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Meta-Analysis
. 2021 Jan 13;1(1):CD012479.
doi: 10.1002/14651858.CD012479.pub2.

Rehabilitation following surgery for flexor tendon injuries of the hand

Susan E Peters  1   2 , Bhavana Jha  1   3   4 , Mark Ross  1   5   6
Affiliations
Meta-Analysis

Rehabilitation following surgery for flexor tendon injuries of the hand

Susan E Peters et al. Cochrane Database Syst Rev. .

Abstract

Background: Various rehabilitation treatments may be offered following surgery for flexor tendon injuries of the hand. Rehabilitation often includes a combination of an exercise regimen and an orthosis, plus other rehabilitation treatments, usually delivered together. The effectiveness of these interventions remains unclear.

Objectives: To assess the effects (benefits and harms) of different rehabilitation interventions after 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 international trials 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 different 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 trial tested one of 14 comparisons, eight of which were of different exercise regimens. The other trials examined the timing of return to unrestricted functional activities after 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 different types of orthoses; different orthosis wearing regimens, including duration; different timings for commencing mobilisation; different types of scar management; or different 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 effect. 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 difference between the two groups in patient-rated function or active finger range of motion at 6 or 12 months follow-up. There is very low-certainty evidence of little between-group difference in adverse events: there were 15 overall. All three tendon ruptures underwent 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 difference 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 difference in self-rated function using the Disability of the Arm, Shoulder and Hand (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 after 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.

Authors' conclusions: There is a lack of evidence from RCTs on most of the rehabilitation interventions used following surgery for flexor tendon injuries of the hand. The limited and very low-certainty evidence for all 14 comparisons examined in the 17 included studies means that we have very little confidence in the estimates of effect for all outcomes for which data were available for these comparisons. The dearth of evidence identified in this review points to the urgent need for sufficiently powered RCTs that examine key questions relating to the rehabilitation of these injuries. A consensus approach identifying these and establishing minimum study conduct and reporting criteria will be valuable. Our suggestions for future research are detailed in the review.

PubMed Disclaimer

Conflict of interest statement

SP: none known. BJ: none known. MR: none known.

Figures

1
1
Diagram showing the flow of studies through the study selection process
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.2
1.2. Analysis
Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 2: Self‐reported function using VAS for ADLs (0 to 10; higher scores = better); secondary analyses
1.3
1.3. Analysis
Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 3: Active finger range of motion (degrees)
1.4
1.4. Analysis
Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 4: Finger range of movement ‐ Poor outcome
1.5
1.5. Analysis
Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 5: Adverse events
1.6
1.6. Analysis
Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 6: Strength (% of the contralateral hand or digit)
2.1
2.1. Analysis
Comparison 2: Early active flexion + active extension exercise regimen (+ modified Kessler suture surgical technique) versus passive flexion + active extension exercise regimen (+ grasping suture and external pull‐out knot surgical technique), Outcome 1: Adverse events
3.1
3.1. Analysis
Comparison 3: Active exercise regimen versus immobilisation regimen, Outcome 1: Range of movement at 12+ months: poor outcome
3.2
3.2. Analysis
Comparison 3: Active exercise regimen versus immobilisation regimen, Outcome 2: Adverse events
4.1
4.1. Analysis
Comparison 4: Early place and hold progressed to tendon gliding exercise regimen versus early passive progressed to active exercise regimen, Outcome 1: Grip strength at 12 weeks (% difference between normal and affected hands)
5.1
5.1. Analysis
Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 1: Function (self‐reported): DASH scores (0 to 100; higher score = more disability)
5.2
5.2. Analysis
Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 2: Range of movement (Total Active Movement) (degrees)
5.3
5.3. Analysis
Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 3: Range of movement (Strickland Criteria) at 8 weeks: Poor outcome
5.4
5.4. Analysis
Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 4: Adverse events
5.5
5.5. Analysis
Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 5: Function (observed): Jebsen Taylor at 52 weeks (seconds)
5.6
5.6. Analysis
Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 6: Function (observed): Purdue pegboard at 52 weeks (pegs)
5.7
5.7. Analysis
Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 7: Satisfaction with hand function (0 to 10: complete satisfaction) at 6 months
6.1
6.1. Analysis
Comparison 6: Unrestricted activity at 8 weeks post‐surgery versus unrestricted activity at 10 weeks, Outcome 1: Adverse event (tendon rupture)
7.1
7.1. Analysis
Comparison 7: Exoskeleton versus physiotherapy, Outcome 1: Function (self‐reported): DASH scores (0 to 100; higher score = more disability)
7.2
7.2. Analysis
Comparison 7: Exoskeleton versus physiotherapy, Outcome 2: Active finger range of motion of PIP joint (degrees)
7.3
7.3. Analysis
Comparison 7: Exoskeleton versus physiotherapy, Outcome 3: Active finger range of motion of DIP joint (degrees)
7.4
7.4. Analysis
Comparison 7: Exoskeleton versus physiotherapy, Outcome 4: Active finger range of motion (Total Active Movement) (degrees)
7.5
7.5. Analysis
Comparison 7: Exoskeleton versus physiotherapy, Outcome 5: Adverse events
7.6
7.6. Analysis
Comparison 7: Exoskeleton versus physiotherapy, Outcome 6: Strength at 18 weeks
8.1
8.1. Analysis
Comparison 8: Continuous passive motion device versus controlled passive progressed to active exercise regimen (Modified Kleinert), Outcome 1: Active finger range of motion (degrees)
8.2
8.2. Analysis
Comparison 8: Continuous passive motion device versus controlled passive progressed to active exercise regimen (Modified Kleinert), Outcome 2: Range of movement at > 6 months (Strickland criteria) ‐ poor outcome
8.3
8.3. Analysis
Comparison 8: Continuous passive motion device versus controlled passive progressed to active exercise regimen (Modified Kleinert), Outcome 3: Adverse event
9.1
9.1. Analysis
Comparison 9: Ultrasound versus control, Outcome 1: Improvement in active range of movement (Difference between 3 and 12 weeks; Total Active Motion measured in degrees)
9.2
9.2. Analysis
Comparison 9: Ultrasound versus control, Outcome 2: Active finger range of motion (Strickland classification) at 3 months ‐ Poor outcome
9.3
9.3. Analysis
Comparison 9: Ultrasound versus control, Outcome 3: Adverse events
10.1
10.1. Analysis
Comparison 10: Low‐level laser therapy versus placebo control, Outcome 1: Active finger range of motion (Total active motion (degrees)) at 12 weeks
10.2
10.2. Analysis
Comparison 10: Low‐level laser therapy versus placebo control, Outcome 2: Range of movement at 12 weeks: poor outcome
10.3
10.3. Analysis
Comparison 10: Low‐level laser therapy versus placebo control, Outcome 3: Adverse events
10.4
10.4. Analysis
Comparison 10: Low‐level laser therapy versus placebo control, Outcome 4: Grip strength at 12 weeks (% lost using uninjured hand as comparison)
11.1
11.1. Analysis
Comparison 11: Motor imagery versus control, Outcome 1: Strength (kg)
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD012479

References

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References to studies excluded from this review

Bainbridge 1994 {published data only}
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References to studies awaiting assessment

Kitis 2009 {published data only}
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Liu 2004 {published data only}
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Naude 2019 {published data only}
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References to ongoing studies

CTRI/2019/01/016821 {published data only}CTRI/2019/01/016821
    1. CTRI/2019/01/016821. Comparison of conventional hand therapy and assistive device in the rehabilitation of flexor tendon injuries. apps.who.int/trialsearch/Trial2.aspx?TrialID=CTRI/2019/01/016821 (first received 1 January 2019).
IRCT201310138177N8 {published data only}IRCT201310138177N8
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IRCT20150721023277N7 {published data only}IRCT20150721023277N7
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NCT03812978 {published data only}NCT03812978
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NCT03850210 {published data only}NCT03850210
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References to other published versions of this review

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