Effectiveness of electrophysical modalities in the sensorimotor rehabilitation of radial, ulnar, and median neuropathies: A meta-analysis.

INTRODUCTION: People with ulnar, radial or median nerve injuries can present significant impairment of their sensory and motor functions. The prescribed treatment for these conditions often includes electrophysical therapies, whose effectiveness in improving symptoms and function is a source of debate. Therefore, this systematic review aims to provide an integrative overview of the efficacy of these modalities in sensorimotor rehabilitation compared to placebo, manual therapy, or between them. METHODS: We conducted a systematic review according to PRISMA guidelines. We perform a literature review in 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. We include studies that discussed the sensorimotor rehabilitation of people with non-degenerative ulnar, radial, or median nerve injury. We assessed the quality of the included studies using the Risk of Bias Tool described in the Cochrane Handbook of Systematic Reviews of Interventions and the risk of bias across studies with the GRADE approach described in the GRADE Handbook. RESULTS: Thirty-eight studies were included in the systematic review and 34 in the meta-analysis. The overall quality of evidence was rated as low or very low according to GRADE criteria. Low-level laser therapy and ultrasound showed favourable results in improving symptom severity and functional status compared to manual therapy. In addition, the low level laser showed improvements in pinch strength compared to placebo and pain (VAS) compared to manual therapy. Splints showed superior results to electrophysical modalities. The clinical significance of the results was assessed by effect size estimation and comparison with the minimum clinically important difference (MCID). CONCLUSIONS: We found favourable results in pain relief, improvement of symptoms, functional status, and neurophysiological parameters for some electrophysical modalities, mainly when applied with a splint. Our results coincide with those obtained in some meta-analyses. However, none of these can be considered clinically significant. TRIAL REGISTRATION: PROSPERO registration number CRD42020168792; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=168792.

Association between the Rosén and Lundborg Score and the Screening Activity Limitation and Safety Awareness scale in hand functional evaluation of patients with leprosy diagnosis.

PURPOSE: To evaluate the association of results from the Rosén and Lundborg Score and the screening activity limitation and Safety Awareness scale for the assessment of hand in patients diagnosed with leprosy. METHOD: An association between the Rosén and Lundborg Score and the Screening Activity Limitation and Safety Awareness scale for hand was evaluated in a cross-section study with 25 people of a mean age of 51 years old (SD 14), undergoing drug treatment for leprosy. RESULTS: The mean quantitative score in the Screening Activity Limitation and Safety Awareness scale was 27.9 (SD 10.5). Rosén and Lundborg Score for the median nerve were 2.43 (SD 0.38) on the right hand and 2.41 (SD 0.54) on the left hand whilst for the ulnar nerve, the scores observed were 2.33 (SD 0.42) for the right hand and 2.31 (SD 0.61) for the left hand. Significant correlations between the two instruments in assessment of the median and ulnar nerves on both hands were found. CONCLUSIONS: Due to the association found between the scales, the Rosén and Lundborg Score may be used in assessment of the hand in patients diagnosed with leprosy, as a tool to assist the result evaluation after the drug treatment, surgical treatment, rehabilitation and follow-up in the hand dysfunction in leprosy. Implications for Rehabilitation The leprosy inflammatory neuropathy may cause limitations and disabilities related to hand functions of patients. Instruments with quantitative scores provide a reliable basis for therapeutic intervention prognosis. New evaluation methods promote a better monitoring of treatment and hand function evolution of people with leprosy.

Similar 2-point discrimination and stereognosia but better locognosia at long term with an independent home-based sensory reeducation program vs no reeducation after low-median nerve transection and repair.

STUDY DESIGN: Prospective controlled study. INTRODUCTION: Previous studies evaluated the effectiveness of sensory reeducation (SR) after peripheral nerve injury and repair. However, evidence for long-term clinical usefulness of SR is inconclusive. PURPOSE OF THE STUDY: The purpose of this study is to compare the sensory results of patients with low-median nerve complete transection and microsurgical repair, with and without SR at long term. METHODS: We prospectively studied 52 consecutive patients (mean age, 36 years; range, 20-47 years) with low-median nerve complete transection and microsurgical repair. When reinnervation was considered complete with perception of vibration with a 256-cycles per second tuning fork (mean, 3.5 months after nerve injury and repair), the patients were sequentially allocated (into 2 groups [group SR, 26 patients, SR; group R, 26 patients, reassured on recovery without SR). SR was conducted in a standardized fashion, in 2 stages, as an independent home-based program: the first stage was initiated when reinnervation was considered complete, and included instruction in home exercises to identify familiar objects and papers of different roughness, and localization of light touch (eyes open and closed); the second stage was initiated when the patients experienced normal static and moving 2-point discrimination (2PD) at the index fingertip of injured hand, and included instruction in home exercises for stereognosia, supplementary exercises for localization of light touch, and identification of small objects (eyes open and closed). Exercises were prescribed for 5-10 minutes, 4 times per day. At 1.5, 3, and 6 years after nerve injury and repair, we evaluated the static and moving 2PD, stereognosia with the Moberg's pick-up test, and locognosia with the modified Marsh test. Comparison between groups and time points was done with the nonparametric analysis of variance (Kruskal-Wallis analysis of variance). RESULTS: Static and moving 2PD and stereognosia were not significantly different between groups at any study period. Locognosia was significantly better at 1.5 and 3 years in group SR; locognosia was excellent in 17 patients of group SR vs 5 patients of group R at 1.5-year follow-up and in 14 patients of group SR vs 5 patients of group R at 3-year follow-up. Locognosia was not different between the study groups at 6-year follow-up. CONCLUSION: A 2-stage home program of SR improved locognosia at 1.5 and 3 years after low-median nerve complete transection and repair without significant differences in other modalities or the 6-year follow-up of a small subsample.

Occupation-based intervention versus rote exercise in modified constraint-induced movement therapy for patients with median and ulnar nerve injuries: a randomized controlled trial.

OBJECTIVE: To investigate effect of practice type during modified constraint-induced movement therapy on hand function in patients with chronic median and ulnar nerve injuries. DESIGN: A prospective, single-blinded, randomized controlled clinical trial. SETTING: Participants' private home. SUBJECTS: A convenience sample of 36 outpatient participants allocated randomly to three equal groups. INTERVENTIONS: Intervention groups underwent 3-hour intensive training of affected hand each day, 3-day a week, 4-week in association with immobilisation of healthy hand: occupation-based group practiced meaningful occupations while rote exercise-based group performed rote exercises during constraint-induced movement therapy. Control group performed different activities with affected hand for 1.5-hour each day during 4-week without restriction of healthy hand. MAIN MEASURES: A blinded assessor tested Canadian occupational performance measure, box and block, Static two-point discrimination, disabilities of arm, shoulder, hand questionnaire, and self-assessment manikin in a random order across sessions 3-time as baseline (pre-test), after 4-week intervention (post-test), and 1-month after intervention period (follow up). RESULTS: Scores significantly changed in intervention groups compared to control. Despite significantly more improvement in occupation-based than rote exercise-based group in subjective measures at post-test and follow up (Canadian occupational performance measure: mean change 4.7 vs. 2.1 for performance, P< 0.001 and mean change 5.3 vs. 2.6 for satisfaction, P< 0.001), it was significant just at follow up for box and block and static two-point discrimination. CONCLUSIONS: Practice content of constraint-induced movement therapy is a critical part of its effectiveness on improving outcomes following peripheral nerve repair in favour of occupation-based intervention in present study.

Differential Diagnosis and Intervention of Proximal Median Nerve Entrapment: A Resident's Case Problem.

Study Design Resident's case problem. Background Entrapment neuropathies represent a diagnostic challenge and require a comprehensive understanding of the nerve's path and the anatomical structures that may cause compression of the nerve. This resident's case problem details the evaluation and differential diagnosis process for median nerve entrapment resulting from forceful and repetitive pronation/supination motions. Diagnosis Median nerve compression syndromes include pronator syndrome, anterior interosseous nerve syndrome, and carpal tunnel syndrome. A cluster of clinical special tests were performed to determine the anatomical site of median nerve entrapment. Based on the patient's history and clinical test results, a diagnosis of pronator syndrome was determined. Provocation testing specific to pronator syndrome assisted with further localizing the site of entrapment to the pronator teres muscle, which guided effective management strategies. Discussion This resident's case problem illustrates the importance of detailed anatomical knowledge and a differential diagnostic process when evaluating a patient with signs and symptoms of an entrapment neuropathy of the median nerve. Electrodiagnostic studies are useful in ruling out carpal tunnel and anterior interosseous nerve syndromes, but are often inconclusive in cases of pronator syndrome. Therefore, a diagnosis of pronator syndrome in this case problem was based on a detailed understanding of median nerve anatomy, potential sites of compression, and unique clinical features associated with this condition. Level of Evidence Differential diagnosis, level 4. J Orthop Sports Phys Ther 2016;46(9):800-808. Epub 5 Aug 2016. doi:10.2519/jospt.2016.6723.

Ultrasonographic median nerve changes under tendon gliding exercise in patients with carpal tunnel syndrome and healthy controls.

STUDY DESIGN: Case control study. PURPOSE OF THE STUDY: To evaluate the ultrasonographic median nerve changes under tendon gliding exercise in patients with carpal tunnel syndrome (CTS) and healthy controls. METHODS: Seventy-three patients with CTS and 53 healthy volunteers were consecutively recruited. Each subject underwent a physical examination, nerve conduction studies and ultrasonographic examinations of the median nerve during tendon gliding exercises. RESULTS: Significant changes in the cross-sectional area of the median nerve were found while moving from the straight position to the hook position and from the hook position to the fist position. There were also significant changes in the flattening ratio when moving from the hook position to the fist position. CONCLUSIONS: Ultrasonography revealed that the median nerve was compressed in the fist position in both CTS patients and healthy volunteers. Thus, forceful grasping should be avoided during tendon gliding exercises performed in the fist position. LEVEL OF EVIDENCE: 3b.

Immediate and long-term effects of selected physiotherapy methods in patients with carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome is a serious therapeutic problem and it considerably impairs the patients' quality of life. Despite many studies, the effectiveness of conservative treatment is still debatable. This study aimed to evaluate the immediate and long-term effects of conservative treatment involving ultrasound therapy combined with massage and kinesiotherapy for carpal tunnel syndrome. MATERIAL AND METHODS: A total of 61 patients with carpal tunnel syndrome were assessed with regard to such symptoms as pain, numbness, tingling sensation, morning stiffness, and self-care difficulties. We used provocation tests and investigated sensory impairments, autonomic disturbances, and Lüthy's sign. Conduction in the median nerve fibres was assessed during a nerve conduction study. We performed computer-aided measurement of the hand joint range of motion and global grip strength. The tests were conducted before and on completion of a rehabilitation programme. The hands were re-examined one year later. The treatment involved ultrasound therapy, massage, and kinesiotherapy. RESULTS: The treatment outcomes confirmed the effectiveness of the therapeutic programme. Significant improvements concerning the majority of the symptoms were observed between the first and second examination as well for the entire follow-up period. We observed significant improvement in the quality of sensation, the hand range of motion and muscle strength. CONCLUSIONS: Ultrasound therapy combined with massage and kinesiotherapy brings the expected, long-term effects in patients with carpal tunnel syndrome.

Effect of sensory re-education after low median nerve complete transection and repair.

PURPOSE: To compare the sensory results of patients with low median nerve complete transection and repair, with and without sensory re-education. METHODS: We studied 40 patients, aged 20 to 32 years, with low median nerve complete transection. Primary epineural repair using 8-0 single-strand sutures was done in all patients. Hands were immobilized in a splint for 4 weeks, followed by physical therapy for 1 month. At a mean of 3.5 months (range, 3-4 months) after surgery, when vibration sense (pallesthesia), using the 256-cycles-per-second tuning fork, was perceived at the fingertips of the 3.5 radial fingers innervated by the median nerve, the patients were randomly assigned to 2 equal groups: group A patients were rehabilitated with a sensory re-education program, and group B patients had no further treatment. Clinical evaluation at 18 months after surgery (range, 17.5-18.5 months) included locognosia (the ability to localize touch), the static and moving 2-point discrimination tests, and the Moberg pick-up test. RESULTS: All patients were included in the postoperative evaluation. Static and moving 2-point discrimination were not statistically significant between groups. Locognosia was significantly improved in group A, and a statistical trend was identified regarding the Moberg pick-up test in group A compared to group B. CONCLUSIONS: Sensory re-education appeared to have significant value only in re-education of locognosia at 18 months after low median nerve complete transection and repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Isolated median sensory neuropathy after acupuncture.

A 47-year-old left-handed man presented with pain and numbness in his left thumb and index finger after acupuncture treatment on an acupoint in his left wrist. A technique of herbal acupuncture, involving the use of a needle coated with apricot seed extract, was used. Median nerve conduction study showed an absence of sensory nerve action potential in the left index finger, whereas the results were normal in all other fingers. The radial and ulnar nerves in the left thumb and ring finger, respectively, showed no abnormality. Infrared thermography of the left index finger showed severe hypothermia. The patient was diagnosed as having an isolated injury to the sensory nerve fibers of the median nerve innervating the index finger. This is the first case report of complications from an herbal acupuncture treatment, and it highlights the possibility of focal peripheral nerve injury caused by acupuncture.

Early use of artificial sensibility to improve sensory recovery after repair of the median and ulnar nerve.

Artificial sensibility based on use of a "tactile glove" which substitutes for lack of sensory afferent inflow with acoustic feedback, was used early after repair of the median and ulnar nerves in a 21-year-old man. After six and 12 months the functional outcome exceeded what is expected in adults, and analysis with calculations for the minimal detectable change (MDC) in tactile gnosis showed a true change. This case highlights the timing of sensory re-education after nerve repair and also emphasises the importance of early restitution of afferent inflow from a denervated hand during rehabilitation.

Median, ulnar, and combined median-ulnar nerve injuries: functional outcome and return to productivity.

BACKGROUND: Forearm and wrist injuries are a common cause of morbidity and are often associated with suboptimal recovery of hand function. This study describes and compares outcome after median, ulnar, or combined median-ulnar nerve injuries. METHODS: Three hundred thirteen wrist and forearm nerve injuries operated on between 1980 and 1997 in a large university hospital were reviewed in relation to complications, return to work, and sensor and motor recovery. Of these 313 patients, 220 (age range, 5-73 years) met the inclusion criteria. RESULTS: Motor recovery, progress of sensory reinnervation, and number of severed structures were related to the type of injury (p < 0.05). Multiple linear regression analysis revealed a relation between the appearance of sensory reinnervation and motor recovery (beta = 0.02; 95% confidence interval, 0.01-0.04; p = 0.01). A probability of 24% of work loss, after a mean follow-up of 17.7 months, was found. Poor sensory and motor recovery were associated with work disability (odds ratio [OR], 2.9; p = 0.002; and OR, 2.9; p = 0.007, respectively). No relationship was found between type of injury and return to work (p = 0.47). Level of injury (OR, 2.6; p = 0.01), type of work (OR, 3.1; p = 0.002), number of complications (p < 0.001), and hand-therapy (OR, 0.24; p = 0.001) were found to influence return to work. CONCLUSION: It may be concluded that peripheral nerve injuries at the forearm level can result in substantial functional loss and have major social consequences. This study identified factors influencing return to work that can be used to optimize postoperative treatment strategy.