Alessia Rabini

A systematic review of conservative treatment of carpal tunnel syndrome

Objective : To assess the effectiveness of conservative therapy in carpal tunnel syndrome. Data sources : A computer-aided search of MEDLINE and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) from January 1985 to May 2006. Review methods : RCTs were included if: (1) the patients, with clinically and electrophysiologically confirmed carpal tunnel syndrome, had not previously undergone surgical release, (2) the efficacy of one or more conservative treatment options was evaluated, (3) the study was designed as a randomized controlled trial. Two reviewers independently selected the studies and performed data extraction using a standardized form. In order to assess the methodological quality, the criteria list of the Cochrane Back Review Group for systematic reviews was applied. The different treatment methods were grouped (local injections, oral therapies, physical therapies, therapeutic exercises and splints). Results : Thirty-three RCTs were included in the review. The studies were analysed to determine the strength of the available evidence for the efficacy of the treatment. Our review shows that: (1) locally injected steroids produce a significant but temporary improvement, (2) vitamin B6 is ineffective, (3) steroids are better than non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, but they can produce side-effects, (4) ultrasound is effective while laser therapy shows variable results, (5) exercise therapy is not effective, (6) splints are effective, especially if used full-time. Conclusion : There is: (1) strong evidence (level 1) on efficacy of local and oral steroids; (2) moderate evidence (level 2) that vitamin B6 is ineffective and splints are effective and (3) limited or conflicting evidence (level 3) that NSAIDs, diuretics, yoga, laser and ultrasound are effective whereas exercise therapy and botulinum toxin B injection are ineffective.

Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty

Objective: To examine the effect of pre-operative physiotherapy before hip arthroplasty in patients with end-stage hip osteoarthritis. Design: A prospective randomized controlled study. Setting: Physical medicine and rehabilitation and orthopaedic departments of Policlinico Gemelli of Rome. Subjects: Twenty-three patients randomized in study and control groups. Intervention: The study group took part in an educational and physiotherapy programme one month before surgery. Both groups took part in the same inpatient rehabilitation programme after surgery. Main outcome measures: Both groups were evaluated one month (T0) and the day before arthroplasty (T1), after 15 days (T2), four weeks (T3) and three months (T4) post surgery, using the Barthel Index, the Short Form-36 (SF-36), the Western Ontario and McMaster Osteoarthritis Index (WOMAC), the Hip Harris Score (HHS), visual analogue scale (VAS), the British Medical Research Council (BMRC) measures of hip abductor and quadriceps strength and range of hip abduction and external rotation. Results: There were no significant differences between groups with regard to the Barthel Index, SF-36, WOMAC and HHS at T4. The study group presented significant improvements of the SF-36 physical composite score at T1. The hip external rotation was significantly higher in the study group at each evaluation and the visual analogue scale values were lower at T1, T3 and T4. Conclusion: Pre-operative physiotherapy in patients undergoing hip arthroplasty does not improve impairment and health-related quality of life after intervention. Physiotherapy and educational therapy may be useful for end-stage osteoarthritis.

Effects of Local Microwave Diathermy on Shoulder Pain and Function in Patients With Rotator Cuff Tendinopathy in Comparison to Subacromial Corticosteroid Injections: A Single-Blind Randomized Trial

STUDY DESIGN Single-blind randomized clinical trial, with a follow-up of 24 weeks. OBJECTIVE To determine the effects of hyperthermia via localized microwave diathermy on pain and disability in comparison to subacromial corticosteroid injections in patients with rotator cuff tendinopathy. BACKGROUND Hyperthermia improves symptoms and function in several painful musculoskeletal disorders. However, the effects of microwave diathermy in rotator cuff tendinopathy have not yet been established. METHODS Ninety-two patients with rotator cuff tendinopathy and pain lasting for at least 3 months were recruited from the outpatient clinic of the Department of Orthopaedics and Traumatology, University Hospital, Rome, Italy. Participants were randomly allocated to either local microwave diathermy or subacromial corticosteroids. The primary outcome measure was the short form of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH). Secondary outcome measures were the Constant-Murley shoulder outcome score and a visual analog scale for pain assessment. RESULTS At the end of treatment and at follow-up, both treatment groups experienced improvements in all outcome measures relative to baseline values. Changes over time in QuickDASH, Constant-Murley, and visual analog scale scores were not different between treatment arms. CONCLUSION In patients with rotator cuff tendinopathy, the effects of localized microwave diathermy on disability, shoulder function, and pain are equivalent to those elicited by subacromial corticosteroid injections.

Short-term effects of local microwave hyperthermia on pain and function in patients with mild to moderate carpal tunnel syndrome: a double blind randomized sham-controlled trial

Objective: To determine the short-term effects of local microwave hyperthermia on pain and function in patients with mild to moderate idiopathic carpal tunnel syndrome. Design: Double-blind randomized sham-controlled trial. Setting: Outpatient clinic of the Department of Physical Medicine and Rehabilitation, University Hospital. Participants: Twenty-two patients with idiopathic carpal tunnel syndrome, 12 of whom had bilateral involvement, for a total of 34 wrists, divided into two groups: a hyperthermia active treatment group (number of wrists = 17) and a sham-controlled group (number of wrists = 17). Intervention: Six sessions, two per week, of either hyperthermia or sham treatment were provided over a period of three weeks. Main measures: Visual analogue scale, Levine–Boston Self-Assessment Questionnaire (part I: evaluation of pain intensity; part II: evaluation of functional status) and neurophysiological assessments, were determined at baseline and at the end of the treatment. Results: The hyperthermia group experienced a significant improvement in pain (visual analogue scale: P = 0.002; Levine–Boston part I: P < 0.0001) and functional status (Levine–Boston part II: P = 0.002) relative to baseline. No improvements in pain intensity or functionality were observed in the sham-treated group. Changes in pain severity between baseline and the end of treatment were larger in the hyperthermia group than in the sham-controlled group (Δ visual analogue scale P = 0.004; Δ Levine–Boston part I: P = 0.009). No differences either intra or between groups were observed for median nerve conduction velocity. Conclusion: Hyperthermia provides short-term improvements in pain and function in patients with mild to moderate carpal tunnel syndrome.

RAsCH vAlIDATIOn Of THE ACTIvITIEs-sPECIfIC BAlAnCE COnfIDEnCE sCAlE AnD ITs sHORT vERsIOns In PATIEnTs wITH PARkInsOn's DIsEAsE

OBJECTIVE To analyse in patients with Parkinsons disease the psychometric performance of the Activities-specific Balance Confidence scale (ABC) and its 3 short versions, using both a classical test theory approach and Rasch analysis. METHODS A sample of 217 patients with Parkinsons disease was assessed by ABC and the 3 short versions: Berg Balance Scale, Fear of Falling Measure, and the Unified Parkinsons Disease Rating Scale. RESULTS Cronbachs α was 0.95 in ABC, and ranged from 0.88 to 0.90 in its short versions. At Rasch analysis the 11 original rating categories were collapsed to 5 levels. In ABC 15 out of 16 items fitted the Rasch model. The ABC showed high correlation only with Fear of Falling Measure (r = 0.85), and excellent correlation with its short versions (r > 0.93). The 3 short versions showed a limited range of item difficulty estimates, low reliability levels, floor effect, a mismatch between mean item difficulty and mean ability of the patients. CONCLUSION In patients with Parkinsons disease: (i) the ABC has an adequate unidimensionality; (ii) the selection of its items is satisfactory, although there is room for some minor refinement; (iii) the 0-10 rating scale should be simplified, and a 5-level response format seems able to improve the measurement qualities of the scale; (iv) the 3 short versions showed some psychometric limitations in comparison with the ABC.

Technological Advances in Instrumental Assessment in Rehabilitation

In rehabilitation research, interest in instrumental assessment is rapidly growing, particularly in the last decade. A large number of tools for instrumental assessment are now available, evaluating different aspects of the single patient or patient groups. Most of these assessment tools are disease-specific and common to other medical disciplines, for example, goniometers, and clinical tests or scales that monitor patient impairment [1]. Technological advances now make it possible to perform an in-depth evaluation of patients, analyzing their abilities across a wide range of performances. In rehabilitation, high-technology assessment tools mainly concern diagnostic devices—used to obtain outcome measurements of variables of interest—or specific equipment that is necessary to apply the tests. In fact, in a period of increasing application of measures in clinical practice, quality control, and audit procedures, assessment has become a key process in the drive to replace the empirical approach with a scientific methodology, fundamental both to the practice of evidence-based medicine and to the strengthening of the quality of research [1]. Assessment is mainly based on a measurement process characterized by the assignment of numerical values or categories to show (according to predefined rules) the quantity of certain characteristics, functions, or behaviors. The possibility of having an objective measurement represents a fundamental advantage in several ways; for example, it provides a scientific basis for interprofessional communication, it documents the effectiveness of treatments, and it attests their scientific credibility. Therefore, researchers are motivated to develop new instrumental assessment tools or improve old ones, demonstrating their good psychometric properties and limits. On the other hand, clinicians, who are going to use a measuring instrument, are invited to base their choice on the presence of the psychometric characteristics necessary for the specific purpose and context (preferring instruments for which the application has already been tested under conditions similar to those of interest). Numerous scientific studies have described the main criteria for selecting an outcome measure [2, 3] and/or evaluating in detail its main psychometric properties and practices [4]. In general, the basic criterion for the choice of an instrumental assessment tool is the presence (as demonstrated through scientific publications) of adequate levels of reliability (the degree to which a measurement is free from error and, hence, the observed score gives a “true” picture), validity (degree of accuracy with which a tool measures what it is intended to measure), and responsiveness (the ability of an instrument to identify modifications or significant differences from the clinical point of view). The first two criteria are necessary for discriminative purposes (differences between subjects or groups) and predictive purposes (classification of subjects in predefined classes for prognostic purposes), while for evaluation purposes (i.e., to detect changes over time within subjects, as in the case of analysis of effectiveness of therapeutic interventions) a good level of responsiveness is also needed. Other requirements that are extremely important to consider when selecting an outcome measure are the appropriateness (degree to which the instrument responds to the questions that the specific evaluation intends to study) and accuracy (the degree to which the measuring instrument is able to capture real differences) [2, 5]. In this special issue, we invited researchers to contribute with original research articles as well as reviews investigating the benefits of instrumental assessment or to propose new technological modalities for instrumental assessment in rehabilitation. Our aim is to stimulate researchers to publish their research in the field of technological assessment in PMR. A wide array of topics is discussed in this special issue, related to areas such as strength assessment, posture, balance and gait analysis, functional assessment tools, and cognitive and robotic assessment. Robotic devices and passive instrumented orthoses have been proposed to assess upper limb patients affected by stroke. New software for computers has been shown to improve the cognitive assessment of neurological patients, facilitating the creation of large databases and opening up new opportunities for home-based rehabilitation. Novel technological devices and assessment protocols have been demonstrated to be reliable in the evaluation of basic motor performances, in postural control, and in gait analysis. We are edified by the large number of papers submitted and by their high scientific level. Finally, we wish to thank not only the authors but also the expert reviewers who, with their valuable work, have made possible the publication of this special issue. Giorgio Ferriero Stefano Carda Sasa Moslavac Alessia Rabini