Rehabilitation following surgery for flexor tendon injuries of the hand / Peters SE, Jha B, Ross M

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Background
Various rehabilitation treatments may be oKered following surgery for flexor tendon injuries of the hand. Rehabilitation oPen includes a combination of an exercise regimen and an orthosis, plus other rehabilitation treatments, usually delivered together. The eKectiveness of these interventions remains unclear.
Objectives
To assess the eKects (benefits and harms) of diKerent rehabilitation interventions aPer surgery for flexor tendon injuries of the hand.
Search methods
We searched the Cochrane Central Register of Controlled Trials, the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register,
MEDLINE, Embase,two additional databases and two internationaltrials registries, unrestricted by language. The last date of searches was 11 August 2020. We checked the reference lists of included studies and relevant systematic reviews.
Selection criteria
We included randomised controlled trials (RCTs) and quasi-RCTs that compared any postoperative rehabilitation intervention with no intervention, control, placebo, or another postoperative rehabilitation intervention in individuals who have had surgery for flexor tendon injuries of the hand. Trials comparing diKerent mobilisation regimens either with another mobilisation regimen or with a control were the main comparisons of interest. Our main outcomes of interest were patient-reported function, active range of motion of the fingers, and number of participants experiencing an adverse event.
Data collection and analysis
Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the quality of the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology.
Main results
We included 16 RCTs and one quasi-RCT, with a total of 1108 participants, mainly adults. Overall,the participants were aged between 7 and 72 years, and 74% were male. Studies mainly focused on flexor tendon injuries in zone II.
The 17 studies were heterogeneous with respect to the types of rehabilitation treatments provided, intensity, duration of treatment and the treatment setting. Each trialtested one of 14 comparisons, eight of which were of diKerent exercise regimens. The othertrials examined the timing of return to unrestricted functional activities aPer surgery (one study); the use of external devices applied to the participant to facilitate mobilisation, such as an exoskeleton (one study) or continuous passive motion device (one study); modalities such as laser therapy (two studies) or ultrasound therapy (one study); and a motor imagery treatment (one study). No trials tested diKerent types of orthoses; diKerent orthosis wearing regimens, including duration; diKerent timings for commencing mobilisation; diKerent types of scar management; or diKerent timings for commencing strengthening.
Trials were generally at high risk of bias for one or more domains, including lack of blinding, incomplete outcome data and selective
outcome reporting. Data pooling was limited to tendon rupture data in a three trial comparison. We rated the evidence available for all reported outcomes of all comparisons as very low-certainty evidence, which means that we have very little confidence in the estimates
of eKect.
We present the findings from three exercise regimen comparisons, as these are commonly used in clinical current practice.
Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol) was compared in one trial of 53 participants with mainly zone II flexor tendon repairs. There is very low-certainty evidence of no clinically important diKerence between the two groups in patient-rated function or active fingerrange of motion at 6 or 12 months follow-up. There is very low-certainty evidence oflittlebetween-groupdiKerence inadverse events:therewere 15 overall.Allthree tendonrupturesunderwent secondary surgery.
An active exercise regimen versus an immobilisation regimen for three weeks was compared in one trial reporting data for 84 participants with zone II flexor tendon repairs. The trial did not report on self-rated function, on range of movement during three to six months or numbers of participants experiencing adverse events. The very low-certainty evidence for poor (under one-quarter that of normal) range of finger movement at one to three years follow-up means we are uncertain of the finding of zero cases in the active group versus seven cases in the immobilisation regimen. The same uncertainty applies to the finding of little diKerence between the two groups in adverse events (5 tendon ruptures in the active group versus 10 probable scar adhesion in the immobilisation group) indicated for surgery.
Place and hold exercise regimen performed within an orthosis versus a controlled passive regimen using rubber band traction was
compared in three heterogeneous trials, which reported data for a maximum of 194 participants, with mainly zone II flexor tendon repairs.
The trials did not report on range of movement during three to six months, or numbers of participants experiencing adverse events. There was very low-certainty evidence of no diKerence in self-rated function using theDisability ofthe Arm, Shoulder andHand (DASH) functional assessment between the two groups at six months (one trial) or at 12 months (one trial). There is very low-certainty evidence from one trial of greater active finger range of motion at 12 months aPer place and hold. Secondary surgery data were not available; however, all seven recorded tendon ruptures would have required surgery.
All the evidence for the other five exercise comparisons as well as those of the other six comparisons made by the included studies was incomplete and, where available, of very low-certainty