Ena Bula Oyola1,3; Juan Manuel Belda Lois2; Rosa Porcar Seder2; Álvaro Page del Pozo1,2
1 Universitat Politècnica de València. Camino de Vera, s/n. (46022) Valencia. Spain
2 Instituto de Biomecánica (IBV). Universitat Politècnica de València. Edificio 9C. Camino de Vera, s/n. (46022) Valencia. Spain
3 Departamento de Diseño, Universidad del Norte.5 vía Puerto Colombia (51820).Barranquilla. Colombia
Three types of therapeutic aids are available for the sensorimotor rehabilitation of the hand: physical therapy, electrophysical modalities and orthoses. A systematic review of the effects of electrophysical therapies has been developed to provide an integrated overview support evidence-based therapeutic decision-making.
INTRODUCTION
People with peripheral upper limb injuries are affected by significant impairment of their sensorimotor functions. Symptoms may include muscular impairments such as partial or total loss of the motor function of the forearm and the hand and/or reduced muscle tone and strength. Some of the most common sensory alterations include decreased or increased sensitivity, pain in response to non-painful stimuli, numbness, pins and needles and/or a stabbing sensation.
The treatment that is normally prescribed includes physical therapy, electrophysical modalities and the use of orthoses. Electrophysical agents are non-invasive interventions that deliver thermal, mechanical, electric or light energy to the patient in order to provide physiological effects and therapeutic benefits such as a reduction of pain and inflammation. At present there is no consensus on the efficacy of electrophysical therapy as a means to improve symptoms and function of the wrist and hand. With this in mind, a systematic review and meta-analysis was conducted to provide an integrative overview of the effects of these modalities in sensorimotor rehabilitation. The performance of the most commonly used rehabilitation agents was contrasted against a placebo, manual therapy, orthoses or each other [1].
MATERIAL AND METHODS
Search strategy and quality assessment
A systematic review was performed in accordance with PRISMA guidelines [2] on the following databases: Biomed Central, Ebscohost, Lilacs, Ovid, PEDro, Sage, Scopus, Science Direct, Semantic Scholar, Taylor & Francis, and Web of Science, for the period 1980-2020. The included studies analyzed the sensorimotor rehabilitation of people with non-degenerative ulnar, radial or median nerve injuries. The quality of the studies was assessed using the risk of bias tool described in the Cochrane Handbook for Systematic Reviews of Interventions [3] and the risk of bias between studies using the GRADE approach described in the GRADE Handbook [4].
Outcome measures
The outcomes of primary interest were the scores for pain (Visual Analogue Scale - VAS), for symptom severity (Symptom Severity Scale - SSS) and for functional status (Functional Status Scale - FSS). Also of interest were the electrophysiological parameters of the nerves: motor latency, motor action potential amplitude, motor conduction velocity, sensory latency, sensory action potential amplitude and sensory conduction velocity. Grip and pinch strength were secondary outcomes.
RESULTS
38 studies were included in the systematic review and 34 in the meta-analysis. We found:
• Favorable results for extracorporeal shock wave therapy plus orthosis and pulsed radiofrequency plus orthosis on pain relief, symptom severity, functional status, sensory conduction velocity, motor latency and motor amplitude in participants with carpal tunnel syndrome (CTS).
• As far as the effectiveness of low-level laser on functional status and neurophysiological parameters in participants with mild to moderate CTS is concerned, there were conflicting results. Continuous ultrasound was better than laser at relieving pain and symptoms in participants with ulnar neuropathy at the elbow.
• No evidence of benefit was found for other modalities and parameters measured.
The summary of the results for each comparison group is set out in table 1.
Clinical significance of the results
Although most research focuses on statistical significance, researchers and clinicians would however be well advised to consider clinically meaningful changes in the presentation of results and decision making. The result of a study may well be statistically significant, but not clinically significant, and vice versa [5]. The minimum clinically important difference (MCID) is a concept that is used to determine whether a medical intervention improves perceived patient outcomes [6] and/or would lead to a change in patient treatment [7]. Changes in results that exceed the established minimum values are considered clinically relevant.
The results of the meta-analysis were compared with the minimum clinically difference benchmarks for each of the measurements. We compared the findings obtained for pain (MCID VAS of 1.2) [8], functional status (MCID FSS of 0.74) [9], symptom severity scale (MCID SSS of 1.04) [10], grip strength (MCID of 2.69 kg) and pinch strength (MCID of 0.68 kg) [11]. No results were found that could be considered clinically significant. The summary of the MCID estimation is set out in Table 2.
CONCLUSIONS
The study which we carried out has made it possible to identify differences in favor of the effects of certain electrophysical modalities, primarily when applied with orthoses. However, none of the results obtained during the course of the review can be considered clinically significant. The available studies from the past 40 years were of fair to middling quality. High quality studies that make it possible to discriminate whether the favorable effects obtained are due to the use of orthoses or to the application of electrophysical agent treatment would be most welcome.
People with peripheral neuropathy should be informed about the limited evidence as to the effectiveness of treatment involving electrophysical agents. These findings can serve as a reference for professional clinicians in their decision-making, taking into account the clinical significance of the effects, the cost of their application, and the associated implications for each patient.
REFERENCES
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