3 posterior/anterior glide with distraction technique to the first CMC joint. Exercise interventions consisted of active range of motion movements of the hand that were designed to improve joint flexibility, as well as grip and pinch strengthening. Patients received 12 sessions over a period of 4 weeks and data was compared to a placebo intervention where patients received the same number of treatment session but only experienced inactive doses of pulsed ultrasound with an intensity of 0W/cm^2 and gentle application of an inert gel for 10 minutes. Outcome measures used consisted of current pain, pressure pain thresholds, pinch strength, and grip strength. Results yielded patients receiving the multimodal intervention experienced a significantly greater reduction in pain, no difference between groups for pain pressure threshold after the intervention, except when measured over the hamate, and no changes in pinch or grip strength.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Based on the results presented in this paper, application of a multimodal intervention consisting of manual therapy and exercise should be considered for patients with CMC joint OA. This diagnosis can cause severe pain, as well as lead to limitations within a patient’s daily life. Joint mobilizations are an intervention that therapists can do in clinic, as well as teach their patients to do themselves at home. As the research has supported this intervention to reduce pain, it should be considered to teach patients proper techniques in the clinic that they would be able to utilize at home.

Hand Passive Mobilization Performed with Robotic Assistance: Acute Effects on Upper Limb Perfusion and Spasticity in Stroke Survivors

Author Names

Massimiliano Gobbo, Paolo Gaffurini, Laura Vacchi, Sara Lazzarini, Jorge Villafane, Claudio Orizio, Stefano Negrini, and Luciano Bissolotti

Reviewer Name

Jessica Fritson, SPT, ATC

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

This single arm pre-post study aimed at evaluating the acute effects induced by a single session of robot-assisted passive hand mobilization on local perfusion and upper limb (UL) function in poststroke hemiparetic participants. Twenty-three patients with subacute or chronic stroke received 20 min passive mobilization of the paretic hand with robotic assistance. Near-infrared spectroscopy (NIRS) was used to detect changes in forearm tissue perfusion. Muscle tone of the paretic UL was assessed by the Modified Ashworth Scale (MAS). Symptoms concerning UL heaviness, joint stiffness, and pain were evaluated as secondary outcomes by self-reporting. Significant (p = 0.014) improvements were found in forearm perfusion when all fingers were mobilized simultaneously. After the intervention, MAS scores decreased globally, being the changes statistically significant for the wrist (from 1.6 ± 1.0 to 1.1 ± 1.0; p = 0.001) and fingers (1.2 ± 1.1 to 0.7 ± 0.9; p = 0.004). Subjects reported decreased UL heaviness and stiffness after treatment, especially for the hand, as well as diminished pain when present. This study supports novel evidence that hand robotic assistance promotes local UL circulation changes, may help in the management of spasticity, and acutely alleviates reported symptoms of heaviness, stiffness, and pain in subjects with poststroke hemiparesis. This opens new scenarios for the implications in everyday clinical practice. Clinical Trial Registration Number is NCT03243123.

NIH Risk of Bias Tool

Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group

Was the study question or objective clearly stated?

Were eligibility/selection criteria for the study population prespecified and clearly described?

Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?

Were all eligible participants that met the prespecified entry criteria enrolled?

Was the sample size sufficiently large to provide confidence in the findings?

Cannot Determine, Not Reported, Not Applicable

Was the test/service/intervention clearly described and delivered consistently across the study population?

Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?

Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

Cannot Determine, Not Reported, Not Applicable

If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Passive mobilization within stroke recovery is an important component to a comprehensive rehabilitation program to aid in the treatment of spasticity, joint stiffness, and pain as well as promote activity.

Key Finding #2

This study suggests a single session of robotic-assisted hand PROM can improve forearm profusion when all fingers were moved simultaneously in subacute and chronic stroke patients with hemiparesis.

Key Finding #3

Spasticity ratings decreased globally within the wrist and fingers using the MAS from the single session of robotic-assisted PROM.

Key Finding #4

Secondary outcomes of self-reported UL heaviness, stiffness, and pain decreased with the single session of robotic-assisted PROM.

Please provide your summary of the paper

This study looked at the acute effects of a single passive hand mobilization performed by robotic assistance in subacute and chronic stroke patients with hemiparesis. Participants must be participating in the study post first event of cerebrovascular stroke, have unilateral paresis, and still be able to remain in a sitting position. Patients were excluded if they had bilateral impairment, cognitive or behavioral dysfunction, finger flexion contractures, DeQuervian’s tenosynovitis, or neurologic conditions where pain perception could be altered. The Gloreha (Idrogenet, Italy) robotic system was used to implement a 20-minute repetitive passive joint mobilization intervention including isolated, pinch, and synchronous movements for twenty-three patients who met the criteria. The outcome measure used to observe perfusion of the UE was near-infrared spectroscopy (NIRS). The functional assessment in the study included self-reported measures of heaviness, joint stiffness, and pain for all joints in the UE using a scale from zero to one hundred with zero being the absence of symptoms. The MAS objectively defined spasticity in motions of shoulder abduction, elbow extension, supination, wrist extension, and fingers extension movements with the patient in resting position. All these measures were performed before the intervention and five to fifteen minutes after the robotic-assisted treatment was completed. The results of this study showed improvement in forearm profusion, global UE spasticity, and reported secondary outcomes of heaviness, stiffness, and pain. The study was limited by the lack of control group to compare the improvements as well a lack of ability to control the treatment time of day which may impact the activity prior to the session or be impacted by the natural circadian patterns within the patients.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study further supports motion, specifically passive motion for stroke patients to address joint stiffness, pain, and increase circulation. Stroke is the most common cause of UE motor impairments in adults. Knowing the high impact stroke may have on UE function and the importance of mobilization within stroke rehabilitation, it is necessary to continue researching and evolving technology to give the best, most efficient care. Further research is needed on robotic-assisted therapy, but it could be something that becomes implemented in rehabilitation settings or at home for patients who don’t have access to so someone who can perform the manual therapy techniques. As discussed in the article, there are both a professional version and a low-cost home-based version that may be implemented more independently for the patient. When in clinical practice, it is important to take into consideration what is most appropriate for the individualized patient when considering which modality of intervention. Robotic-assisted passive motion may be a technology that will benefit some patients.

The Effectiveness of a Manual Therapy and Exercise Protocol in Patients With Thumb Carpometacarpal Osteoarthritis: A Randomized Controlled Trial

Author Names

Villafañe, J. H, Cleland, J. A., & Fernández-de-las-Peñas, C

Reviewer Name

Jada Holmes, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

STUDY DESIGN: Double-blind, randomized controlled trial. OBJECTIVE: To examine the effectiveness of a manual therapy and exercise approach relative to a placebo intervention in individuals with carpometacarpal (CMC) joint osteoarthritis (OA). BACKGROUND: Recent studies have reported the outcomes of exercise, joint mobilization, and neural mobilization interventions used in isolation in patients with CMC joint OA. However, it is not known if using a combination of these interventions as a multimodal approach to treatment would further improve outcomes in this patient population. METHODS: Sixty patients, 90% female (mean  SD age, 82  6 years), with CMC joint OA were randomly assigned to receive a multimodal manual treatment approach that included joint mobilization, neural mobilization, and exercise, or a sham intervention, for 12 sessions over 4 weeks. The primary outcome measure was pain. Secondary outcome measures included pressure pain threshold over the first CMC joint, scaphoid, and hamate, as well as pinch and strength measurements. All outcome measures were collected at baseline, immediately following the intervention, and at 1 and 2 months following the end of the intervention. Mixed-model analyses of variance were used to examine the effects of the interventions on each outcome, with group as the between-subject variable and time as the within-subject variable. RESULTS: The mixed-model analysis of variance revealed a group-by-time interaction (F = 47.58, P<.001) for pain intensity, with the patients receiving the multimodal intervention experiencing a greater reduction in pain compared to those receiving the placebo intervention at the end of the intervention, as well as at 1 and 2 months after the intervention (P<.001; all group differences greater than 3.0 cm, which is greater than the minimal clinically important difference of 2.0 cm). A significant group-by-time interaction (F = 3.19, P = .025) was found for pressure pain threshold over the hamate bone immediately after the intervention; however, the interaction was no longer significant at 1 and 2 months post-intervention. CONCLUSION: This clinical trial provides evidence that a combination of joint mobilization, neural mobilization, and exercise is more beneficial in treating pain than a sham intervention in patients with CMC joint OA. However, the treatment approach has limited value in improving pressure pain thresholds, as well as pinch and grip strength. Future studies should include several therapists, a measure of function, and long-term outcomes. Trial registration: Current Controlled Trials ISRCTN37143779.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The application of a multi-modal manual therapy intervention of joint mobilization, neural mobilization, and exercise is beneficial to reduce pain in patients with CMC joint OA.

Key Finding #2

No changes in PPT and motor function were observed.

Please provide your summary of the paper

This study shows that when looking at short-term effects of joint mobilization, neural mobilization, and exercise when treating OA in the CMC joint, this produces better results for pain than ultrasound. This study used grade 3 PA glides with distraction of the 1st CMC joint, nerve sliders, and AROM stretching exercises as the treatment protocol for the intervention group versus ultrasound as the placebo group. The intervention group had significantly improved pain compared to the placebo group but had no difference in physical performance tests or grip strength between the groups. Some previous research has looked at the difference between the effects joint and neural mobilizations on PPTs, but this was not observed in this case. Future studies should investigate which treatment and exercise protocols are most appropriate for reducing pain and improving function in patients with OA in the CMC joint.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Some, if not all, of these manual therapy techniques can be used on patients with CMC joint OA to help improve pain but will most likely not help function. It’s unclear if these treatments all work in conjunction together or if some will work on their own, so it’s important that you individualize your care to each patient and how they feel. If something isn’t helping their pain, make sure to modify or consult with another PT to see if there’s other treatments you haven’t thought of trying with what you’re already doing.

Effectiveness of Manual Therapy Versus Surgery in Pain Processing Due to Carpal Tunnel Syndrome: A Randomized Clinical Trial

Author Names

Fernandez-de-las-Penas, C., Cleland, J., Fuensalida-Novo, S., Alonso-Blanco, C., Pareja, J. A., & Alburquerque-Sendin, F.

Reviewer Name

Jada Holmes, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: People with carpal tunnel syndrome (CTS) exhibit widespread pressure pain and thermal pain hypersensitivity as a manifestation of central sensitization. The aim of our study was to compare the effectiveness of manual therapy versus surgery for improving pain and nociceptive gain processing in people with CTS. Methods: The trial was conducted at a local regional Hospital in Madrid, Spain from August 2014 to February 2015. In this randomized parallel group, blinded, clinical trial, 100 women with CTS were randomly allocated to either manual therapy (n = 50), who received three sessions (once/week) of manual therapies including desensitization manoeuvres of the central nervous system, or surgical intervention (n = 50) group. Outcomes including pressure pain thresholds (PPT), thermal pain thresholds (HPT or CPT), and pain intensity which were assessed at baseline, and 3, 6, 9 and 12 months after the intervention by an assessor unaware of group assignment. Analysis was by intention to treat with mixed ANCOVAs adjusted for baseline scores. Results: At 12 months, 95 women completed the follow-up. Patients receiving manual therapy exhibited higher increases in PPT over the carpal tunnel at 3, 6 and 9 months (all, p < 0.01) and higher decrease of pain intensity at 3-month follow-up (p < 0.001) than those receiving surgery. No significant differences were observed between groups for the remaining outcomes. Conclusions: Manual therapy and surgery have similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with CTS. Neither manual therapy nor surgery resulted in changes in thermal pain sensitivity. Significance: The current study found that manual therapy and surgery exhibited similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with carpal tunnel syndrome at medium- and long-term follow-ups investigating changes in nociceptive gain processing after treatment in carpal tunnel syndrome.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The results of the current trial suggest that multimodal manual therapy and surgery exhibited similar outcomes in pain and pressure sensitivity at mid- and long-term follow-up periods, but manual therapy exhibited significant better improvements at short-term in pain and localized pressure pain sensitivity, in women with CTS.

Key Finding #2

No changes in thermal pain sensitivity were observed after either manual therapy or surgery.

Please provide your summary of the paper

This study shows that implementing a manual therapy program including desensitization maneuvers of the CNS resulted in similar improvements as surgery on pain intensity and widespread pressure pain sensitivity at mid and long-term follow-up periods when treating carpal tunnel syndrome. Patients that underwent manual had a higher decrease in pain at 3 months and improvements in pressure pain thresholds (PPTs) at 3, 6, and 9 months. However, neither surgery nor manual therapy was helpful in changing thermal pain sensitivity in this patient population. The results from this study agreed with previous literature that found nerve tensioner intervention did little for reducing pain and PPTs, but that desensitization maneuvers were more effective. It was also found that sensitivity to heat or cold wasn’t changed within either group (manual therapy or surgical group). Overall, the current findings are similar with that of previous literature which all find that similar manual therapy programs were more effective at short-, but equally effective and mid and long-term, as surgery for improving pain and self-reported function in a different sample of women with CTS.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Overall, the current findings are similar with that of previous literature which all find that similar manual therapy programs were more effective at short-, but equally effective and mid and long-term, as surgery for improving pain and self-reported function in a different sample of women with CTS. These findings are important when providing patients with potential treatment options for severe symptoms of carpal tunnel syndrome. They may want to weigh which treatment option is best by looking at more than just outcomes because they have very similar long-term outcomes. In this case, it may be easier to promote the conservative treatment (manual therapy) unless they are adamant about getting surgery. It might be easier to discuss a more invasive treatment option.

A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome

Author Names

Burke, J., Buchberger, D., Carey-Loghmani, T., Dougherty, P., Greco, D., & Dishman, J.

Reviewer Name

Natalie Hosmer, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: The purpose of this study was to determine the clinical efficacy of manual therapy interventions for relieving the signs and symptoms of carpal tunnel syndrome (CTS) by comparing 2 forms of manual therapy techniques: Graston Instrument–assisted soft tissue mobilization (GISTM) and STM administered with the clinician hands. Methods: The study was a prospective comparative research design in the setting of a research laboratory. Volunteers were recruited with symptoms suggestive of CTS based upon a phone interview and confirmed by electrodiagnostic study findings, symptom characteristics, and physical examination findings during an initial screening visit. Eligible patients with CTS were randomly allocated to receive either GISTM or STM. Interventions were, on average, twice a week for 4 weeks and once a week for 2 additional weeks. Outcome measures included (1) sensory and motor nerve conduction evaluations of the median nerve; (2) subjective pain evaluations of the hand using visual analog scales and Katz hand diagrams; (3) self-reported ratings of symptom severity and functional status; and (4) clinical assessments of sensory and motor functions of the hand via physical examination procedures. Parametric and nonparametric statistics compared treated CTS hand and control hand and between the treatment interventions, across time (baseline, immediate post, and at 3 months’ follow-up). Results: After both manual therapy interventions, there were improvements to nerve conduction latencies, wrist strength, and wrist motion. The improvements detected by our subjective evaluations of the signs and symptoms of CTS and patient satisfaction with the treatment outcomes provided additional evidence for the clinical efficacy of these 2 manual therapies for CTS. The improvements were maintained at 3 months for both treatment interventions. Data from the control hand did not change across measurement time points. Conclusions: Although the clinical improvements were not different between the 2 manual therapy techniques, which were compared prospectively, the data substantiated the clinical efficacy of conservative treatment options for mild to moderate 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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

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?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Cannot Determine, Not Reported, or Not Applicable

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

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?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Cannot Determine, Not Reported, or Not Applicable

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

There was no significant difference between the use of Graston Instrument—assisted soft tissue mobilization and soft tissue massage administered with the clinician’s hands.

Key Finding #2

The data collected supports manual therapy as an option for the conservative treatment of mild to moderate CTS.

Please provide your summary of the paper

This pilot study was a prospective comparative research design that examined the effects of two manual therapy techniques, Graston Instrument—assisted soft tissue mobilization and soft tissue mobilization— on individuals with Carpal Tunnel Syndrome. The study found that overall, the use of both of these techniques resulted in clinical improvements. Additionally, the study concluded that neither technique was found to be more effective than the other. A major limitation to this study is the sample size. Only 26 patients were initially enrolled in this study and 4 dropped out during the study. While the data collected supports the use of manual therapy as a conservative treatment option in this population of individuals with mild to moderate CTS, a further study should include at least 81 patients (per the post hoc power analysis) to confirm that this data is clinically meaningful.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The data collected from this study supports the use of manual therapy as a way to conservatively treat CTS.

Comparative Efficacy of Routine Physical Therapy with and without Neuromobilization in the Treatment of Patients with Mild to Moderate Carpal Tunnel Syndrome

Author Names

Junaid Ijaz, M, Karimi, H, Ahmad, A, Amer Gillani, S, Anwar, N, and Asad Chaudhary, M

Reviewer Name

Anne Jacob

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background Median nerve mobilization is a relatively new technique that can be used to treat carpal tunnel syndrome. But literature about additional effects of neuromobilization for the management of carpal tunnel syndrome is scarce. Objective To examine and compare the role of median nerve neuromobilization at the wrist as compared to routine physical therapy in improving pain numeric pain rating scale (NPRS), range of motion (Ballestero-Pérez et al., 2017), muscle strength, and functional status. Methods A sample size of 66 patients was recruited using convenient sampling and distributed randomly in two groups. After assessing both groups using ROM, manual muscle strength, pain at NPRS, and functional status on the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), which consists of two further scales (the symptom severity scale (SSS) and the functional status scale (FSS)), Group 1 received conservative treatment including ultrasound therapy two days a week for six weeks, using a pulsed mode 0.8 W/cm2 and frequency 1 MHz, wrist splinting, and tendon gliding exercises, while Group 2 received both conservative treatments including ultrasound, splinting, and tendon gliding exercises as well as a neuromobilization technique. Treatment was given for 6 weeks, 2 sessions/week, and patients were reassessed at the end of the 3rd and 6th weeks. Results Although both groups improved significantly in terms of all the outcome measures used, the neuromobilization groups showed a statistically more significant increase in flexion, extension, decrease in pain, decrease in SSS, decrease in FSS, and BCTQ as compared to the routine physical therapy group. Conclusions The addition of neuromobilization in the rehabilitation program of carpal tunnel syndrome has better effects on treatment outcomes.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

Repeated measurement ANOVA (Table 3) revealed that there was a significant increase in range of motion in all four movements and muscle strength of all four groups, i.e., flexors, extensor, ulna, and radial deviators (<0.001).

Key Finding #2

Pain measured at Numeric Pain Rating Scale, the severity of symptoms measured by symptom severity scale index, activity limitation measured by functional status scale index, and overall change in symptoms measured by BCTQ (Boston Carpal Tunnel Syndrome Questionnaire) also improved statistically with <0.001 shown by repeated measurement ANOVA.

Key Finding #3

After the treatment, flexion, extension, pain intensity at NPRS, symptom severity at SSS index, FSS, and BCTQ all differed statistically and denoted that the addition of neuromobilization was much better for management of CTS as compared to routine physical therapy.

Please provide your summary of the paper

This was a randomized control trial looking at the effects of median nerve mobilization on patients with carpal tunnel syndrome. Patients were split into two groups, once receiving conservative treatment and group two receiving both conservative treatment as well as neuromobilization techniques. This study found that addition of neuromobilization had significant effects, despite not having direct strength improvements.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study showed the clinical value of incorporating median nerve mobilizations into treatment of mild to moderate carpal tunnel syndrome. They result in better outcomes in range of motion, pain, functional outcomes, and symptom severity. While the effects of this treatment are short term, they are still important to take note of. Helping patients report less pain in the moment can allow for more effective treatment through the remainder of the plan of care, since pain can often be seen as a fairly limiting factor for effective treatment.

The Effectiveness of Manual Therapy Versus Surgery on Self Reported Function, Cervical Range of Motion, and Pinch Grip Force in Carpal Tunnel Syndrome: A randomized Clinical Trial

Author Names

Fernández-de-las-Peñas, C., PT, PhD, DMSc; Cleland, J., PT, PhD, OCS, FAAOMPT; Palacios-Ceña, M., PT; Fuensalida-Novo, S., PT; Pareja, J., MD, PhD; Alonso-Blanco, C., PT, PhD

Reviewer Name

Jordan Jaklic, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Abstract

Study Design

Randomized parallel-group trial.

Background

Carpal tunnel syndrome (CTS) is a common pain condition that can be managed surgically or conservatively.

Objective

To compare the effectiveness of manual therapy versus surgery for improving self-reported function, cervical range of motion, and pinch-tip grip force in women with CTS.

Methods

In this randomized clinical trial, 100 women with CTS were randomly allocated to either a manual therapy (n = 50) or a surgery (n = 50) group. The primary outcome was self-rated hand function, assessed with the Boston Carpal Tunnel Questionnaire. Secondary outcomes included active cervical range of motion, pinch-tip grip force, and the symptom severity subscale of the Boston Carpal Tunnel Questionnaire. Patients were assessed at baseline and 1, 3, 6, and 12 months after the last treatment by an assessor unaware of group assignment. Analysis was by intention to treat, with mixed analyses of covariance adjusted for baseline scores.

Results

At 12 months, 94 women completed the follow-up. Analyses showed statistically significant differences in favor of manual therapy at 1 month for self-reported function (mean change, −0.8; 95% confidence interval [CI]: −1.1, −0.5) and pinch-tip grip force on the symptomatic side (thumb-index finger: mean change, 2.0; 95% CI: 1.1, 2.9 and thumb-little finger: mean change, 1.0; 95% CI: 0.5, 1.5). Improvements in self-reported function and pinch grip force were similar between the groups at 3, 6, and 12 months. Both groups reported improvements in symptom severity that were not significantly different at all follow-up periods. No significant changes were observed in pinch-tip grip force on the less symptomatic side and in cervical range of motion in either group.

Conclusion

Manual therapy and surgery had similar effectiveness for improving self-reported function, symptom severity, and pinch-tip grip force on the symptomatic hand in women with CTS. Neither manual therapy nor surgery resulted in changes in cervical range of motion.

Level of Evidence

Therapy, level 1b. Prospectively registered September 3, 2014 at www.clinicaltrials.gov (NCT02233660). J Orthop Sports Phys Ther 2017;47(3):151–161. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7090

NIH Risk of Bias Tool

Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group

Was the study question or objective clearly stated?

Were eligibility/selection criteria for the study population prespecified and clearly described?

Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?

Were all eligible participants that met the prespecified entry criteria enrolled?

Was the sample size sufficiently large to provide confidence in the findings?

Cannot Determine, Not Reported, Not Applicable

Was the test/service/intervention clearly described and delivered consistently across the study population?

Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?

Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

Key Finding #1

Patients receiving manual therapy instead of surgery had better self-reported function, symptom severity, and pinch grip strength than patients receiving surgery after 1 month.

Key Finding #2

Similar outcomes were achieved in self-reported function, symptom severity, and pinch grip strength at 6 and 12 months in the manual therapy and surgery groups.

Key Finding #3

There were no changes in cervical range of motion of either group, despite the manual therapy group receiving targeted interventions to the cervical spine for musculoskeletal restrictions.

Please provide your summary of the paper

This paper is a randomized control trial that assessed the difference in cervical mobility, self reported outcomes, symptoms severity, and pinch grip strength in women experiencing carpal tunnel syndrome (CTS). The women were assigned to either a manual therapy group or surgical group. The assessor, whom were blind to which group the participant was in, reassessed the patients at 1, 3, 6, and 12 months. Patient were assessed using the Boston Carpal Tunnel Questionnaire for self reported outcomes and symptom severity, pinch-tip grip force, and active cervical range of motion. Participants were included in the study if they met the following criteria: pain and paresthesia in the median nerve distribution, positive Tinel sign, and positive Phalen sign. Symptoms had to have persisted for at least 12 months. Further, the electrodiagnostic examination had to reveal deficits of sensory and motor median nerve conduction (ie, median nerve sensory conduction velocity less than 40 m/s and median nerve distal motor latency greater than 4.20 milliseconds). Patients were excluded if they met any of the following criteria: (1) any sensory and/or motor deficit in either the ulnar or radial nerve; (2) age greater than 65 years; (3) previous surgery or steroid injections; (4) multiple diagnoses on the upper extremity (eg, coexisting cervical radiculopathy); (5) cervical, shoulder, or hand trauma; (6) systemic disease causing CTS (eg, diabetes mellitus, thyroid disease); (7) comorbid musculoskeletal medical conditions (eg, rheumatoid arthritis or fibromyalgia); (8) pregnancy; or (9) male sex. The study lost 6 participants by 12 months, but was able to conclude that participants receiving manual therapy had better self reported outcomes, pinch grip strength and symptom severity than those that received surgery. However, at 6 and 12 months, there were no statistical differences in these categories between the groups. Additionally, no changes were seen in cervical range of motion despite the manual group receiving target therapy for cervical musculoskeletal deficits.

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 will be beneficial to clinicians in not only explaining to patients that manual therapy is as effective as surgery long term, but it can help clinicians advocate for the profession. One aspect that was addressed in the article is that manual therapy allows the patient to continue to work and engage in activities, while surgery impedes function in the short-term. When seeing patients with CTS, it may be beneficial to explain to them that more patients have seen better short term results from manual therapy and equal long term results to surgery. This paper can also be used to help clinicians advocate for the profession. With research showing the manual therapy is just as effective as surgery, this can help PTs advocate that a more conservative and cost-effective option is available for equal results. A few aspects that may need to be considered is that this study was only conducted with women and chronic pain. This does not consider men with CTS or subacute pain that patients may be experiencing. Additionally, cervical manual therapy was shown to be ineffective for CTS. When considering patients with CTS, cervical manual therapy may not be beneficial to spend time on unless symptoms persist to the shoulder or neck. If pain does persist that far from the carpal tunnel, it may be of benefit to assess for cervical radiculopathy or a brachial plexus injury and/or compression.

Comparison of Two Manual Therapy Programs, including Tendon Gliding Exercises as a Common Adjunct, While Managing the Participants with Chronic Carpal Tunnel Syndrome

Author Names

Sheereen, F. J., Sarkar, B., Sahay, P., Shaphe, M. A., Alghadir, A. H., Iqbal, A., Ali, T., & Ahmad, F

Reviewer Name

Emma Kosbab, LAT, ATC, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background. Carpal tunnel syndrome (CTS) is the symptomatic compression neuropathy of the median nerve at the wrist level that may become a reason for upper limb disability, in the women and men population. Objective. This study aimed to compare the efficacy of the neurodynamic technique (NT) and carpal bone mobilization technique (CBMT) incorporated with tendon gliding exercises (TGE) as an effect-enhancing adjunct while managing the participants with chronic CTS. Methods. The study followed a two-arm parallel-group randomized comparative design. Thirty participants (aged 30–59 years) with chronic CTS were recruited randomly to both the NT and CBMT groups. In addition to the TGE (a common adjunct), NT and CBMT were performed in the NT and CBMT groups, respectively, for three weeks. The primary outcome measures including pain intensity, functional status, grip strength, and motor nerve conduction study were assessed using a visual analogue scale (VAS), Boston Carpal Tunnel Questionnaire (BCTQ), hand-held dynamometer, and electromyograph, respectively, at baseline, 3 weeks postintervention, and follow-up at one week post end of the intervention. Paired and unpaired t-test were used to calculate the differences in intervention effects within and between the groups with keeping the level of significance α at 0.05. Results. The data analysis revealed a significant (95% CI, p < 0.05) difference for all outcomes within each group compared across different time intervals. Similarly, a significant difference was found for all outcomes except pain and grip strength compared between groups at 3 weeks postintervention and follow-up at one week post end of the intervention. Conclusions. The NT revealed more effectiveness than the CBMT when incorporated with TGE to improve nerve conduction velocity and functional status of the hand. However, both NT and CBMT were equally effective in improving pain and grip strength while managing the participants with chronic CTS. In addition, the TGE contributed as a beneficial, effect-enhancing adjunct to the NT and CBMT differently. Significance. The study will guide the physiotherapist in applying either of the combination techniques suitable for achieving treatment objectives while managing the participants with chronic CTS.

NIH Risk of Bias Tool

Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group

Was the study question or objective clearly stated?

Were eligibility/selection criteria for the study population prespecified and clearly described?

Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?

Were all eligible participants that met the prespecified entry criteria enrolled?

Was the sample size sufficiently large to provide confidence in the findings?

Was the test/service/intervention clearly described and delivered consistently across the study population?

Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?

Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Following three weeks of intervention, NT produced a statistically significant improvement in functional status and nerve conduction speed as noted by the Boston Carpal Tunnel Questionaire (BCTQ), Nerve conduction study for median nerve (NCSa and NCSb).

Key Finding #2

Both NT and CBMT interventions (in conjunction with tendon gliding exercises) showed similar improvement in pain (visual analog scale) and grip strength (hand-held dynamometry).

Key Finding #3

Both treatment groups provided improved subjective and objective symptoms over the three week period without surgical intervention.

Please provide your summary of the paper

This study compared two intervention strategies for treatment of carpal tunnel syndrome. One group used neurodynamic technique and tendon gliding exercises (NT group) and the other used carpal bone mobilization technique in addition to the tendon gliding exercises (CBMT group) all applied for three weeks. The NT group interventions specifically included passive median nerve mobilization in the supine position performed by the physical therapist moving to ranges that did not produce pain for 2 sets of 5 minutes with 1 minute rest between sets 3 times per week for the 3 week period. The CBMT group received AP and Pa mobilizations joints of the carpal bones, radius, ulna, and adjunct metacarpals for 3 sets of 30 repetitions 3 times per week for the 3 week period. The interventions did present statistically significant findings in both interventions for the majority of outcomes (related to pain and function). The analysis included 30 participants, but may have been more conclusive with a control group that did not receive any interventions to justify their efficacy more completely.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Based on the outcomes that showed improvement, it could be assumed that the neurodynamic technique in conjunction with tendon gliding exercises is most useful if the patient’s goals to improve functional status and for general improvement in the physiology of the nerve conduction. Both approaches demonstrated improvements in pain and grip strength which may be helpful in achieving patient goals. Understanding the value of each variable to achieve patient goals is critical, but the common tendon gliding may be most useful of the three interventions as it is the intervention that provides the patient with autonomy in their rehabilitation. Clinically, it is important to know the nerve conduction and integrity along with general function is improved more by NT, but CBMT was equally as beneficial at NT for the pain and strength outcomes. Overall patient goals, clinical experience, and ensuring there are options for home application are important considerations for application.

The Use of Joint Mobilization to Improve Clinical Outcomes in Hand Therapy: A Systematic Review of the Literature

Author Names

Rick Heiser, Virginia H. O’Brien, and Deborah A. Schwartz

Reviewer Name

Adrienne Maniktala, LAT, ATC, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study design: Systematic review. Introduction: Joint mobilizations are used as an intervention for improving range of motion (ROM), decreasing pain and ultimately improving function in patients with a wide variety of upper extremity diagnoses. However, there are only a limited number of studies describing this treatment for conditions affecting the elbow, wrist, and hand. Furthermore, it is unclear as to the most effective joint mobilization technique utilized and the most beneficial functional outcomes gained. Purpose: Examine the current evidence describing joint mobilizations for treatment of conditions of the elbow, wrist and hand, and offer informative practical clinical guidance. Methods: Twenty-two studies dated between 1980 and 2011 were included in the systematic review for analysis. Results: The current evidence provides moderate support for the inclusion of joint mobilizations in the treatment of lateral epicondylalgia (LE). In particular, mobilization with movement (MWM) as described by Mulligan is supported with evidence from nine randomized clinical trials as an effective technique for the treatment of pain. Other described techniques include those known as Kaltenborn, Cyriax physical therapy, and Maitland, but the evidence for these techniques is limited. There is also limited evidence for the joint mobilizations in the treatment of wrist and hand conditions. Conclusions: The current literature offers limited support for joint mobilizations of the wrist and hand, and moderate support for joint mobilizations of the elbow for LE. There is moderate support for mobilization with movement.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

For patients with lateral epicondylalgia there is moderate evidence for the following: MWM will decrease pain and improve strength, elbow joint mobilizations will improve ROM, that mobilization is just as beneficial as injections long-term, and that mobilizations have a positive impact on short and long-term function.

Key Finding #2

In distal radius fractures, moderate evidence demonstrates MWM has been shown for pain relief and Maitland has been beneficial for ROM change.

Key Finding #3

There is limited evidence for carpal tunnel syndrome, limited ROM in MCP and 1st CMC OA that mobilizations improve ROM or decrease pain.

Please provide your summary of the paper

The authors of this study compiled 22 pieces of literature on joint mobilizations for the distal upper extremities. The authors note that there is still limited evidence on these areas and state that further research is needed on the short and long-term effects of mobilizations in this part of the body. They were able to find research on elbow mobilizations, wrist mobilizations and hand mobilizations. Although the studies suggest joint mobilization of the upper extremity can have improvement with range of motion and strength, they were all completed along with exercise indicating that manual therapy on its own is not as beneficial. The strongest evidence in this systematic review was found in the elbow and wrist joint mobilizations, indicating that there is positive improvement in pain, strength, and range of motion in short term assessments. Only the studies looking at elbow joint mobilizations were able to find evidence of long-term function assessment.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The information in this study can be correlated to clinical practice because the research in this article can help clinicians determine the best course of treatment for their patients with distal upper extremity injuries. This article also can help clinical practice by encouraging clinicians to develop their practical skills in areas where it may not be used as commonly.

Comparison of Two Manual Therapy Techniques in Patients with Carpal Tunnel Syndrome: A Randomized Clinical Trial

Author Names

Talebi, G., Saadat, P. Javadian, Y. and Taghipour, M.

Reviewer Name

Haley Mills, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Manual therapy techniques are part of physiotherapy treatment of carpal tunnel syndrome (CTS) which are classified into two groups including nerve mobilization and mechanical interface mobilization. The aim of the study was to find which manual therapy method-technique directed to mechanical interface and nerve mobilization–has superior beneficial effects on clinical and electrophysiological findings in conservative management of patients with CTS. Methods: Thirty patients with CTS participated into two groups namely: mechanical interface and nerve mobilization in this randomized clinical trial. The intervention was performed three times weekly for 4 weeks. Mechanical interface mobilization was directed to structures around the median nerve at the forearm and wrist. Techniques of median nerve gliding and tension were used in the nerve mobilization group. The outcome measures included visual analogue scale (VAS), symptom severity scale (SSS), hand functional status scale (FSS) and motor and sensory distal latencies of median nerve. Paired t-test and ANCOVA were used for statistical analysis. Results: At the end of the 4th week of the treatment, the mean of VAS, SSS and FSS significantly improved in both groups (p<0.05), but the difference was not significant between the two groups (P>0.05). Although the mean of motor and sensory distal latencies of median nerve at the end of the treatment period only improved in the nerve mobilization group (p<0.05), the difference was not significant between the two groups (P>0.05). Conclusion: Mechanical interface mobilization and nerve mobilization techniques are not superior to each other in reducing pain and improving hand symptoms and functional status.

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?

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

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?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

Manual therapy methods, including mobilization of the mechanical interface and specific neurodynamic techniques, have significant therapeutic benefits for the conservative treatment of mild to moderate forms of carpal tunnel syndrome.

Key Finding #2

The benefits of manual therapy for mild to moderate carpal tunnel syndrome include but are not limited to improvements in hand symptoms and functional status and reduction of pain.

Key Finding #3

These manual techniques, mechanical interface, and nerve mobilization, are not superior to each other in reducing pain and improving hand symptoms and functional status.

Key Finding #4

Research should be done comparing sliding and tensioning neurodynamic techniques to get more information on separate treatment potentials.

Please provide your summary of the paper

In this randomized control trial, researchers aimed to determine which manual therapy techniques were superior for the conservative management of carpal tunnel syndrome. The two manual therapy methods they were comparing were mechanical interface (wrist distraction, transverse carpal ligament stretch, palmar fascia release, finger flexor glides, and upper forearm fascia and muscle release) and nerve mobilization (median nerve glide and tension maneuvers). They initially had 57 participants enter the study, 18 did not meet the inclusion criteria and 9 did not complete all pre-intervention outcome measures ending in removal from the study, leaving researchers with 30 participants to split randomly into the two treatment groups. Interventions were performed 3 times per week for 4 weeks. Both groups received 15 minutes of intervention per session. The outcome measure used to assess pre vs post-intervention outcomes was the Boston Questionnaire, which includes questions regarding symptom severity and functional status. After 4 weeks the results were collected and evaluated. The researchers concluded that both techniques successfully improved hand symptoms and functional status and reduced pain, noting that one method was not superior to the other. They recommend that some combination of both methods be used for best results. They recognize some limitations of their study as being too short, the use of ultrasound and TENS in conjunction with manual therapies, and the small sample size. That being said, they recommend longer studies be done to further investigate these effects.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study can be extremely valuable in helping physical therapists as they prepare a plan of care for patients with carpal tunnel syndrome. Since the researchers found that neither method of manual therapy was superior, therapists could feel comfortable using either method or a combination of the two. The fact that the researchers included specifics regarding dosage makes this information easy to replicate for future research and in the clinic when treating a patient with carpal tunnel syndrome. It is worth mentioning however that the use of US and TENS for each patient in the study in conjunction with the manual therapies could be a huge confounding variable to the research and a potential barrier if attempting to apply these findings in practice if a therapist does not have access to these modalities. Another limitation of the study, the small sample size, is worth noting but in my interpretation does not eliminate the value of the findings. However, the researchers disclosed these limitations, making them easy to filter through, allowing for ease of understanding and application for future research and clinical practice.

Do Short-Term Effects Predict Long-Term Improvements in Women Who Receive Manual Therapy or Surgery for Carpal Tunnel Syndrome? A Bayesian Network Analysis of a Randomized Clinical Trial

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

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?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

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.

Manual Mobilization of the Wrist: A Pilot Study in Rehabilitation of Patients with a Chronic Hemiplegic Hand Post-Stroke

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

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?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

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?

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)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

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.

Influence of Spinal Manipulation on Muscle Spasticity and Manual Dexterity in Participants with Cerebral Palsy: Randomized Controlled Trial

Author Names

Kachmar,O; Kushnir,A; Matiushenko,O; Hasiuk,M

Reviewer Name

Katharina Nevsimal SPT Class of 2024

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives: The aim of this study was to investigate the short-term effects of spinal manipulation (SM) on wrist muscle spasticity and manual dexterity in participants with cerebral palsy (CP). Methods: After baseline examination, 78 participants with spastic CP (7-18 years) without contractures or hyperkinetic syndrome were randomly allocated into 2 groups. The experimental group underwent SM to the cervical, thoracic, and lumbar spine, and the control group received sham SM. A second evaluation was performed 5 minutes postintervention. Wrist muscle spasticity was measured quantitatively with NeuroFlexor (Aggero MedTech AB, Solna, Sweden), a device assessing resistance to passive movements of different velocities. Between-group difference was calculated using the Mann-Whitney U test. Manual dexterity was evaluated by the Box and Block test. Results: In the experimental group, muscle spasticity was reduced by 2.18 newton from median 5.53 with interquartile range 8.66 to median 3.35 newton with interquartile range 7.19; the difference was statistically significant (P = .002). In the control group, reduction in spasticity was negligible. The between-group difference in change of muscle spasticity was statistically significant (P = .034). Improvement of manual dexterity was not statistically significant (P = .28). Conclusions: These findings suggest that SM may, in the short term, help to reduce spasticity in participants with CP. Long-term effects of SM on muscle spasticity have yet to be studied.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

A treatment plan that includes spinal manipulation at the lumbar, thoracic, and cervical levels has the ability to decrease spasticity in those with Cerebral Palsy.

Key Finding #2

While spinal manipulation helped decrease spasticity it did not have an effect on dexterity.

Key Finding #3

This study had a short-term design due to difficulties in recruiting people for longer-term observation. The spinal manipulation was given during the first half of the day when participants arrived for treatment. There needs to be a longer follow-up period in future studies to understand the effects.

Key Finding #4

This study while showing positive support of decreased spasticity through spinal manipulations, the findings are preliminary and further studies need to be done.

Please provide your summary of the paper

This randomized controlled trial studied the effects of spinal manipulation to the cervical, thoracic, and lumbar spine on wrist muscle spasticity and manual dexterity in participants with spastic cerebral palsy. The participants were split up randomly into two groups: experimental group who received spinal manipulation and the control group who received sham spinal manipulation. The participants, 79 total, ranged from the ages of 8-18 years old. Muscle spasticity in the wrist was the primary outcome measure and was measured at baseline and postintervention. Spasticity was measured quantitatively with a NeuroFlexor device which looked at the resistance to passive movements of the wrist performed at different velocities. The secondary outcome measure looked at manual dexterity at baseline and after the intervention through the Box and Block test. The manual therapy protocol included high-velocity, low-amplitude for all levels of the spine. For the cervical spine the participant was in a seated position with the head flexed sideways and slightly rotated and the weight of the head supported by the practitioner’s hand with traction/side-bending force applied. Thoracic manipulation was done with the patient in prone while applying a postero-anterior pressure in a counterclockwise rotation. For the lumbar spine the patient was in a lateral recumbent position with the upper leg flexed at the hip and knee, lower leg straight, and the lumbar spine put into extension with rotational forces applied at the shoulder and thigh. While the controlled group did not receive the spinal manipulations, they received sham of the spinal manipulation that physically and visually resembles the spinal manipulations of the experimental group but without applying substantial force. The study showed a statistically significant decrease of spasticity after spinal manipulation in the experimental group but was not statistically significant in the control group. Regarding hand dexterity the experimental group had a more pronounced improvement with a difference of 1.05 blocks per minute in between-group analysis. This difference was not statistically significant. No conclusion could be drawn in on the influence of spinal manipulation on manual dexterity in participants with spastic cerebral palsy. Thus, using the manual therapy techniques on the spine can help decrease spasticity, especially at the wrist, in cerebral palsy but does not influence the dexterity of the participant. This was a short-term study, and the long-term effects were not measured.

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 to help decrease spasticity for the neurologic patient population of Cerebral Palsy. It discussed the importance of spinal manipulations for the cervical, thoracic, and lumbar levels in order to help with a decrease in muscle spasticity and improve manual dexterity. While no statistical significance was found between the experimental and control group regarding dexterity, manual therapy of the spine did show to decrease spasticity in the short-term. This is important for this patient population because it will allow them to move more freely while also helping improve motor development throughout their treatment sessions with physical therapists.

Efficacy of Manual Therapy Including Neurodynamic Techniques for the Treatment of Carpal Tunnel Syndrome: A Randomized Controlled Trial

Author Names

Wolny T, Saulicz E, Linek P, Shacklock M, Myśliwiec A

Reviewer Name

Margaret Pohl, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: The purpose of this randomized trial was to compare the efficacy of manual therapy, including the use of neurodynamic techniques, with electrophysical modalities on patients with mild and moderate carpal tunnel syndrome (CTS). Methods: The study included 140 CTS patients who were randomly assigned to the manual therapy (MT) group, which included the use of neurodynamic techniques, functional massage, and carpal bone mobilizations techniques, or to the electrophysical modalities (EM) group, which included laser and ultrasound therapy. Nerve conduction, pain severity, symptom severity, and functional status measured by the Boston Carpal Tunnel Questionnaire were assessed before and after treatment. Therapy was conducted twice weekly and both groups received 20 therapy sessions. Results: A baseline assessment revealed group differences in sensory conduction of the median nerve (P < .01) but not in motor conduction (P = .82). Four weeks after the last treatment procedure, nerve conduction was examined again. In the MT group, median nerve sensory conduction velocity increased by 34% and motor conduction velocity by 6% (in both cases, P < .01). There was no change in median nerve sensory and motor conduction velocities in the EM. Distal motor latency was decreased (P < .01) in both groups. A baseline assessment revealed no group differences in pain severity, symptom severity, or functional status. Immediately after therapy, analysis of variance revealed group differences in pain severity (P < .01), with a reduction in pain in both groups (MT: 290%, P < .01; EM: 47%, P < .01). There were group differences in symptom severity (P < .01) and function (P < .01) on the Boston Carpal Tunnel Questionnaire. Both groups had an improvement in functional status (MT: 47%, P < .01; EM: 9%, P < .01) and a reduction in subjective CTS symptoms (MT: 67%, P < .01; EM: 15%, P < .01). Conclusion: Both therapies had a positive effect on nerve conduction, pain reduction, functional status, and subjective symptoms in individuals with CTS. However, the results regarding pain reduction, subjective symptoms, and functional status were better in the MT group. Keywords: Carpal Tunnel Syndrome; Manual Therapy; Physical Therapy.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Participants who were in the manual therapy group benefited more from therapy and saw more significant improvements than those in the electrophysical modalities group.

Key Finding #2

Both groups experiences a significant reduction in pain and increase in function, but the manual therapy group had a larger magnitude of pain reduction and function increase.

Key Finding #3

In comparison to other studies, this study looked at manual therapy performed by a physical therapist, rather than self manual therapy techniques. The study found that techniques performed by a PT were effective in decreasing pain and increasing function.

Please provide your summary of the paper

This study looked to compare the efficacy of manual therapy and neurodynamic techniques, with electrophysical modalities on patients with mild and moderate carpal tunnel syndrome (CTS). The study consisted of 140 patients with CTS who were randomly put into one of two groups, the manual therapy group (MT) or the electrophysical modalities group (EM). The MT treatment included the use of neurodynamic techniques, functional massage and carpal bone mobilizations while the EM group included laser and ultrasound therapy. Both groups received 20 therapy sessions in total. Overall, both therapies had a positive impact on nerve conduction, reduced pain, increased functional status and improved subjective symptoms of the patients and the MT therapy group had better results in pain reduction, subjective symptoms and functional abilities.

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 supports the idea that both manual therapy and electrophysical modalities can be effective in treatment of CTS, and neither increases pain or decreases function. It also supports the idea that while both are effective, manual therapy may be more effective in increasing functional abilities and decreasing pain related to CTS. This study is important to clinical practice as many other studies have not looked at manual therapy’s effect when performed by a physical therapist, but rather a self manual therapy technique. As this study is a large sample size and showed significant improvements when manual therapy was performed by a clinician, manual therapy should be considered as a treatment technique, by a PT, for individuals with CTS in practice.

Effects of Early Manual Therapy on Functional Outcomes After Volar Plating of Distal Radius Fractures: A Randomized Controlled Trial

Author Names

Tomruk, M; Gelecek, N; Basçi, O; Özkan, M.H

Reviewer Name

Abigail Reichow, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

We sought to investigate the effects of early manual therapy on functional outcomes in patients treated with volar plating of a distal radius fracture (DRF). This was a prospective, single-blinded, randomized controlled trial. Patients treated with volar plating of a DRF were randomly assigned to either Early Manual Therapy Group (EMTG, n = 19) or Standard Physiotherapy Group (SPG, n = 20). While SPG received standard physiotherapy, EMTG received standard physiotherapy plus Mulligan’s Mobilization with Movement technique two sessions a week, through 12 weeks. Function, pain intensity, range of motion, grip strength and the level of disability were assessed using the Patient Rated Wrist Evaluation (PRWE), Visual Analog Scale (VAS), goniometer, hand dynamometer and Disabilities of Arm, Shoulder and Hand (DASH) Questionnaire, respectively. Measurements were made at 3, 6, and 12 weeks postoperatively. Of the 54-screened patients, 39 met the inclusion criteria and were randomized. In total, 32 patients (EMTG, n = 15; SPG, n = 17) were analyzed. EMTG had significantly better DASH score and wrist flexion at 12 weeks, less pain and better PRWE total score, wrist extension, ulnar/radial deviation, supination and grip strength at all time points. Moreover, wrist flexion increased more with the addition of early manual therapy than standard physiotherapy alone (26.50 ± 13.19 versus 16.21 ± 16.06). The addition of early manual therapy to standard physiotherapy may contribute to better functional outcomes and be more effective in increasing wrist flexion in patients treated with volar plating of a DRF.

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Cannot Determine, Not Reported, or Not Applicable

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?

Cannot Determine, Not Reported, or Not Applicable

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?

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)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Is the review based on a focused question that is adequately formulated and described?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Key Finding #1

Implementing early manual therapy in addition to standard physical therapy interventions following volar plating produced better functional outcomes postoperatively when compared to standard physical therapy interventions as the sole treatment.

Key Finding #2

Patients who received early manual therapy combined with standard physical therapy interventions had significantly better DASH scores and wrist flexion range of motion 12-weeks post-operatively when compared to the group who received no manual therapy.

Key Finding #3

Patients who received early manual therapy combined with standard physical therapy interventions had lower pain, better self-reported wrist function, grip strength, and wrist extension, ulnar/radial deviation and supination range of motion at every check point when compared to the group who received no manual therapy.

Please provide your summary of the paper

This study was a randomized control trial that aimed to determine the efficacy of implementing early manual therapy in rehabilitation following volar plate surgery for distal radial fractures. 39 patients met the inclusion criteria and were split into two groups, early manual therapy (EMT, n=15) or standard physical therapy (SPT, n=17). The study was single-blinded. Subjects in the EMT group received standard physical therapy interventions with Mulligan’s Mobilization with Movement technique twice a week. Outcomes of wrist function (patient rated wrist evaluation), pain (visual analog scale), range of motion (goniometer), grip strength (hand dynamometer), and disability (Disabilities of Arm, Shoulder, and Hand Questionnaire) were assessed in both groups at 3-, 6-, and 12-weeks post op. There was no significant difference between the two groups at the start of the study with the exception of age (P=0.017). The study found that patients in the EMT group had significantly better disability scores and wrist flexion range of motion at the 12-week mark. Additionally, the EMT group had lower pain, better self-reported wrist function, grip strength, and wrist extension, ulnar/radial deviation and supination range of motion at every check point when compared to the SPT group who received no manual therapy.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The findings of this study are extremely clinically relevant in the outpatient orthopedic setting as distal radial fractures are among some of the most common fractures. Currently, volar plating as a method of open reduction internal fixation is the most frequent surgical treatment for this condition. Many patients experience higher levels of pain with range of motion following this procedure, delaying, and in some cases, limiting functional outcomes post-operatively. The Mulligans Mobilization with Movement technique is believed to help patients perform active range of motion with reduced pain as the therapist assists with proper positioning and tracking of the joint during movement. This study showed that utilizing this manual therapy technique in early rehabilitation of these patients was successful in improving pain and functional outcomes. This technique should therefore, be implemented in conjunction with standard physical therapy interventions when treating patients following volar plating for distal radius fractures.

Manual Therapy and Related Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis

Author Names

Du, J., Yuan, Q., Wang, XY., Qian, JH., An, J., Dai, Q., Yan, XY., Xu, B., Luo, J., & Wang, HZ.

Reviewer Name

Hope Reynolds, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: Systematic review and meta-analysis to assess the efficacy of Manual therapy and related interventions in the treatment of carpal tunnel syndrome (CTS) based on Boston carpal tunnel questionnaire. Design: Systematic review and meta-analysis. Subjects: Carpal tunnel syndrome. Interventions: Manual therapy and related interventions versus other therapies or manual therapy and related interventions plus other therapies versus other therapies. Outcomes measures: Boston carpal tunnel questionnaire. Results: A total of 6 studies were included, including 211 cases in the manual therapy group and 211 cases in the control group. The quality of the included articles was high, and the results of meta-analysis showed that manual therapy and related interventions were superior in terms of improving the Boston carpal tunnel questionnaire Symptom Severity score in patients with CTS (standardised mean difference [SMD] -1.13, 95% CI -1.40 to -0.87), were superior to control groups in terms of improving the Boston carpal tunnel questionnaire functional capacity scale in patients with CTS (SMD -1.01,95% CI -1.24 to -0.77). Conclusion: The results of this meta-analysis suggested that manual therapy and related interventions were better than control groups in treating CTS. Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS. Registration: The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; No. CRD 42020201389). Contribution of the Article: Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Key Finding #1

The results of this systematic review and meta-analysis support manual therapy and related interventions, including osteopathic manipulation, manual therapy, and massage techniques as effective treatments for CTS.

Key Finding #2

Manual therapy and associated interventions are superior to control groups, including laser, physical, surgical, and other treatment methods, in terms of improving the Symptom Severity score and functional capacity scale on the Boston carpal tunnel questionnaire in patients with CTS.

Please provide your summary of the paper

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome and includes symptoms such as numbness, tingling, pain, and weakness following the median nerve distribution distal to the carpal tunnel in the affected limb. Laser therapy, pharmacotherapy, therapeutic ultrasound, manipulation and splinting, and surgical treatment are among the current treatments for CTS. The purpose of this review was to assess the potential role of manual therapy in the management and treatment of CTS and its impacts on symptom severity and function in these patients. Results showed that manual therapy and related interventions were superior to control groups in terms of improving the Symptom Severity score and functional capacity scale on the Boston carpal tunnel questionnaire in patients with CTS. Therefore, manual therapy is supported as an effective and conservative treatment strategy for patients with CTS and is widely utilized as such. However, due to a lack of clinical evidence, there is no specific guidance for clinical practice of manual therapy to treat CTS. Therefore, more research is needed to determine the short-, medium-, and long-term effects of manual therapy on patients with CTS and specifically its effect for patients with varying levels of severity of CTS.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Manual therapy and its related interventions, including manipulations and massage techniques, are effective in treating CTS, decreasing symptom severity, and improving hand function in patients with CTS. Therefore, these techniques, are recommended as a conservative therapy option in the treatment of CTS. However, more research is needed to determine the short- and long-term effects of manual therapy on CTS patients and the effect of manual therapy on patients with different severities of CTS.

Adding Mobilisation with Movement to Exercise and Advice Hastens the Improvement in Range, Pain and Function After Non-Operative Cast Immobilisation for Distal Radius Fracture: A Multicentre, Randomised Trial

Author Names

Reid, S. A., Andersen, J. M., & Vicenzino, B.

Reviewer Name

Alli Shaw, SPT

Reviewer Affiliation(s)

Duke University DPT

Paper Abstract

Question: Does adding mobilisation with movement (MWM) to usual care (ie, exercises plus advice) improve outcomes after immobilisation for a distal radius fracture? Design: A prospective, multicentre, randomised, clinical trial with concealed allocation, blinding and intention-to-treat analysis. Participants: Sixty-seven adults (76% female, mean age 60 years) treated with casting after distal radius fracture. Intervention: The control group received exercises and advice. The experimental group received the same exercises and advice, plus supination and wrist extension MWM. Outcome measures: The primary outcome was forearm supi- nation at 4 weeks (immediately post-intervention). Secondary outcomes included wrist extension, flexion, pronation, grip strength, QuickDASH (Disabilities of Arm, Shoulder and Hand), Patient-Rated Wrist Evalua- tion (PRWE) and global rating of change. Follow-up time points were 4 and 12 weeks, with patient-rated measures at 26 and 52 weeks. Results: Compared with the control group, supination was greater in the experimental group by 12 deg (95% CI 5 to 20) at 4 weeks and 8 deg (95% CI 1 to 15) at 12 weeks. Various secondary outcomes were better in the experimental group at 4 weeks: extension (14 deg, 95% CI 7 to 20), flexion (9 deg, 95% CI 4 to 15), QuickDASH (211, 95% CI 218 to 23) and PRWE (213, 95% CI 223 to 24). Benefits were still evident at 12 weeks for supination, extension, flexion and QuickDASH. The experimental group were more likely to rate their global change as ‘improved’ (risk difference 22%, 95% CI 5 to 39). There were no clear benefits in any of the participant-rated measures at 26 and 52 weeks, and no adverse effects. Conclusion: Adding MWM to exercise and advice gives a faster and greater improvement in motion im- pairments for non-operative management of distal radius fracture. Registration: ACTRN12615001330538. [Reid SA, Andersen JM, Vicenzino B (2020) Adding mobilisation with movement to exercise and advice hastens the improvement in range, pain and function after non-operative cast immobilisation for distal radius fracture: a multicentre, randomised trial. Journal of Physiotherapy 66:105–112]

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

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

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?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

At week 4, the experimental group had on average 12 more degrees of supination compared to the control group. At week 12, the experimental group has on average 8 more degrees of supination compared to the control group.

Key Finding #2

At week 4 and 12, wrist flexion and extension range of motion were greater in experimental group compared to control groups.

Key Finding #3

Patient-reported outcome measures of the experimental group indicated improvement of all aspects of the PRWE and QUICKDash at week 4; however, this effect was no longer present by week 12.

Key Finding #4

Benefits from MWM were present at week 4 and 12; however, there was no statistical difference between outcomes of the experimental and control group at week 26 and 52.

Please provide your summary of the paper

Initial medical management of distal radius fractures involve immobilization of the wrist in a flexed, pronated, and ulnar deviated position for up to 6 weeks, resulting in stiffness and pain particularly with supination and extension. Limited evidence supports the use of joint mobilizations applied by the clinician. This study’s aim was to establish the efficacy of wrist extension and forearm supination mobilization with movement (MWM) techniques as part of a treatment plan for nonoperative management of distal radius fractures. A prospective, parallel, two-group randomized control trial was conducted with appropriate measures taken to ensure randomization and minimize bias. Appropriate exclusion criteria was incorporated. Baseline measurements of outcome measures (participant ratings of pain and disability, forearm and inter carpal supination range of motion, wrist flexion and extension range of motion, forearm pronation range of motion, grip strength, and a functional pouring task) were obtained, interventions were performed for 4 weeks, and outcomes were assessed at week 4, 12, 26, and 52. All participants performed range of motion exercises and were informed of other management strategies (i.e., controlling swelling, skin care, etc.). The experimental group received MWM techniques. The physiotherapist performed the technique on the patient during visits but also instructed patient on how to perform self-MWM technique. The researchers found that MWM techniques are an effective adjunct to exercise and education for management of nonsurgical distal radius fractures.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Patients can expect to reach the same functional level regardless of whether a MWM technique was incorporated into their treatment plan; however, these improvements were reached quicker when MWM techniques were utilized.

Effectiveness of Manual Therapy in Patients with Distal Radius Fracture: A Systematic Review and Meta-Analysis

Author Names

Gutiérrez-Espinoza, H., Araya-Quintanilla, F., Olguín-Huerta, C., Valenzuela-Fuenzalida, J., Gutiérrez-Monclus, R., Moncada-Ramírez, V.

Reviewer Name

Paula Stonehouse Salinas

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To determine the effectiveness of manual therapy (MT) for functional outcomes in patients with distal radius fracture (DRF). Methods: An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that included MT techniques with or without other therapeutic interventions in functional outcomes, such as wrist or upper limb function, pain, grip strength, and wrist range of motion in patients older than 18 years with DRF. Results: Eight clinical trials met the eligibility criteria; for the quantitative synthesis, six studies were included. For supervised physiotherapy plus joint mobilization versus home exercise program at 6 weeks follow-up, the mean difference (MD) for wrist flexion was 7.1 degrees (p = 0.20), and extension was 11.99 degrees (p = 0.16). For exercise program plus mobilization with movement versus exercise program at 12 weeks follow-up, the PRWE was −10.2 points (p = 0.02), the DASH was −9.86 points (p = 0.0001), and grip strength was 3.9 percent (p = 0.25). For conventional treatment plus manual lymph drainage versus conventional treatment, for edema the MD at 3–7 days was −14.58 ml (p = 0.03), at 17–21 days −17.96 ml (p = 0.009), at 33– 42 days −15.34 ml (p = 0.003), and at 63–68 days −13.97 ml (p = 0.002). Conclusion: There was very low to high evidence according to the GRADE rating. Adding mobilization with movement and manual lymphatic drainage showed statistically significant differences in wrist, upper limb function, and hand edema in patients with DRF.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Key Finding #1

Adding joint mobilization did not show clinical or statistically significant differences in wrist range of motion in patients with DRF.

Key Finding #2

Mobilization with movement showed statistically significant differences in wrist, upper limb function, and hand edema.

Please provide your summary of the paper

The purpose of this study was to determine the effectiveness of manual therapy (MT) for functional outcomes in patient with distal radius fracture (DRF). Eight studies were included in the systematic review with an overall population of 335 patients (174 in the MT group and 181 in the Control group). These were the following results. For supervised PT plus joint mobilization versus home exercise, there were no clinical or statistically significant differences in wrist ROM. For exercise program plus mobilization with movement versus exercise program there were statistically significant differences in wrist and upper limb function at 12 weeks. The mobilization forces were applied to the radiocarpal and ulnocarpal joints with manual glide of the carpal row during active wrist flexion and extension. Previous systematic reviews did not support the added use of joint mobilization after DRF and another one showed limited evidence, which shows it does not translate to an improvement for functional results. The authors discussed that the current use of systematic reviews is less than optimal for these studies due to the small number of studies published and the limited methodological quality of RCTs that have looked at joint mobilization techniques in DRF. For conventional treatment plus manual lymph drainage versus conventional treatment for edema, there was a statistically significant decrease in the short term.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

These findings are important when providing patients with potential treatment options for DRF, especially in the short-term. Clinicians should take an individualized patient approach to decide which treatment option is best for that patient, as the study looked at various techniques, each with multiple outcomes. If a patient has edema, it is possible to use manual lymphatic drainage to see significant decrease in the edema. If a clinician decides to use a manual therapy technique, it is important that they know the technique will be most effective when the mobilization is done with movement. There is limited research for this topic and some conflicting evidence, so clinicians should use their expert clinical judgement and skills to best serve their patients.

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