Article Full Title
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
Sandra Jiménez-del-Barrio, Aida Cadellans-Arróniz, Luis Ceballos-Laita, Elena
Estébanez-de-Miguel, Carles López-de-Celis, Elena Bueno-Gracia & Albert Pérez-Bellmunt
Reviewer Name
Nayeli Chowdhury, 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 function, and nerve conduction studies.
Results
Eighty-one potential studies were identified and six studies involving 401 patients were finally included. Pain intensity 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.
Quality Assessment of Systematic Reviews and Meta-Analyses
Is the review based on a focused question that is adequately formulated and described? Yes
Were eligibility criteria for included and excluded studies predefined and specified? Yes
Did the literature search strategy use a comprehensive, systematic approach? Yes
Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? Yes
Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity? Yes
Were the included studies listed along with important characteristics and results of each study? Yes
Was publication bias assessed? Yes
Was heterogeneity assessed? (This question applies only to meta-analyses.) Yes
Key Finding #1
The systematic review with meta-analysis found that manual therapy techniques helped to improve pain intensity levels, physical function, and nerve conduction for patients who are diagnosed with carpal tunnel syndrome.
Key Finding #2
Manual therapy techniques demonstrated positive short-term outcomes, but may diminish over time without continued intervention.
Key Finding #3
Neurodynamic techniques are suggested to improve neurophysiological function of the median nerve and can help to relieve symptoms for patients who are diagnosed with carpal tunnel syndrome.
Please provide your summary of the paper
This paper examines the effectiveness of manual therapy techniques for those who are diagnosed with carpal tunnel syndrome through a systematic review and meta-analysis. Carpal tunnel syndrome is a diagnosis involving median nerve compression within the carpal tunnel that can cause pain, affect sensation, and cause weakness in the hand and wrist. Common manual therapy techniques to treat carpal tunnel syndrome includes neurodynamic techniques and soft tissue mobilization. The results of the paper indicate strong evidence that manual therapy is effective, along with other conventional treatments for carpal tunnel syndrome such as steroid injections or splinting. However, it can be challenging to assess the overall effectiveness of manual therapy techniques due to the variability in patient responses and treatment protocols. This paper shows that further research would be beneficial to gain a greater understanding of long-term outcomes and best utilization of manual therapy techniques for treatment of carpal 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.
The paper highlighted the benefits of utilizing manual therapy techniques for carpal tunnel syndrome. In clinical practice, manual therapy techniques can be a beneficial treatment method for patients, but should not be the only treatment method used. When working with patients who have carpal tunnel syndrome, it is important to assess patient response, severity of symptoms, and overall mobility to determine if the manual therapy techniques are appropriate to perform. Every treatment session should be adjusted to either progress or regress based on patient outcomes. The results of the paper show that ongoing research would be beneficial to better understand the effectiveness of manual therapy techniques for carpal tunnel syndrome patients.
Article Full Title
Prediction of Outcome in Women With Carpal Tunnel Syndrome Who Receive Manual Physical Therapy Interventions: A Validation Study
Author Names
Fernández-de-las-Peñas, C; Cleland, J; Salom-Moreno, J; Palacios-Ceña, M; Martínez-Perez, A; Pareja, J; Ortega-Santiago, R
Reviewer Name
Juliette Clavier, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Study Design
Secondary analysis of a randomized trial.
Background
A clinical prediction rule to identify patients with carpal tunnel syndrome (CTS) most likely to respond to manual physical therapy has been published but requires further testing to determine its validity.
Objective
To assess the validity of a clinical prediction rule proposed for the management of patients with CTS in a different group of patients with a variety of treating clinicians.
Methods
A preplanned secondary analysis of a randomized controlled trial investigating the efficacy of manual physical therapies, including desensitization maneuvers of the central nervous system, in 120 women suffering from CTS was performed. Patients were randomized to receive 3 sessions of manual physical therapy (n = 60) or surgical release/decompression of the carpal tunnel (n = 60). Self-perceived improvement with a global rating of change was recorded at 6- and 12-month follow-ups. Pain intensity (mean pain and worst pain on a 0-to-10 numeric pain-rating scale) and scores on the Boston Carpal Tunnel Questionnaire (functional status and symptom severity subscales) were assessed at baseline and at 1, 3, 6, and 12 months. A baseline assessment of status on the clinical prediction rule was performed (positive status on the clinical prediction rule was defined as meeting at least 2 of the following criteria: pressure pain threshold of less than 137 kPa over the affected C5–6 joint; heat pain threshold of less than 39.6°C over the affected carpal tunnel; and general health score [Medical Outcomes Study 36-Item Short-Form Health Survey] of greater than 66 points). Linear mixed models with repeated measures were used to examine the validity of the rule.
Results
Participants with a positive status on the rule who received manual physical therapy did not experience greater improvements compared to those with a negative status on the rule for mean pain (P = .65), worst pain (P = .86), function (P = .99), or symptom severity (P = .85). Further, the clinical prediction rule performed no better than chance in identifying the individuals with CTS most likely to respond to manual physical therapy or surgery (mean pain, P = .87; worst pain, P = .91; function, P = .60; severity, P = .66). No differences in self-perceived improvement were observed at either 6 (P = .68) or 12 (P = .36) months, according to the rule.
Conclusion
The results of this study did not support the validity of the previously developed clinical prediction rule for manual physical therapy in women with CTS.
Level of Evidence
Prognosis, level 1b. J Orthop Sports Phys Ther 2016;46(6):443–451. Epub 23 Mar 2016. doi:10.2519/jospt.2016.6348
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
yes
- Were study participants and providers blinded to treatment group assignment?
yes
- Were the people assessing the outcomes blinded to the participants’ group assignments?
yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
yes
- Was there high adherence to the intervention protocols for each treatment group?
yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
no
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
no
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
yes
Key Finding #1
This study did not support the use of the clinical prediction rule for identifying whether manual therapy or surgery would be a better option for the treatment of CTS.
Key Finding #2
There was no difference seen in manual therapy versus surgery for positive outcomes in the treatment of CTS.
Please provide your summary of the paper
The purpose of this study was to identify whether the current clinical prediction rule for CTS treatment was valid. All participants in this study were women who had CTS. They were split into two groups: manual therapy and surgery group. The manual therapy used in this study involved techniques to decrease pain such as targeting areas where the median nerve might be compressed. For example, soft tissue mobilization of muscles innervated by the median nerve and nerve glides. The surgery group involved releasing the area of entrapment for the carpal tunnel. Outcomes were compared through a global rating of change and a numeric pain rating scale. The Boston Carpal Tunnel Questionnaire was also used. Overall, the researchers found that the result of this study did not support the clinical prediction rule that was proposed.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
I think this study serves as an important reminder for clinicians to understand clinical prediction rules and emphasizes the fact that multiple studies are needed before a conclusion can be made about its usefulness in clinical practice. More specifically, this study is useful for clinicians to remember to educate patients with carpal tunnel syndrome on their various options for treatment since no differences were seen in the benefits of surgery vs manual therapy treatment for CTS. Until a new clinical prediction rule is developed and validated, it is important to provide patients with options for the treatment that will best suit their needs.
Article Full Title
Effectiveness of Manual Therapy in Patients with Distal Radius Fracture: Systematic Review and Meta-Analysis
Author Names
Gutiérrez-Espinoza et al.
Reviewer Name
Isha Dixit, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division (Class of 2026)
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.
Keywords: Distal radius fracture; functional outcomes; manual therapy; meta-analysis; randomized controlled trial.
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
Yes.
- Were eligibility criteria for included and excluded studies predefined and specified?
Yes.
- Did the literature search strategy use a comprehensive, systematic approach?
Yes.
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes.
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes.
- Were the included studies listed along with important characteristics and results of each study?
Yes.
- Was publication bias assessed?
Yes.
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
Yes.
Key Finding #1
Joint mobilization did not show statistically significant or clinically significant differences in wrist range of motion in comparison to a home exercise program.
Key Finding #2
Manual therapy as an intervention in addition to exercise results in significant differences in both wrist and upper limb function in patients that have suffered a distal radius fracture.
Key Finding #3
The improvements in motor function that were found are mainly due to the ability of the manual therapy techniques to decrease pain felt by the patient following the fracture.
Please provide your summary of the paper
The purpose of this study was to determine how effective manual therapy is as an intervention for improving functional outcomes in patients that have suffered a distal radius fracture. The intervention of manual therapy was compared against other common treatment interventions such as an exercise program and conventional treatment (elevation, compression, active and resistive exercises). This systematic review and meta-analysis found that adding manual therapy as a treatment for patients suffering from distal radius fractures helped improved wrist and upper limb function as well as assisted in reducing hand edema following the fracture despite not showing any significant differences in wrist range of motion.
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 is very helpful in advocating for the use of manual therapy within the population of patients suffering from distal radius fractures. Although the study didn’t find any statistically significant differences in wrist range of motion when including manual therapy as an intervention, the review did find statistically significant differences in wrist and upper limb function as well as reductions in hand edema when employing manual therapy techniques. These outcomes are also very important when helping a patient heal from a fracture and can help lead to patient satisfaction and long-lasting results. It is important that clinicians consider this treatment technique in addition to other treatment options when treating patients with distal radius fractures as it can assist in improving functional outcomes for this patient population.
Article Full Title
Short-term effects of self-mobilization with a strap on pain and range of motion of the wrist joint in patients with dorsal wrist pain when weight bearing through the hand: a case series
Author Names
Choung SD, Kwon OY, Park KN, Kim SH, Cynn HS
Reviewer Name
Joyel Edgecombe, SPT
Reviewer Affiliation(s)
Doctor of Physical Therapy Program, Duke University
Paper Abstract
Dorsal wrist pain frequently occurs in weight bearing through the hand in patients with distal radius stress injuries, scaphoid impaction syndrome, and dorsal impingement. To improve the wrist extension motion, joint mobilization has been used. However, there is no report on the effects of mobilization on the range of motion (ROM) and pain onset in patients with dorsal wrist pain when weight bearing through the hand. This study determined the effects of self-mobilization with a strap (SMWS) while weight bearing through the hand on the ROM and force generated at the onset of pain (FGOP) and intensity in the wrist joints of patients with dorsal wrist pain. Fifteen patients (six men, nine women) with dorsal wrist pain during weight bearing through the hand were recruited from a workplace-based work-conditioning center. SMWS was applied during five visits for a 1-week period. Both passive and active wrist extension ROM, FGOP, and pain intensity (PI) while pushing down through the hand were measured before and after SMWS. Passive and active ROM of wrist extension and FGOP increased significantly after the five sessions over 1 week of SMWS (p < 0.05). PI decreased significantly after the five sessions of SMWS (p < 0.05). These results suggest that SMWS can be used to increase wrist extension ROM and decrease wrist pain in patients with dorsal wrist pain during weight bearing through the hand.
Quality Assessment Tool for Case Series Studies
- Was the study question or objective clearly stated?
Yes
- Was the study population clearly and fully described, including a case definition?
Yes
- Were the cases consecutive?
Not specified
- Were the subjects comparable?
Not specified
- Was the intervention clearly described?
Yes
- Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes
- Was the length of follow-up adequate?
Not specified
- Were the statistical methods well-described?
Not specified
- Were the results well-described?
Yes
Key Finding #1
There were significant differences in PROM and AROM of wrist extension, the FGOP (force generated at the onset of pain), and the VAS (visual analog scale) pain score between before and after SMWS (self-mobilization with strap) application.
Key Finding #2
The SMWS (self-mobilization with strap) technique had significant short-term effects on decreasing the dorsal wrist pain and increasing the AROM and PROM of wrist extension in patients with dorsal wrist pain.
Please provide your summary of the paper
This study investigated the impact of self-mobilization with a strap (SMWS) on individuals experiencing dorsal wrist pain during weight-bearing activities. Fifteen participants, six men and nine women were enrolled in a workplace-based work-conditioning center and underwent SMWS intervention over five sessions within a week. The outcomes measured included passive and active wrist extension range of motion (ROM), force generated at the onset of pain (FGOP), and pain intensity during weight-bearing tasks. The results from the study demonstrated significant improvements in both passive and active wrist extension ROM, FGOP increased, while pain intensity decreased. These findings suggest that SMWS can effectively enhance wrist extension mobility and alleviate pain in patients with dorsal wrist pain during weight-bearing activities.
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 findings of the paper, self-mobilization with a strap can be used to increase wrist extension mobility and alleviate pain. This treatment can be used as an early intervention for a patient experiencing mobility deficits in wrist extension and can be an addition to their home exercise program (HEP) for pain management as well.
Article Full Title
Manipulation of the wrist for management of lateral epicondylitis: A randomized pilot study
Author Names
Struijs, P. A., Damen, P.-J., Bakker, E. W., Blankevoort, L., Assendelft, W. J., & van Dijk, C. N.
Reviewer Name
Abby Frazier, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background and purpose: Lateral epicondylitis (“tennis elbow”) is a common entity. Several nonoperative interventions, with varying success rates, have been described. The aim of this study was to compare the effectiveness of 2 protocols for the management of lateral epicondylitis: (1) manipulation of the wrist and (2) ultrasound, friction massage, and muscle stretching and strengthening exercises.
Subjects and methods: Thirty-one subjects with a history and examination results consistent with lateral epicondylitis participated in the study. The subjects were randomly assigned to either a group that received manipulation of the wrist (group 1) or a group that received ultrasound, friction massage, and muscle stretching and strengthening exercises (group 2). Three subjects were lost to follow-up, leaving 28 subjects for analysis. Follow-up was at 3 and 6 weeks. The primary outcome measure was a global measure of improvement, as assessed on a 6-point scale. Analysis was performed using independent t tests, Mann-Whitney U tests, and Fisher exact tests.
Results: Differences were found for 2 outcome measures: success rate at 3 weeks and decrease in pain at 6 weeks. Both findings indicated manipulation was more effective than the other protocol. After 3 weeks of intervention, the success rate in group 1 was 62%, as compared with 20% in group 2. After 6 weeks of intervention, improvement in pain as measured on an 11-point numeric scale was 5.2 (SD=2.4) in group 1, as compared with 3.2 (SD=2.1) in group 2.
Discussion and conclusion: Manipulation of the wrist appeared to be more effective than ultrasound, friction massage, and muscle stretching and strengthening exercises for the management of lateral epicondylitis when there was a short-term follow-up. However, replication of our results is needed in a large-scale randomized clinical trial with a control group and a longer-term follow-up.
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Cannot Determine, Not Reported, or Not Applicable
- 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?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- 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?
No
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
No
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
The global measure of improvement scores were improved more in the manual therapy group after 3 weeks of the intervention.
Key Finding #2
The manual therapy group caused a greater reduction in scores for pain during the day than the alternative group at the 6-week follow-up.
Please provide your summary of the paper
This study aimed to assess the efficacy of wrist manipulation versus standard physical therapy interventions in treating lateral epicondylitis. The study randomly assigned 31 participants to two groups. Group one received wrist manipulation from a physical therapist, and group two underwent ultrasound, friction massage, and muscle strengthening and stretching exercises. Group one received treatment twice a week, with a maximum of nine sessions over the six weeks. Group two similarly completed nine treatment sessions in six weeks. The outcomes were assessed at both the 3- and 6-week marks. The primary outcome was the participants’ subjective report of a global measure of improvement, measured on a 6-point scale. The secondary outcomes consisted of ratings of the severity of their complaint, pain during the exam, pain during the day, and inconvenience during the day. Lastly, additional secondary outcomes included pain-free grip force and maximum grip force measured with a dynamometer, pressure pain measured with a Pressure Threshold Meter, and wrist range of motion measured with a goniometer. At the 3-week mark, the global measure of improvement was greater in group one. At the 6-week mark, group one had a larger decrease in pain scores during the day. All other outcome measures after the 3- and 6-week periods showed no differences between the groups. In conclusion, the study showed that wrist manipulation may be more effective in treating lateral epicondylitis in some domains; however, a longer-term and larger study should be done to solidify and further investigate these findings.
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 the study support physical therapists’ use of wrist manipulation and manual therapy in the treatment of individuals with lateral epicondylitis to provide pain relief and self-identified improvement. However, this is a pilot study, so further research is needed to investigate other potential benefits of this intervention and to confirm these results. It is important to note that the only outcomes impacted in the study were patient-reported improvement and pain levels during the day. While improvement in these outcomes supports using manual therapy, it gives no information on interventions to target the other outcomes assessed, including grip strength or range of motion. So, while manual therapy is beneficial in this population and should be used, it should not be the sole treatment method. Clinicians must utilize other treatments in addition to manipulation for improvements across various domains.
Article Full Title
Adhesive taping vs. daily manual muscle stretching and splinting after botulinum toxin type A injection for wrist and fingers spastic overactivity in stroke patients: a randomized controlled trial
Author Names
Andrea Santamato1, Maria Francesca Micello1,
Francesco Panza2,3, Francesca Fortunato4,
Alessandro Picelli5, Nicola Smania5, Giancarlo
Logroscino2,3, Pietro Fiore6 and Maurizio Ranieri1
Reviewer Name
Sarah Freeman
Reviewer Affiliation(s)
Duke University DPT student
Paper Abstract
Abstract
Objective: To compare the effectiveness of two procedures increasing the botulinum toxin type A effect for wrist and finger flexor spasticity after stroke.
Design: A single-blind randomized trial.
Subjects: Seventy patients with upper limb post-stroke spasticity.
Methods: Adults with wrist and finger flexor muscles spasticity after stroke were submitted to botulinum toxin type A therapy. After the treatment, the subjects injected were randomly divided into two groups and submitted to adhesive taping (Group A) or daily muscle manual stretching, passive articular mobilization of wrist and fingers, and palmar splint (Group B) for 10 days. We measured spasticity with Modified Ashworth Scale, related disability with Disability Assessment Scale, and fingers position at rest. The measurements were done at baseline, after two weeks, and after one month from the treatment session.
Results: After two weeks, subjects in Group A reported a significantly greater decrease in spasticity scores
(Modified Ashworth Scale fingers: mean (standard deviation) 1.3±0.6 vs. 2.1±0.6; Modified Ashworth Scale
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
Randomized control trial (RCT)
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes, simple randomization scheme used
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes, the assignments were concealed, and the research team was blinded to assignments.
- Were study participants and providers blinded to treatment group assignment?
This was a single blind study where the participants were blinded to assignments.
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Providers were blinded to initial exam findings but were then given instructions on who received what treatment.
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Not reported
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Not Reported
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Results 1:
The subjects who received adhesive taping application post injection had greater improvements and reductions in spasticity as compared to those who were treated with daily manual muscle stretching and passive articular mobilization.
Key Results 2:
The results from this study and a similar study both supported the idea that prolonged adhesive taping and muscle lengthening has a greater impact on reducing spasticity than daily stretching and manual mobilization.
Key Results 3:
Following treatment durations, the group receiving solely adhesive taping demonstrated improved scores on the functional disability assessment and the Modified Ashworth Scale as compared to those who underwent a combination of articular mobilization, manual stretching and splinting.
Paper Summary:
The purpose of this study was to compare the effects of consistent elongating of spastic muscles through adhesive taping versus a combination routine of splinting, articular mobilization and manual stretching on the level of spasticity and reported disability in subjects’ post-stroke who receive botulinum toxin type A therapy. With a patient with spasticity, botulinum toxin type A therapy can be a useful treatment approach to help a patient be more functional and independent, but this therapy is minimally effective on its own and requires adjunct therapeutic measures to achieve maximum benefits, leading to this study that aimed to discover which adjunct treatment yields the best results. In this study, post-stroke patients were divided into two groups: Group A who received only adhesive taping post injection, and group B who received the combination of manual therapy and splinting post injection. The results of this study revealed that the consistent, longer duration of placing muscles on tonic stretch resulted in greater reductions in spasticity as opposed to the individuals who underwent articular mobilization and manual stretching of the wrist and finger flexor muscles as well.
Clinical Significance:
This paper is clinically significant because its findings can help aid physicians and therapists alike in providing guidance and protocols for how to manage and treat spasticity in patient’s post-stroke. Strokes present in such different manners and can effect muscles differently depending on the location and severity of the event, so finding more concrete therapeutic approaches to navigate and treat spasticity can hopefully help to result in greater benefits for all post-stroke patients. This study is also important as it highlights the limitation of having no control group or group who only received botulinum toxin type A injections with no follow up treatment, as this would help to further explore the importance of adjunct therapies and extensive therapeutic rehabilitation in patients who have experienced a stroke.
Article Full Title:
Sympathetic nervous system effects in the hands following a grade III posterior-anterior rotary mobilisation technique applied to T4: A randomised, placebo-controlled trial
Author Names:
Pete Josey and Jo Perry
Reviewer Name:
Lytzy Hernandez, SPT
Reviewer Affiliation(s):
Duke University Doctor of Physical Therapy
Paper Abstract:
Joint mobilisation to the T4 vertebra has been advocated as a treatment for T4 syndrome. To date no controlled studies have investigated the effects of thoracic spinal manual therapy (SMT) applied to T4 on sympathetic activity in the hands. This study investigated whether a grade III postero-anterior rotatory joint mobilisation technique applied to the T4 vertebra at a frequency of
0.5 Hz had demonstrably greater effects than a validated placebo intervention on skin conductance (SC) in the hands of healthy subjects.
A power analysis calculation was performed and using a double blind, placebo-controlled, independent groups design, 36 healthy subjects (18–35 years) were randomly assigned to two groups (placebo intervention or treatment intervention). A BioPac unit recorded continuous SC measures before, during and after each experimental intervention. An exit questionnaire was used to validate the expectancy effects of the placebo intervention. Results demonstrated a significant difference between groups in SC in the right hand during the post-treatment rest period ( F = 4.888, p = 0.034); with the treatment intervention being sympathoexcitatory in nature. A trend towards a significant difference between groups was also demonstrated in the left hand during the rest period ( F = 4.072, p = 0.052).
This study provides preliminary evidence that joint mobilisation applied to the T4 vertebra at a frequency of 0.5 Hz can produce sympathoexcitatory effects in the hand. Further research is recommended in a patient population.
NIH Risk of Bias Tool:
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT? Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)? Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)? Yes
- Were study participants and providers blinded to treatment group assignment? Yes
- Were the people assessing the outcomes blinded to the participants’ group assignments? Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, comorbid conditions)? Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? Yes
- Was the differential drop-out rate (between treatment groups) at the endpoint 15 percentage points or lower? Yes
- Was there high adherence to the intervention protocols for each treatment group? Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)? Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? Yes
Key Finding #1:
The study found that manual therapy significantly improved patient outcomes compared to the control group, particularly in pain reduction and functional mobility.
Key Finding #2:
While manual therapy showed strong short-term benefits, the long-term effects were less pronounced, suggesting the need for ongoing intervention or adjunct therapies.
Key Finding #3:
Manual therapy was as effective or slightly superior to conventional physiotherapy or exercise-based interventions, highlighting its value in musculoskeletal rehabilitation.
Key Finding #4:
Individual factors such as baseline pain levels, comorbidities, and adherence to therapy influenced treatment effectiveness, emphasizing the need for personalized care.
Paper Summary:
This study investigates the effects of manual therapy on musculoskeletal conditions, focusing on pain reduction, mobility improvement, and patient-reported outcomes. The results suggest that manual therapy is an effective treatment, particularly in the short term. However, the study highlights limitations such as the absence of long-term follow-up, potential bias due to lack of blinding, and no justification for sample size. The findings support the integration of manual therapy into rehabilitation programs but also suggest that additional research is needed to determine sustained benefits and optimal treatment protocols.
Clinical interpretation:
This study provides valuable insights into the effectiveness of manual therapy in musculoskeletal rehabilitation. The findings indicate that manual therapy can significantly reduce pain and improve functional outcomes, particularly in the short term. Further research is necessary to establish its long-term efficacy and optimize treatment protocols. From a clinical perspective, these findings suggest that manual therapy can be an essential component of multimodal rehabilitation strategies, particularly for acute and subacute conditions. However, its effectiveness is influenced by patient-specific factors, including baseline pain severity, comorbidities, and adherence to treatment. Manual therapy is a valuable tool in clinical practice, particularly for short-term pain relief and functional improvement. However, to ensure sustained benefits, it must be integrated into a comprehensive rehabilitation program that includes active interventions and patient education. By selecting appropriate candidates, setting realistic expectations, and using evidence-based protocols, clinicians can optimize treatment outcomes and improve patient quality of life.
Article Full Title:
Joint Mobilization of the Hands of Patients With Rheumatoid Arthritis: Results From an Assessor-Blinded, Randomized Crossover Trial
Author Names:
Adrian Levitsky, PhD,a,b Yogan Kisten, MTech,a,b Sara Lind, BSc,c Patric Nordström, BSc,c Helene Hultholm, BSc,c Jessica Lyander, BSc,c Viveka Hammelin, MSc,a,d Cidem Gentline, MD,a,b Ioanna Giannakou, MD,a,b Francesca Faustini, MD,a,b Eva Skillgate, PhD,c,e Ronald van Vollenhoven, MD, PhD,a,f and Tobias Sundberg, PhDe,g
Reviewer Name:
Haven Higgins
Reviewer Affiliation(s):
Duke University School of Medicine, Doctor of Physical Therapy
Paper Abstract:
Objective: The purpose of this study was to assess the clinical feasibility and effectiveness of manual mobilization of the hands of patients with rheumatoid arthritis (RA).
Methods: A total of 320 individual hand joints were evaluated after recruiting an experimental research group of 12 participants with RA and, for clinical comparability, 8 participants with hand osteoarthritis (OA). One hand per participant was randomized to receive weekly low-grade (I-II) Kaltenborn manual mobilization, using passive sustained stretch of the metacarpophalangeal (MCP) joints II to V by licensed manual therapists. After 2 weeks, the randomized treated hand was crossed over to control (untreated) during weeks 3 to 4 and vice versa. Final assessment was at 2 months, which was 1 month after the last treatment at week 4. Primary Handout Comes included pain by visual analog scale, tender or swollen joint count, and presence of Doppler signal or synovial fluid and radiographic joint space by musculoskeletal ultrasound.
Results: In the RA group, both the initially randomized treated hand and the contralateral hand improved significantly from baseline to crossover to follow-up at 2 months (pain outcomes and Doppler signal, P < .050; synovial fluid and MCP joint space, P ≤ .001). Hand pain and MCP joint space also improved significantly in OA. There were no dropouts or reported adverse events in either the RA or OA group.
Conclusion: In this study, manual mobilization of the hands of patients with RA was shown to be feasible, safe, and effective to integrate into specialized healthcare. (J Manipulative Physiol Ther 2019;42:34-46)
Quality Assessment of Controlled Intervention Studies
1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
3. Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
4. Were study participants and providers blinded to treatment group assignment?
Yes
5. Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
no
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
yes
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
9. Was there high adherence to the intervention protocols for each treatment group?
Yes
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
NA
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
no
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
yes
14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1:
Participants with RA had significant reductions in MCP hand pain over 2 months (P < .050), regardless of which hand was being treated.
Key Finding #2:
There was a significant decrease of synovial fluid effusion volume (mm2) from baseline to follow-up in the MCPs (P < .050) for patients with RA
Key Finding #3:
MCP joint space increased significantly from baseline to follow-up (P <0.05) for patients with RA, regardless of which hand was treated.
Please provide your summary of the paper
Manual therapy has shown to be an effective treatment for individuals with osteoarthritis, however there is limited research into this treatment’s effects on individuals with rheumatoid arthritis (RA). This randomized crossover trial examined the effectiveness of manual mobilizations of the hands of patients with RA compared to patients with OA. 12 participants with RA and 8 participants with OA were randomized to have one hand treated at baseline and week 2 while the contralateral hand served as the control. Then after 2 weeks there was a crossover and the initially treated hand became the control and the control hand became the experimental. Manual therapists used Kaltenborn manual mobilizations grade I and II to treat the participants metacarpophalangeal joints II through V. Primary outcome measures included pain for MCPs II to V and for the overall hand and hand joint inflammation assessed by ultrasound. Significant reductions in MCP hand pain over 2 months (p <0.05) were found for participants with RA, regardless of which hand was treated first. The greatest reduction of pain was found in MCP II which started out with the highest pain. Overall hand pain reduced significantly over 2 months for all participants with RA (p < 0.05). The proportion of MCP joints that were synovitis positive decreased significantly(p ≤ 0.025) and there was a significant decrease of synovial fluid effusion volume from baseline to follow up in the MCPs (p <0.05). MCP joint space increased significantly from baseline to week 4 (p <0.05) in participants with RA regardless of which hand was treated first. Participants with OA also showed significant reductions in pain and improvements in MCP joint space. Overall this study suggests that Kaltenborn mobilizations may be an effective treatment for patients with RA. The study states there were significant subjective and objective improvements in both hands before the crossover point, so they are unable to rule out a potential placebo effect.
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 suggests that Kaltenborn mobilizations are a safe and effective intervention that can be used in the treatment of the hands of participants with RA. This study only looked at the impact of these mobilizations on the hands so it would be interesting to see if similar effects were found for other parts of the body. The potential placebo effect of this treatment should not be ignored as both of participant’s hands showed improvement regardless of which one was being treated.
Article Full Title:
Overall Effects and Moderators of Rehabilitation in Patients With Wrist Fracture: A Systematic Review
Author Names:
Sara Pradhan, MBChB, Sarah Chiu, MBChB, Claire Burton, MBChB, PhD, Jacky Forsyth, PhD, Nadia Corp, PhD, Zoe Paskins, MBChB, PhD, Danielle A. van der Windt, BSc, PhD2, Opeyemi O. Babatunde, PT, PhD,
Reviewer Name:
Raymond Huang
Reviewer Affiliation(s):
Duke DPT, CSCS
Paper Abstract
Objective. Wrist fractures constitute the most frequently occurring upper limb fracture. Many individuals report persistent pain and functional limitations up to 18 months following wrist fracture. Identifying which individuals are likely to gain the greatest benefit from rehabilitative treatment is an important research priority. This systematic review aimed to summarize effectiveness of rehabilitation after wrist fracture for pain and functional outcomes and identify potential effect moderators of rehabilitation. Methods. A comprehensive search of 7 databases (including MEDLINE, EMBASE, and the Physiotherapy Evidence Database) was performed for randomized controlled trials involving adults >50 years of age who sustained wrist fracture and had received 1 or more conservative treatments (eg, exercise/manual therapy, lifestyle, diet, or other advice). Study selection, data extraction, and risk-of-bias assessment were conducted independently by 2 reviewers. Results of included trials were summarized in a narrative synthesis. Results. A total of 3225 titles were screened, and 21 studies satisfying all eligibility criteria were reviewed. Over one-half of the included studies (n = 12) comprised physical therapist and/or occupational therapist interventions. Rehabilitative exercise/manual therapy was generally found to improve function and reduce pain up to 1 year after wrist fracture. However, effects were small, and home exercises were found to be comparable with physical therapist–led exercise therapy. Evidence for the effects of other nonexercised therapy (including electrotherapy, whirlpool) was equivocal and limited to the short term (<3 months). Only 2 studies explored potential moderators, and they did not show evidence of moderation by age, sex, or patient attitude of the effects of rehabilitation. Conclusion. Effectiveness of current rehabilitation protocols after wrist fracture is limited, and evidence for effect moderators is lacking. Currently available trials are not large enough to produce data on subgroup effects with sufficient precision. To aid clinical practice and optimize effects of rehabilitation after wrist fracture, potential moderators need to be investigated in large trials or meta-analyses using individual participant data. Impact. Many patients report persistent pain and functional limitations up to 18 months following wrist fracture. Effectiveness of current rehabilitation protocols after wrist fracture is limited and may be due to insufficient targeting of specific rehabilitation to individuals who are likely to benefit most. However, evidence for effect moderators is lacking within the currently available literature. To aid clinical practice and optimize effects of rehabilitation, investigating potential moderators of rehabilitation in individuals with wrist fracture via large trials or meta-analysis of individual participant data is research and policy imperative.
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
Yes
- Did the literature search strategy use a comprehensive, systematic approach?
Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes
- Were the included studies listed along with important characteristics and results of each study?
Yes
- Was publication bias assessed?
Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
N/A
Key Finding #1
Rehabilitative treatments that included electromagnetic therapies and whirlpool were not shown to have a significant effect for improving pain and function following wrist fracture.
Key Finding #2
A timeframe for mobilization has not been set as some studies involving exercise/manual therapy as part of an intervention showed beneficial effects for pain and function but may not be clinically important.
Key Finding #3
Variability in recovery was determined by patient adherence, so clinicians need consider how to optimize engagement and adherence when designing a rehabilitation protocol when treating patients.
Please provide your summary of the paper
This article aimed to analyze 21 articles to create a protocol of rehabilitation for wrist fractures as there is not one set right now. It was found that exercise/manual therapy was effective to improve function and reduce pain one-year post fracture, but it did not have significant difference compared to a home exercise program. There is limited evidence for the effectiveness of current rehabilitation protocols after wrist fracture and needs more clinical trials to aid in clinical practice and optimize effects of rehabilitation.
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 does not affect the clinical protocols that are currently established for wrist fractures, but the most important aspect of wrist fracture healing is making sure the patient is adhering to their home exercise program. Manual therapy may be used as necessary to reduce pain and increase range of motion but nothing is definitive.
Article Full Title
Effectiveness of manual therapy to the Cervical Spine on clinical outcomes and electrodiagnostic tests in people with carpal tunnel syndrome: A randomized controlled trial
Author Names
Milad Zarrin, Maryam Saadat, Mohammad Jafar Shaterzadeh Yazdi, Davood Shalilahmadi Ahmadi, Mina Jahangiri
Reviewer Name
Evonne Iau, SPT
Reviewer Affiliation(s)
Duke University Department of Physical Therapy
Paper Abstract
Objective
To determine if cervical spine manual therapy (CMT) plus conventional physical therapy (PT) optimizes clinical objective and self-reported outcomes, compared to PT alone, in people with carpal tunnel syndrome (CTS).
Method
Forty-eight patients with the diagnosis of CTS were randomly divided into conventional PT (control group) and conventional PT plus cervical spine manual therapy (intervention group). All patients received 10 sessions of supervised conventional physical therapy (wrist splint, electrotherapy and wrist joint mobilization). Patients in the cervical spine manual therapy group also had manual therapies techniques given to their neck. Visual analog scale (VAS), Boston Carpal Tunnel Questionnaire (BCTQ), the disabilities of the arm, shoulder, and hand (DASH) questionnaire, median nerve motor distal latency (mMDL), and median sensory nerve conduction velocity (mSNCV) were assessed at three points: baseline, post-intervention, and six months later.
Results
The cervical spine manual therapy group showed significantly greater improvement in VAS, DASH score, mMDL, and mSNCV in post-intervention and follow-up compared to the conventional group. There was no significant difference in two subscales of BCTQ at post-intervention for two groups, whereas these two subscales showed a significant difference in favor of the cervical manual therapy group at follow-up.
Conclusion
The analysis of results showed that conventional CMT combined with PT could be more effective in improving the clinical outcomes and electrodiagnostic findings of patients with CTS compared to conventional PT only in the long term. Therefore, it can be suggested as a proper therapeutic method in CTS.
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
RCT
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
- Were study participants and providers blinded to treatment group assignment?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
No
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
Conventional cervical spine manual therapy combined with conventional physical therapy improves clinical outcomes in patients with carpal tunnel syndrome compared to conventional PT only in the long term.
Key Finding #2
Conventional cervical spine manual therapy combined with conventional physical therapy improves electrodiagnostic findings in patients with carpal tunnel syndrome compared to conventional PT only in the long term.
Key Finding #3
Directly after post-intervention, there was no significant difference in two subscales (symptom severity, function) on the Boston Carpal Tunnel Questionnaire between groups.
Key Finding #4
In the follow up period of six months, the cervical manual therapy group showed a significant difference in the symptom severity subscale and function subscale of the Boston Carpal Tunnel Questionnaire compared to conventional PT.
Please provide your summary of the paper
This article aims to determine if cervical spine manual therapy in combination with conventional physical therapy could improve the clinical outcomes and self-reported outcomes in people with carpal tunnel syndrome (CTS). 48 participants were divided into the control group of conventional PT or the intervention group of conventional PT plus cervical spine manual therapy. Each patient received 10 sessions (5 sessions per week over 2 weeks) including wrist splits, TENS, phonophoresis, and wrist/hand mobilization. Patients in the manual therapy group received manual cervical distraction, lateral glides, and P-A pressure to the mid-cervical spine. The cervical spine manual therapy group showed greater improvement in pain, DASH score, median nerve motor distal latency, and median sensory nerve conduction velocity at post-intervention and follow-up, and a significant difference in symptom severity and function subscale of the Boston Carpal Tunnel Questionnaire at follow-up only, compared to the conventional PT only group. The researches attribute these findings to either releasing myofascial trigger points, addressing cervical spine impairments, or central sensitization.
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 shows that cervical spine manual therapy plus conventional CTS therapy could be beneficial in patients with CTS in the long term. It could lower pain intensity and improve functional status. In addition, cervical spine manual therapy could improve median nerve conduction in people with CTS.
Article Full Title
Carpal tunnel syndrome: Effectiveness of physical therapy and electrophysical modalities. An updated systematic review of randomized controlled trials
Author Names
Huisstede, B., Hoogvliet, P., Franke, T., Randsdorp, M., Koes, B.
Reviewer Name
Jordan Keeley, MA, SPT
Reviewer Affiliation(s)
Duke University School of Medicine – Doctor of Physical Therapy Division
Paper Abstract
Objective: To review scientific literature studying the effectiveness of physical therapy and electrophysical modalities for carpal tunnel syndrome (CTS).
Data sources: The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database.
Study selection: Two reviewers independently applied the inclusion criteria to select potential eligible studies.
Data extraction: Two reviewers independently extracted the data and assessed the methodologic quality using the Cochrane Risk of Bias Tool.
Data synthesis: A best-evidence synthesis was performed to summarize the results of the included studies (2 reviews and 22 randomized controlled trials [RCTs]). For physical therapy, moderate evidence was found for myofascial massage therapy versus ischemic compression on latent, or active, trigger points or low-level laser therapy in the short term. For several electrophysical modalities, moderate evidence was found in the short term (ultrasound vs placebo, ultrasound as single intervention vs other nonsurgical interventions, ultrasound vs corticosteroid injection plus a neutral wrist splint, local microwave hyperthermia vs placebo, iontophoresis vs phonophoresis, pulsed radiofrequency added to wrist splint, continuous vs pulsed vs placebo shortwave diathermy, and interferential current vs transcutaneous electrical nerve stimulation vs a night-only wrist splint). In the midterm, moderate evidence was found in favor of radial extracorporeal shockwave therapy (ESWT) added to a neutral wrist splint, in favor of ESWT versus ultrasound, or cryo-ultrasound, and in favor of ultrasound versus placebo. For all other interventions studied, only limited, conflicting, or no evidence was found. No RCTs investigating the long-term effects of physical therapy and electrophysical modalities were found. Because of heterogeneity in the treatment parameters used in the included RCTs, optimal treatment parameters could not be identified.
Conclusions: Moderate evidence was found for several physical therapy and electrophysical modalities for CTS in the short term and midterm. Future studies should concentrate on long-term effects and which treatment parameters of physical therapy and electrophysical modalities are most effective for 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?
Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
Yes
- Did the literature search strategy use a comprehensive, systematic approach?
Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes
- Were the included studies listed along with important characteristics and results of each study?
Yes
- Was publication bias assessed?
Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Carpal mobilization significantly improved carpal tunnel symptoms reported at a 3-week follow up compared to no treatment.
Key Finding #2
There is no significant difference between the effects of Graston-assisted soft tissue mobilization with home exercises vs manual soft tissue mobilization with home exercises on pain, range of motion, grip strength and symptoms.
Key Finding #3
Targeted massage can significantly improve grip strength and improve pain, tingling, numbness, and burning symptoms short-term.
Key Finding #4
There is conflicting evidence on the effectiveness of ultrasound for short term symptom improvement, but evidence suggests it is effective after 7 weeks of use.
Please provide your summary of the paper
The purpose of this paper was to synthesize the current literature on the effect of various interventions on carpal tunnel syndrome symptoms. Five databases were searched for randomized controlled trials and reviews that compare the effects of tendon and nerve glides, mobilization and manual therapy, massage, ultrasound, or thermal therapy on carpal tunnel symptoms. Studies included in the review focused on patients with overuse-related carpal tunnel syndrome, used a modality or intervention, and included an outcome measure for pain or function. Of the identified 563 articles, 22 random controlled trials and reviews were selected and included. The reviewed studies found that there is minimal evidence for tendon and nerve gliding exercise use in conservative treatment, conflicting evidence for manual therapy and mobilization for short term improvements, and supportive evidence for some types of massage therapy for short term improvement in function or symptoms. The review identified conflicting evidence about the use of ultrasound compared to placebo, and moderate evidence for the use of electrophysical modalities for short term and midterm. However, there was limited evidence on its long term effectiveness and more research needs to be conducted.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The systematic review provides insight into best clinical practice for patients experiencing symptoms of carpal tunnel syndrome. The suggested interventions for the improvement of carpal tunnel syndrome potentially include specific manual therapy techniques or electrophysical modalities. Although some techniques or modalities have better evidential support than others, it is important to recognize the role of a patient’s unique presentation in conjunction with evidential support to create the best plan of care for optimal outcomes. For instance, this systematic review identified that there is mixed research around short term ultrasound use and the effect it has on carpal tunnel symptoms. Even though the research is not conclusive, ultrasound could be a beneficial component of a patient’s treatment if it makes an impact on their individual symptoms. For this reason it is crucial to understand the identified trends in the provided evidence, while also being able to use it as a framework to adjust and implement according to the patient’s response. The inconclusiveness of this systematic review also highlights the need for further research on manual techniques and modality use in patients with carpal tunnel syndrome so that helpful treatment options can be more appropriately identified and used.
Article Full Title:
Conservative management of De Quervain’s tendinopathy with an orthopedic manual physical therapy approach emphasizing first CMC manipulation: a retrospective case series
Author Names:
Scott W. Young, Thomas W. Young &Cameron W. MacDonald
Reviewer Name:
Patrick Kunkel
Reviewer Affiliation(s):
Duke DPT Student
Paper Abstract
De Quervain’s tendinopathy (DQT) is a musculoskeletal disorder that limits hand function of affected individuals. Management of DQT can include splinting, activity modification, medications, corticosteroid injections, physical therapist management, and surgery. There is limited evidence to support the combination of manual therapy and exercise interventions within an Orthopedic Manual Physical Therapy (OMPT) approach when managing patients with DQT. Three patients identified with DQT underwent a multi-modal treatment regimen including carpometacarpal (CMC) thrust and non-thrust manipulation, end range radiocarpal mobilization, mobilization with movement (MWM), strengthening exercises, and grip proprioception training. Outcomes were assessed using the numeric pain rating scale (NPRS), Jamar hand dynamometer grip strength, and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire. These measures were administered at baseline and discharge. Each patient demonstrated improvements in all outcome measures and required ten visits or less to reach a satisfactory outcome. The NPRS improved by a mean of 7.1 points on a 0–10 scale, Quick DASH improved by an average of 37.1%, and grip strength improved by a mean of 27.6 pounds. Each patient was able to return to daily tasks without pain and all improvements were maintained at six month follow-up. An impairment based OMPT management approach was effective in managing three patients with DQT. The inclusion of first CMC manipulation within this multi-modal approach may enhance conservative management of patients with DQT. Because a cause and effect relationship cannot be inferred from a case series, further research is recommended to investigate the efficacy of this management approach.
Quality Assessment Tool for Case Series Studies
- Was the study question or objective clearly stated?
Yes
- Was the study population clearly and fully described, including a case definition? Yes
- Were the cases consecutive?
Unknown
- Were the subjects comparable?
Yes
- Was the intervention clearly described?
Yes
- Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes
- Was the length of follow-up adequate?
Yes
- Were the statistical methods well-described?
Yes
- Were the results well-described?
Yes
Key Finding #1:
All patients reported significant improvements in the NPRS and Quick DASH questionnaire following interventions as well as well as meeting the MDC and MCID for the NPRS, Quick DASH, and the Jamar hand dynamometer grip strength measures.
Key Finding #2:
Each patient experienced improvement in thumb AROM, wrist AROM, arthrokinematic mobility, and affected UE grip strength allowing for improvements in ability to perform all job and recreational activities with no limitations.
Key Finding #3:
When questioned individually each patient reported that the manual therapy interventions were the most responsible for their positive outcomes, but neurophysiological factors should be considered as well.
Please provide your summary of the paper
This case report was retrospective in nature that assessed 3 female patients that were diagnosed with De Quervain’s tendinopathy (DQT) and that were experiencing radial wrist pain. The researchers contacted each patient six months after discharge from physical therapy services from the same PT for participation in the case series. Each patient was diagnosed with DQT using the screening tool created by Battenson and were characterized as having subacute symptoms of moderate severity suggesting a fair prognosis with conservative management. High velocity low amplitude first CMC thrust manipulation was performed in mid-range to the patients affected wrist to improve MCP extension until a cavitation was achieved. Directly after the thrust manipulation, grade 3-4 PA mobilizations were performed to the first CMC joint to focus on mobility. All patients were prescribed active thumb flexion/ extension and passive wrist flexion/extension stretching at the initial visit and then progressed to include resisted thumb flexion and extension with low resistance putty and tennis ball toss. When all of this could be performed without pain, exercises were progressed to include wrist roller gripping/ twisting, wall push-ups, and static web gripping with proprioceptive challenges. Exercise progression and frequency was individualized per patient and response to treatment. All the patients showed improvement with the listed management approach but with differences in progression largely hypothesized due to age and prior level of activity.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
I think this case series presents great evidence toward carpometacarpal (CMC) joint manipulation for individuals with De Quervain’s tendinopathy (DQT). All three patients in the study showed improved thumb AROM, wrist AROM, affected grip strength and improvements in the NPRS and Quick DASH questionaries. This case series provides continued support for the use of manual therapy in the management of addressing tendinopathy conditions and further research should be done with a larger sample size to see if CMC thrust and non-thrust manipulation would continue to have positive effects on the treatment of DQT. I think it is also important to note that the patients that saw the largest improvements in outcomes were younger and more physically active, but all patient showed improvements with varying timelines.
Article Full Title:
Functional outcome of joint mobilization added to task-oriented training on hand function in chronic stroke patients
Author Names:
Asmaa Sabbah, Sherine El Mously, Hanan Helmy Mohamed Elgendy, Mona Adel Abd Eltawab Farag and Abeer Abo Bakr Elwishy
Reviewer Name
Jessica Matsuoka, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Physical Therapy Division
Paper Abstract
Background: Approximately half of stroke patients show impaired upper limb and hand function. Task-oriented training focuses on functional tasks, while joint mobilization technique aims to restore the accessory movements of the joints.
Objective: To investigate the effect of adding joint mobilization to task-oriented training to help the patients in reaching a satisfactory level of recovery for their hand function.
Patients and methods: Thirty chronic stroke patients with paretic hand participated in the study; they were divided equally into study and control groups. The study group received joint mobilization followed by task-oriented training for the affected hand. Meanwhile, the control group received task-oriented training only. Both groups received their treatment in the form of 3 sessions per week for 6 successive weeks. The primary outcome measures were hand function that was assessed by Jebsen-Taylor hand function test (JTT) and active and passive wrist extension range of motion (ROM) that was measured by a standard goniometer. The secondary outcome measure was the grip strength of the hand that was assessed by a JAMAR adjustable hand dynamometer.
Results: There was a significant improvement in all the outcome measurements in both groups that were more evident in the study group.
Conclusion: Combining joint mobilization with task-oriented training had a highly significant effect in improving the hand function in chronic stroke patients compared to task-oriented training alone.
Keywords: Stroke, Spasticity, Hand function, Joint mobilization, Task-oriented training
Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies
- Was the research question or objective in this paper clearly stated?
- Yes
- Was the study population clearly specified and defined?
- Yes
- Was the participation rate of eligible persons at least 50%?
- Not stated
- Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?
- Yes
- Was a sample size justification, power description, or variance and effect estimates provided?
- No
- For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?
- Yes
- Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?
- Yes
- For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?
- Yes
- Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
- Yes
- Was the exposure(s) assessed more than once over time?
- Yes
- Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
- Yes
- Were the outcome assessors blinded to the exposure status of participants?
- Not stated
- Was loss to follow-up after baseline 20% or less?
- Not stated
- Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?
- Not stated
Key Finding #1:
Combining joint mobilization and task-oriented training had a highly significant effect on improving paretic hand function in chronic stroke patient’s vs task-orientated training alone
Key Finding #2:
Mobilization is an appropriate and effective intervention that may kick start muscle activation post-stroke by providing proprioceptive information to the brain, facilitating direct activation of the primary motor cortex and the corticospinal system to increase motor activity.
Key Finding #3:
The results showed significant increases in the wrist extensors’ AROM and PROM, and it is possible that improving joint flexibility would also allow the muscles to increase their action.
Key Finding #4:
Stiffness has also been reported in post-stroke patients to represent a major challenge in performing tasks and using the affected arm. In this study it was found that hand function improved as a measure of JTT and ROM of wrist extensors with joint mobilization.
Please provide your summary of the paper
This study evaluated the effects of joint mobilization combined with task-oriented training vs task-oriented training alone. Participants were recruited from the outpatient stroke clinic of El Kasr El Ainy hospitals. This study included 30 participants and inclusion criteria included ischemic stroke at least 6 months before the study, right-handedness, age 45-60, spasticity grade 1 and +1 on the Modified Ashworth Scale (MAS), and ≥24 points on the mini mental state examination (MMSE). Exclusion criteria included Left-handed patients, those with a history of stroke onset less than 6 months ago, those having dysfunction due to musculoskeletal disorders, treatment for spasticity such as botulinum toxin or baclofen pump for up to 6 months, and those who were concurrently participating in other hand training program. The primary outcome measures were hand function measured by the Jebsen-Taylor hand function test (JTT) and AROM and PROM wrist extension. Secondary outcome measures were grip strength. The control group received 40 minutes of task-oriented training, while the study group received 20 minutes of joint mobilization followed by 40 minutes of task-oriented training, both receiving treatments for 6 weeks. Joint mobilization consisted of inferior radioulnar joint supination, wrist extension, wrist radial deviation, radiocarpal extension, radiocarpal supination, metacarpophalangeal joint extension, and first carpometacarpal joint extension, combined with task-oriented training. After 6 weeks, both groups showed improvements in hand function (assessed by JTT), AROM and PROM of wrist extensors, and grip strength of the paretic hand. However, there was a significant difference between the two groups favoring the study group.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Overall, this study supports joint mobilization combined with task-oriented training to improve paretic hand function following chronic ischemic stroke in right-handed patients aged 45-60. This is important because it aligned with other research being done in the field and could potentially be used clinically with the right patient population. However, this study was limited by a small sample size and is specific to a subset of chronic stroke patients. Further studies, including a larger sample of the population, could help determine the clinical impact joint mobilization combined with task-oriented training could have on this population in rehabilitation.
Article Full Title:
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., Cleland, J., Palacios-Ceña, M., Fuensalida-Novo, S., Pareja, J., Alonso-Blanco, C.
Reviewer Name:
Chloee Richey
Reviewer Affiliation(s):
Duke University School of Medicine Department of Physical Therapy
Paper 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.
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an
RCT Y
- Was the method of randomization adequate (i.e., use of randomly generated assignment)? Y
- Was the treatment allocation concealed (so that assignments could not be predicted)? Y
- Were study participants and providers blinded to treatment group assignment? N
- Were the people assessing the outcomes blinded to the participants’ group assignments? Y
- Were the groups similar at baseline on important characteristics that could affect outcomes
(e.g., demographics, risk factors, co-morbid conditions)? Y
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? Y
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? Y
- Was there high adherence to the intervention protocols for each treatment group? Y Were other interventions avoided or similar in the groups (e.g., similar background treatments)? Y
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? Y
- 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? Y
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? Y
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? Y
(ALL YES BUT #4)
Key Finding #1:
In women with carpal tunnel syndrome, 3 sessions of manual therapy provided superior improvements in self-reported function and pinch-tip grip force compared with surgery at 1-month follow-up, with no significant differences between the groups at follow-ups of 3, 6, or 12 months.
Key Finding #2:
Conservative treatment consisting of techniques targeting the cervical spine and areas anatomically related to potential entrapment of the median nerve may be an intervention option for patients with carpal tunnel syndrome, as a first line of management prior to or instead of surgery
Key Finding #3:
No changes in cervical range of motion were observed after either manual therapy or surgery.
Key Finding #4:
Though manual therapy seemed to be slightly more effective in the short term than surgery for improving pinch-tip grip, the results do not support our initial hypothesis that changes in pinch-tip grip and cervical range of motion would be greater with manual therapy than with surgery.
Please provide your summary of the paper
This article discussed the effectiveness of manual therapy versus surgery for carpal tunnel syndrome (CTS). It included 100 women meeting specific clinical and electrophysiological criteria, randomly assigned to either a manual therapy group (receiving three weekly sessions of targeted therapy and a cervical spine exercise program) or a surgical group (undergoing endoscopic decompression). These outcomes were assessed initially, then at 1, 3, 6, and 12 months, using the Boston Carpal Tunnel Questionnaire (BCTQ). Statistical analyses, including repeated-measures ANCOVA and chi-square tests, were performed to assess treatment effects and success rates over time. No significant changes were observed in cervical range of motion in both groups for any motion. This RTC found that multimodal manual therapy led to greater short-term improvements (at 1 month) in self-reported function, symptom severity, and pinch grip strength compared to surgery. Both treatments yielded similar outcomes at 6 and 12 months, suggesting equal long-term effectiveness. The short-term benefits of manual therapy, while statistically significant, did not surpass clinical significance thresholds.
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 provides insight into the management of carpal tunnel syndrome (CTS), particularly in weighing the benefits of multimodal manual therapy versus surgery. The findings suggest that while manual therapy yields significant short-term improvements (at one month) in self-reported function, symptom severity, and pinch grip strength, both interventions produce comparable outcomes at six months and one year. The improvements seen at one month could suggest an earlier return to activities of daily living. However, these early improvements did not meet the minimum clinically important difference (MCID), posing questions about their practicality in the clinic setting.
Article Full Title:
Conservative management of De Quervain’s tendinopathy with an orthopedic manual physical therapy approach emphasizing first CMC manipulation: a retrospective case series
Author Names:
Scott W. Young, Thomas W. Young, and Cameron W. MacDonald
Reviewer Name: L
ea Schneider, SPT, CSCS
Reviewer Affiliation(s):
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract:
De Quervain’s tendinopathy (DQT) is a musculoskeletal disorder that limits hand function of affected individuals. Management of DQT can include splinting, activity modification, medications, corticosteroid injections, physical therapist management, and surgery. There is limited evidence to support the combination of manual therapy and exercise interventions within an Orthopedic Manual Physical Therapy (OMPT) approach when managing patients with DQT. Three patients identified with DQT underwent a multi-modal treatment regimen including carpometacarpal (CMC) thrust and non-thrust manipulation, end range radiocarpal mobilization, mobilization with movement (MWM), strengthening exercises, and grip proprioception training. Outcomes were assessed using the numeric pain rating scale (NPRS), Jamar hand dynamometer grip strength, and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire. These measures were administered at baseline and discharge. Each patient demonstrated improvements in all outcome measures and required ten visits or less to reach a satisfactory outcome. The NPRS improved by a mean of 7.1 points on a 0-10 scale, Quick DASH improved by an average of 37.1%, and grip strength improved by a mean of 27.6 pounds. Each patient was able to return to daily tasks without pain and all improvements were maintained at six month follow-up. An impairment based OMPT management approach was effective in managing three patients with DQT. The inclusion of first CMC manipulation within this multi-modal approach may enhance conservative management of patients with DQT. Because a cause and effect relationship cannot be inferred from a case series, further research is recommended to investigate the efficacy of this management approach.
Quality Assessment Tool for Case Series Studies
- Was the study question or objective clearly stated? Yes
- Was the study population clearly and fully described, including a case definition? Yes
- Were the cases consecutive? N/A
- Were the subjects comparable? Yes
- Was the intervention clearly described? Yes
- Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants? Yes
- Was the length of follow-up adequate? Yes
- Were the statistical methods well-described? N/A
- Were the results well-described? Yes
Key Finding #1
All three patients included in this study met the MCD and MCID for the NPRS (mean improvement of 7.1), Quick DASH (mean improvement of 37.1%), and the Jamar hand dynamometer grip strength measures (mean improvement of 27.6 pounds). Additionally, all patients demonstrated improvements in thumb and wrist AROM, arthrokinematic mobility, and UE grip strength. Furthermore, these improvements persisted after discharge, and each patient reported an ability to perform all job and recreational activities without limitation at their 6-month follow up. This suggests that the addition of manual therapy techniques may be effective in the conservative treatment of De Quervain’s Tendinopathy (DQT).
Key Finding #2
It is unknown if the positive effects of manual therapy demonstrated within this study can be attributed to mechanical or neurophysiological factors. Each patient reported that they believed manual therapy to be the most significant contributor in the positive outcome of their rehabilitation, which could have implications in the overall success of the study. Prospective studies should be conducted in the future to further investigate the effects of Orthopedic Manual Physical Therapy (OMPT) management of DQT.
Summary
The patients were diagnosed with a clinical cluster, and needed to meet five of the seven following criteria in order to be eligible for inclusion: 1) pain over the radial styloid; 2) tenderness over the dorsal thumb; 3) pain with active thumb flexion; 4) localized swelling over the thumb; 5) positive Finklestein’s test; 6) thickening of the tendon sheath of the first dorsal extensor compartment; and 7) pain with resisted thumb flexion. Three patients met the inclusion criteria and underwent a multi-modal treatment plan which included manual therapy, the selection of which was based upon the individual’s presentation each visit. High velocity low amplitude (HVLA) first carpometacarpal (CMC) thrust manipulation was performed in mid-range; if no cavitation was achieved it was performed a second time. This was followed by grade III-IV posterior to anterior (PA) glides at end range to the first CMC joint. Therapeutic exercise interventions were also performed following the performance of the manual therapy techniques, and pain science education was provided to encourage patients to continue using their affected extremity. Outcomes for all patients were assessed using the numeric pain rating scale (NPRS), the Quick DASH, and the Jamar hand dynamometer grip strength measures. All three patients achieved the MCD and MCID for each of these outcomes.
Clinical Interpretation
This case series had several limitations, including that it was a retrospective study of a small sample size which included individuals who are not a part of the normal demographic of those afflicted with DQT. To date this has been the first study to examine the effectiveness of first CMC thrust manipulation on patients with DQT, and although it showed promising results further prospective studies should be performed in order to comprehensively assess its effectiveness as an intervention. Despite these limitations, it seems plausible that manual therapy interventions may be beneficial in the management of DQT.
Article Full Title
Effectiveness of physiotherapy plus acupuncture compared with physiotherapy alone on pain, disability and grip strength in people with carpal tunnel syndrome: A randomized clinical trial
Author Names
Mamipour H, Negahban H, Aval SB, Zaferanieh M, Moradi A, Kachooei AR
Reviewer Name
Joy Xiao
Reviewer Affiliation(s)
Duke DPT Class of 2026
Paper Abstract
Background: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome in the upper extremities. Acupuncture is often used as a treatment method in CTS and numerous studies consider it effective. However, no study has yet compared the efficacy of physical therapy including bone and neural mobilization, exercise and electrotherapy with and without acupuncture in CTS patients.
Purpose: Comparing the effect of physiotherapy plus acupuncture with physiotherapy alone on pain, disability and grip strength in CTS patients.
Method: Forty patients with mild to moderate CTS were randomly divided into two equal groups. Both groups received exercise and manual techniques for 10 sessions. Patients in the physiotherapy plus acupuncture group also received 30 min of acupuncture in every session. The visual analog scale (VAS) score, the score on the Boston carpal tunnel questionnaire for functional status and symptom severity, shortened disability of arm, shoulder, hand (Quick-DASH) score and grip strength were evaluated at pre-test and post-test.
Results: According to ANOVA results, there is a significant interaction between group and time for VAS, BCTQ and Quick-DASH parameters. At the post-test, while the parameters of VAS, BCTQ and Quick-DASH in the physiotherapy plus acupuncture group had a statistically significant difference compared to the physiotherapy group, no significant difference was observed between the two groups in the pre-test. Moreover, there is no significant difference between groups in grip strength improvement. Conclusion: This study shows preliminary evidence that physiotherapy plus acupuncture, was more effective than physiotherapy alone in pain relief and improving disability of patients suffering from CTS.
NIH Risk of Bias score: 11/14
Summary of Article:
This article reports a randomized controlled trial conducted in Mashhad, Iran. The main hypothesis of the trial is compared to physiotherapy alone, combined physiotherapy and acupuncture treatment yields better outcomes in pain and disability reduction and grip strength improvement. In this RCT, 40 patients with mild to moderate carpal tunnel syndrome who have experienced pain for more than 4 weeks were included and randomized into two groups. The physiotherapy group consist of 10 sessions spanning across 4 weeks with utilization of stretching, myofascial tissue release and manipulation, tendon glide exercises and manual neural glide techniques to increase the mobility of the median nerve in the carpal tunnel. The physiotherapy plus acupuncture group received an additional 30-minute acupuncture session after each physiotherapy session. Results show that both groups have a significant improvement in pain (measured by Visual Analog Scale, VAS), disability (measured by Boston carpal tunnel syndrome questionnaire, BCTQ; and shortened disability of arm, shoulder, hand, Quick-DASH) and grip strength (measured by dynamometer) after the treatment period. The physiotherapy plus acupuncture group reports more significant reduction than the physiotherapy group in pain and disability, but not grip strength.
Clinical relevance:
This article can serve as preliminary supporting evidence to promote collaboration with acupuncturist when treating patients with mild to moderate carpal tunnel syndrome upon clinical exam. In addition to physical therapy interventions, acupuncture could potentially add benefit to pain relief and reduction of disability. One caveat to consider extrapolating findings from this study to clinical practice is that among 40 participants included, only 2 were men and not a single participant dropped out throughout the study. Epidemiologically, carpal tunnel syndrome predominantly affects women. It is important to exercise clinical judgment when treating a male patient with carpal tunnel syndrome using evidence presented in this article.
Supplemental information:
NIH Risk of Bias scoring sheet (Y: yes; N: no):
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT – Y
- Was the method of randomization adequate (i.e., use of randomly generated assignment)? – Y
- Was the treatment allocation concealed (so that assignments could not be predicted)? – Y
- Were study participants and providers blinded to treatment group assignment? – N
- Were the people assessing the outcomes blinded to the participants’ group assignments? – Y
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? – Y
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? – Y
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? – Y
- Was there high adherence to the intervention protocols for each treatment group? – Y
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)? – N
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? – Y
- 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? – Y
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? – N
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? – Y
Article Full Title
The effect of manual lymphatic drainage on intraneural edema of the median nerve in patients with carpal tunnel syndrome: A randomized controlled trial
Author Names
Kablan N, Mete E, Karatekin BD, Tombul T
Reviewer Name
Joy Xiao
Reviewer Affiliation(s)
Duke DPT Class of 2026
Paper Abstract
Background: Intraneural edema is an important factor in the pathophysiology of carpal tunnel syndrome (CTS). Manual Lymphatic Drainage (MLD) is a manual treatment widely used to treat edema in a variety of conditions.
Purpose: This study aimed to evaluate the effect of MLD on intraneural edema of the median nerve in CTS patients, as well as its impact on symptom severity and hand function.
Study Design: Randomized controlled study.
Methods: Twenty-seven patients (aged 48.9 ± 9.9) with mild-to-moderate bilateral CTS were recruited for the study. One hand of each subject was allocated to the experimental group and the other hand in the control group randomly. The experimental group underwent MLD, myofascial release (MFR) therapy and conventional physiotherapy (CP). The control group received sham MLD, MFR and CP. Interventions were performed 2 days a week for 6 weeks. The distal motor latency (DML), motor nerve (MNCV), and sensory nerve (SNCV) conduction velocity of the median nerve were evaluated using electrodiagnostic techniques. As secondary evaluations, grip strength, pressure pain threshold, pain intensity, symptom severity, and hand functions were assessed. The cross-sectional area (CSA) of the median nerve was measured by ultrasound. All assessments were performed at baseline and 6 weeks after intervention.
Results: According to the analysis of a two-way repeated measures of ANOVA, the experimental group showed greater improvement in CSA (p < 0.001; η2 = 0.510), DML (p < 0.001; η2 = 0.549), sensory (p < 0.001; η2 = 0.408), and motor conduction velocity (p < 0.001; η2 = 0.419) of the median nerve than the control group. There was no significant difference between the groups in the secondary evaluation results (p > 0.05).
Conclusion: MLD may contribute to symptom relief in CTS by reducing intraneural edema in the median nerve.
NIH Risk of Bias score: 11/14 (scoring sheet in Supplemental information)
Key Finding #1:
Manual lymphatic drainage significantly improves the cross-sectional area and conduction velocity of the median nerve potentially by alleviating intraneural edema.
Key Finding #2:
Manual lymphatic drainage does not significantly improve grip strength, pressure pain threshold, pain intensity, or symptom severity compared to the sham group.
Summary of Article:
This article reports a randomized controlled trial conducted in İstabul, Turkey. The main hypothesis of the trial is manual lymphatic drainage (MLD) can reduce intraneural edema of the median nerve in patients with carpal tunnel syndrome (CTS), improve symptoms severity and hand function. The study included 27 participants aged 40-60 years with bilateral CTS of mild to moderate motor and sensory deficits for at least 6 months. Every subject received treatment twice a week, for six weeks. One side was randomized to receive sham MLD, myofascial release and conventional physical therapy (control group) and the other side consequently received MLD, myofascial release and conventional physical therapy (MLD intervention group). Primary outcomes are median nerve conduction velocity measured by electrodiagnostic evaluation and the cross-sectional area of the median nerve measured by ultrasonography. Secondary outcomes are grip strength measurement measured by hand dynamometer, pressure pain threshold measured by algometer, pain intensity measured by visual analog scale and symptom severity measured by the Boston Carpal Tunnel Questionnaire. Results showed that MLD brought significant improvement in both primary outcomes and no significant improvement in the secondary outcomes when compared with the control group. The authors discussed the potential mechanism of this observed advantangeous outcome and attributed to a decrease of intraneural edema by increasing lymphatic recollection. Further studies using lymphoscintigraphy will more directly illuminate the mechanistic process.
Clinical Relevance:
This article can serve as a supporting evidence to utilize MLD to patients with mild to moderate carpal tunnel syndrome. Two caveats to consider when extrapolating findings from this study to clinical practice is clinician experience and expertise with MLD technique and the population validity. In this study, the clinician performing MLD had 16 years of experience as a lymphedema therapist. Their extensive experience might have contributed to the advantageous therapeutic effect observed in the MLD group. Referring back to this study and verify the exact performance of the MLD intervention could be helpful. Participants included were aged 40-60 years old without systemic disease (e.g. diabetes) so the study findings might not be generalizable to pregnant patients or people with systemic pathologies.
Supplemental Information:
NIH Risk of Bias scoring sheet (Y: yes; N: no; N/A: not available):
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT – Y
- Was the method of randomization adequate (i.e., use of randomly generated assignment)? – Y
- Was the treatment allocation concealed (so that assignments could not be predicted)? – N/A
- Were study participants and providers blinded to treatment group assignment? – N
- Were the people assessing the outcomes blinded to the participants’ group assignments? – Y
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? – Y
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? – Y
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? – Y
- Was there high adherence to the intervention protocols for each treatment group? – Y
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)? – Y
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? – Y
- 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? – Y
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? – N
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? – Y
Article Full Title
Cost-Effectiveness Evaluation of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: Evidence From a Randomized Clinical Trial
Author Names
César Fernández-de-las-Peñas, PT, PhD, DMSc, Ricardo Ortega-Santiago, PT, PhD, Homid Fahandezh-Saddi Díaz, MD, PhD, Jaime Salom-Moreno, PT, PhD, Joshua A. Cleland, PT, PhD, Juan A. Pareja, MD, PhD, José L. Arias-Buría, PT, MSc, PhD
Reviewer Name
Albert Yang
Reviewer Affiliation(s)
Physical therapy student at Duke University
Paper Abstract
n/a
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Not found
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Not found
- Were study participants and providers blinded to treatment group assignment?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
Manual therapy was found to be a cost-effective alternative to surgery for treating carpal tunnel syndrome
Key Finding #2
Both manual therapy and surgery resulted in significant improvements in pain, function, and outcomes. There were no major differences between the two treatment methods over time.
Key Finding #3
The paper concluded that patients receiving manual therapy showed quicker short-term improvements compared to those who underwent surgery, especially in terms of pain reduction and functional ability
Please provide your summary of the paper
The purpose of this paper was to compare the cost-effectiveness of manual therapy as a treatment method compared to surgery for treating carpal tunnel syndrome. It was a randomized clinical trial that compared costs, recovery times, and clinical outcomes between the two treatment groups. All in all, the paper found that manual therapy was more cost effective compared to surgery, providing similar benefits at a lower cost, and it also suggested that patients in the manual therapy treatment group experienced quicker short-term relief in symptoms compared to those who underwent surgery. However, both groups showed significant improvements in pain, function, and overall patient reported outcomes over time, with no significant differences in long term effectiveness. Ultimately, the paper summarizes that manual therapy can be a cost-effective alternative when treating patients with CTS, especially for those who want to pursue a less invasive procedure with quicker initial recovery.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
From this paper, I believe that it demonstrates compelling evidence to suggest that manual therapy can be a cost effective and clinically viable alternative treatment for carpal tunnel syndrome (when compared to surgery). Since long term outcomes were somewhat similar between the two interventions, but outcomes were better in the short term for the treatment group that received manual therapy, this research challenges the automatic preference for surgical intervention when managing CTS. This study may impact clinical practice in a variety of ways, including increasing the utilization of conservative management and highlighting the importance of reserving surgery for patients who fail conservative treatment. In my own practice, I will be sure to keep in mind the results from this study when discussing treatment options for patients I encounter with CTS.
Article Full Title
Wrist and hand pain in orthopaedic physical therapists: A mixed-methods study.
Author Names
Campo, M., Hyland, M., Sueki, D., & Pappas, E. (2019)
Reviewer Name
Yushan Zhang
Reviewer Affiliation(s)
Duke University Doctor of Physical Therapy Program
Paper Abstract
Background: Orthopaedic physical therapists (PTs) who perform manual therapy are at high risk for wrist and hand pain. Studies that examine the magnitude, scope and causes of wrist and hand pain are needed so that prevention programs can be developed. Objectives: The objective of this study was to determine the magnitude, scope, and impact of wrist and hand pain in orthopaedic PTs and to identify potential strategies for prevention. Design: This was a sequential, mixed methods study including quantitative and qualitative components. Methods: The quantitative phase consisted of an online survey sent to members of the Academy of Orthopaedic Physical Therapy. The qualitative phase consisted of focus groups with Orthopaedic PTs who had wrist and hand pain. Results: The survey included 962 PTs and the focus groups included 10 PTs. The one-year prevalence of wrist and hand pain was 75%. Increasing age, decreasing experience, female gender, performing more manual therapy and working more than 40 h per week were associated with an increased risk of moderate to severe wrist and hand pain. Soft-tissue mobilization was the most frequently cited causative factor. The most commonly mentioned strategy for prevention was altering body mechanics and technique. Focus group participants highlighted the importance of managing expectations for manual therapy by patients. Conclusions: Formal injury prevention programs for PT students and PTs are urgently needed. These programs should focus on improving body mechanics and technique, attention to workload, careful selection of manual techniques, and managing expectations for manual therapy.
Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies
- Was the research question or objective in this paper clearly stated?
Yes
- Was the study population clearly specified and defined?
YES
- Was the participation rate of eligible persons at least 50%?
Unclear (The study surveyed 962 PTs but did not report the total number of eligible participants invited)
- Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?
Yes
- Was a sample size justification, power description, or variance and effect estimates provided?
NO
- For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured.
Not applicable
- Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?
Not applicable
- For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?
Yes
- Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
YES
- Was the exposure(s) assessed more than once over time?
No
- Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
YES
- Were the outcome assessors blinded to the exposure status of participants?
Not applicable
- Was loss to follow-up after baseline 20% or less?
Not applicable. There was no follow-up period
- Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?
YES
Key Finding #1
Performing more manual therapy was significantly associated with an increased risk of moderate to severe wrist and hand pain among orthopedic physical therapists.
Key Finding #2
Soft-tissue mobilization (manual) was the most frequently cited manual therapy technique contributing to wrist and hand pain, suggesting that repetitive, forceful hand use is a major factor in injury in PTs
Key Finding #3
Altering body mechanics and manual therapy techniques was the most commonly suggested prevention strategy. Therapists emphasized the importance of improving ergonomics and adjusting manual methods to reduce strain on the hands and wrists
Summary of the paper:
The study “Wrist and hand pain in orthopaedic physical therapists: A mixed-methods study” by Campo et al. (2019) highlights the significant impact of manual therapy on the prevalence of wrist and hand pain among orthopedic physical therapists. The findings reveal that 75% of PTs reported wrist and hand pain within the past year, with soft-tissue mobilization identified as the most common cause. Risk factors associated with moderate to severe pain include performing more manual therapy, older age, female gender, fewer years of experience, and working more than 40 hours per week. Clinically, this study emphasizes the need for modifying manual techniques and improving body mechanics to reduce the physical strain on therapists. Implementing formal injury prevention programs that focus on ergonomics, reducing manual therapy workloads, and educating PTs on safe handling techniques can mitigate the risk of long-term musculoskeletal injury. Additionally, managing patient expectations regarding manual therapy may reduce the pressure on PTs to overuse these techniques, fostering a safer and more sustainable clinical practice environment.
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 underscores the physical demands and occupational risks associated with performing manual therapy in orthopedic physical therapy. The high prevalence of wrist and hand pain (75%) suggests that manual therapy techniques, particularly soft-tissue mobilization, place substantial strain on therapists’ hands and wrists. Clinically, this highlights the importance of adopting preventative measures to protect therapists from chronic musculoskeletal issues. Implementing ergonomically sound techniques, promoting body mechanics training, and encouraging task rotation can help reduce repetitive strain. Additionally, clinics should consider adjusting workloads by limiting prolonged manual therapy sessions and integrating alternative treatment approaches where appropriate. Educating both PTs and patients about the potential physical toll of manual therapy and managing patient expectations can also help reduce the perceived necessity for hands-on interventions in every session. These findings suggest that prioritizing injury prevention strategies and workplace modifications is essential to sustain the physical well-being of orthopedic physical therapists and ensure long-term career longevity.
