BACKGROUND: Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve causing pain and numbness and tingling typically in the thumb, index and middle finger. It sometimes results in muscle wasting, diminished sensitivity and loss of dexterity. Splinting the wrist (with or without the hand) using an orthosis is usually offered to people with mild-to-moderate findings, but its effectiveness remains unclear.
OBJECTIVES: To assess the effects (benefits and harms) of splinting for people with CTS.
SEARCH METHODS: On 12 December 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov, and WHO ICTRP with no limitations. We checked the reference lists of included studies and relevant systematic reviews for studies.
SELECTION CRITERIA: Randomised trials were included if the effect of splinting could be isolated from other treatment modalities. The comparisons included splinting versus no active treatment (or placebo), splinting versus another disease-modifying non-surgical treatment, and comparisons of different splint-wearing regimens. We excluded studies comparing splinting with surgery or one splint design with another. We excluded participants if they had previously undergone surgical release.
DATA COLLECTION AND ANALYSIS: Review authors independently selected trials for inclusion, extracted data, assessed study risk of bias and the certainty in the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology.
MAIN RESULTS: We included 29 trials randomising 1937 adults with CTS. The trials ranged from 21 to 234 participants, with mean ages between 42 and 60 years. The mean duration of CTS symptoms was seven weeks to five years. Eight studies with 523 hands compared splinting with no active intervention (no treatment, sham-kinesiology tape or sham-laser); 20 studies compared splinting (or splinting delivered along with another non-surgical intervention) with another non-surgical intervention; and three studies compared different splinting regimens (e.g. night-time only versus full time). Trials were generally at high risk of bias for one or more domains, including lack of blinding (all included studies) and lack of information about randomisation or allocation concealment in 23 studies. For the primary comparison, splinting compared to no active treatment, splinting may provide little or no benefits in symptoms in the short term (< 3 months). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) (scale 1 to 5, higher is worse; minimal clinically important difference (MCID) 1 point) was 0.37 points better with splint (95% confidence interval (CI) 0.82 better to 0.08 worse; 6 studies, 306 participants; low-certainty evidence) compared with no active treatment. Removing studies with high or unclear risk of bias due to lack of randomisation or allocation concealment supported our conclusion of no important effect (mean difference (MD) 0.01 points worse with splint; 95% CI 0.20 better to 0.22 worse; 3 studies, 124 participants). In the long term (> 3 months), we are uncertain about the effect of splinting on symptoms (mean BCTQ SSS 0.64 better with splinting; 95% CI 1.2 better to 0.08 better; 2 studies, 144 participants; very low-certainty evidence). Splinting probably does not improve hand function in the short term and may not improve hand function in the long term. In the short term, the mean BCTQ Functional Status Scale (FSS) (1 to 5, higher is worse; MCID 0.7 points) was 0.24 points better (95% CI 0.44 better to 0.03 better; 6 studies, 306 participants; moderate-certainty evidence) with splinting compared with no active treatment. In the long term, the mean BCTQ FSS was 0.25 points better (95% CI 0.68 better to 0.18 worse; 1 study, 34 participants; low-certainty evidence) with splinting compared with no active treatment. Night-time splinting may result in a higher rate of overall improvement in the short term (risk ratio (RR) 3.86, 95% CI 2.29 to 6.51; 1 study, 80 participants; number needed to treat for an additional beneficial outcome (NNTB) 2, 95% CI 2 to 2; low-certainty evidence). We are uncertain if splinting decreases referral to surgery, RR 0.47 (95% CI 0.14 to 1.58; 3 studies, 243 participants; very low-certainty evidence). None of the trials reported health-related quality of life. Low-certainty evidence from one study suggests that splinting may have a higher rate of adverse events, which were transient, but the 95% CIs included no effect. Seven of 40 participants (18%) reported adverse effects in the splinting group and 0 of 40 participants (0%) in the no active treatment group (RR 15.0, 95% CI 0.89 to 254.13; 1 study, 80 participants). There was low- to moderate-certainty evidence for the other comparisons: splinting may not provide additional benefits in symptoms or hand function when given together with corticosteroid injection (moderate-certainty evidence) or with rehabilitation (low-certainty evidence); nor when compared with corticosteroid (injection or oral; low certainty), exercises (low certainty), kinesiology taping (low certainty), rigid taping (low certainty), platelet-rich plasma (moderate certainty), or extracorporeal shock wave treatment (moderate certainty). Splinting for 12 weeks may not be better than six weeks, but six months of splinting may be better than six weeks of splinting in improving symptoms and function (low-certainty evidence).
AUTHORS' CONCLUSIONS: There is insufficient evidence to conclude whether splinting benefits people with CTS. Limited evidence does not exclude small improvements in CTS symptoms and hand function, but they may not be clinically important, and the clinical relevance of small differences with splinting is unclear. Low-certainty evidence suggests that people may have a greater chance of experiencing overall improvement with night-time splints than no treatment. As splinting is a relatively inexpensive intervention with no plausible long-term harms, small effects could justify its use, particularly when patients are not interested in having surgery or injections. It is unclear if a splint is optimally worn full time or at night-time only and whether long-term use is better than short-term use, but low-certainty evidence suggests that the benefits may manifest in the long term.
BACKGROUND: Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well-being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients' global impression of change for certain chronic pain conditions. However, there has not been a network meta-analysis (NMA) examining all antidepressants across all chronic pain conditions.
OBJECTIVES: To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache).
SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022.
SELECTION CRITERIA: We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double-blind. We included RCTs with active comparators that were unable to be double-blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow-up was less than two weeks and those with fewer than 10 participants in each arm. DATA COLLECTION AND ANALYSIS: Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta-analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta-Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta-analysis (ROB-MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB-MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal.
MAIN RESULTS: This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo-controlled (83), and parallel-armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short-term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest-ranked antidepressant with moderate- to high-certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate-certainty evidence) and continuous pain intensity (standardised mean difference (SMD) -0.31, 95% CI -0.39 to -0.24; 18 studies, 4959 participants; moderate-certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD -0.22, 95% CI -0.39 to 0.06; 4 studies, 1866 participants; moderate-certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD -0.5, 95% CI -0.78 to -0.22; 1 study, 406 participants; low-certainty evidence), while duloxetine showed a small effect (SMD -0.16, 95% CI -0.22 to -0.1; 26 studies, 7952 participants; moderate-certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest-ranked antidepressants with moderate-certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low-certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes.
AUTHORS' CONCLUSIONS: Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high-quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long-term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point.
BACKGROUND: Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012.
OBJECTIVES: To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU).
SEARCH METHODS: We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials.
SELECTION CRITERIA: RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end.
DATA COLLECTION AND ANALYSIS: Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment.
MAIN RESULTS: We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned.
AUTHORS' CONCLUSIONS: We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT.
BACKGROUND: Assistive products are items which allow older people and people with disabilities to be able to live a healthy, productive and dignified life. It has been estimated that approximately 1.5% of the world's population need a prosthesis or orthosis.
OBJECTIVE: The objective of this study was to systematically identify and review the evidence from randomized controlled trials assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions.
METHODS: Literature searches, completed in September 2015, were carried out in fourteen databases between years 1995 and 2015. The search results were independently screened by two reviewers. For the purpose of this manuscript, only randomized controlled trials which examined interventions using orthotic or prosthetic devices were selected for data extraction and synthesis.
RESULTS: A total of 342 randomised controlled trials were identified (319 English language and 23 non-English language). Only 4 of these randomised controlled trials examined prosthetic interventions and the rest examined orthotic interventions. These orthotic interventions were categorised based on the medical conditions/injuries of the participants. From these studies, this review focused on the medical condition/injuries with the highest number of randomised controlled trials (osteoarthritis, fracture, stroke, carpal tunnel syndrome, plantar fasciitis, anterior cruciate ligament, diabetic foot, rheumatoid and juvenile idiopathic arthritis, ankle sprain, cerebral palsy, lateral epicondylitis and low back pain). The included articles were assessed for risk of bias using the Cochrane Risk of Bias tool. Details of the clinical population examined, the type of orthotic/prosthetic intervention, the comparator/s and the outcome measures were extracted. Effect sizes and odds ratios were calculated for all outcome measures, where possible.
CONCLUSIONS: At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high quality research to allow strong conclusions on their effectiveness and cost-effectiveness.
OBJECTIVES: Many interventions are available to manage chronic pain; understanding the durability of treatment effects may assist with treatment selection. We sought to assess which noninvasive nonpharmacological treatments for selected chronic pain conditions are associated with persistent improvement in function and pain outcomes at least 1 month after the completion of treatment.
DATA SOURCES: Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews) through November 2017, reference lists, and ClinicalTrials.gov.
REVIEW METHODS: Using predefined criteria, we selected randomized controlled trials of noninvasive nonpharmacological treatments for five common chronic pain conditions (chronic low back pain; chronic neck pain; osteoarthritis of the knee, hip, or hand; fibromyalgia; and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to <6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months).
RESULTS: Two hundred eighteen publications (202 trials) were included. Many included trials were small. Evidence on outcomes beyond 1 year after treatment completion was sparse. Most trials enrolled patients with moderate baseline pain intensity (e.g., >5 on a 0 to 10 point numeric rating scale) and duration of symptoms ranging from 3 months to >15 years. The most common comparison was against usual care. Chronic low back pain: At short term, massage, yoga, and psychological therapies (primarily CBT) (strength of evidence [SOE]: moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain. Effects on intermediate-term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (SOE: low), and psychological therapies (SOE: moderate). Improvements in pain continued into intermediate term for exercise, massage, and yoga (moderate effect, SOE: low); mindfulness-based stress reduction (small effect, SOE: low); spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects, SOE: moderate). For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term (SOE: low). Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (SOE: moderate). At short and intermediate term, multidisciplinary rehabilitation slightly improved pain compared with exercise (SOE: moderate). High-intensity multidisciplinary rehabilitation (≥20 hours/week or >80 hours total) was not clearly better than non–high-intensity programs. Chronic neck pain: At short and intermediate terms, acupuncture and Alexander Technique were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: low), but no improvement in pain was seen at any time (SOE: llow). Short-term low-level laser therapy was associated with moderate improvement in function and pain (SOE: moderate). Combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function short and long term (SOE: low). Osteoarthritis: For knee osteoarthritis, exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control, or sham procedure (SOE: moderate for exercise, low for ultrasound), which persisted into the intermediate term only for exercise (SOE: low). Exercise was also associated with moderate improvement in pain (SOE: low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (SOE: low). Evidence was sparse on interventions for hip and hand osteoarthritis . Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care short term (SOE: low). The effect on function was sustained intermediate term (SOE: low). Fibromyalgia: In the short term, acupuncture (SOE: moderate), CBT, tai chi, qigong, and exercise (SOE: low) were associated with slight improvements in function compared with an attention control, sham, no treatment, or usual care. Exercise (SOE: moderate) and CBT improved pain slightly, and tai chi and qigong (SOE: low) improved pain moderately in the short term. At intermediate term for exercise (SOE: moderate), acupuncture, and CBT (SOE: low), slight functional improvements persisted; they were also seen for myofascial release massage and multidisciplinary rehabilitation (SOE: low); pain was improved slightly with multidisciplinary rehabilitation in the intermediate term (SOE: low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: low for all); massage (SOE: low) improved long-term pain slightly, but no clear impact on pain for exercise (SOE: moderate) or multidisciplinary rehabilitation (SOE: low) was seen. Short-term CBT was associated with a slight improvement in function but not pain compared with pregabalin. Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain short term versus usual care, and laser acupuncture was associated with slight pain improvement short term compared with sham (SOE: low). There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited.
CONCLUSIONS: Exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions. Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.
Antecedentes: El dolor lumbar (LBP) se asocia con enormes cargas personales y sociales, especialmente cuando alcanza el estado crónico del trastorno (dolor de más de tres meses). De hecho, las personas que llegan a la etapa crónica tienden a mostrar un curso más persistente, y representan la mayoría de los costos sociales y económicos. Como resultado, cada vez se hace más hincapié en la importancia de intervenir en las primeras etapas de la LBP. Según el modelo biopsicosocial, LBP es una condición mejor entendida con referencia a una interacción de influencias físicas, psicológicas y sociales. Esto ha llevado al desarrollo de programas multidisciplinarios de rehabilitación biopsicosocial (MBR) que apuntan a factores de los diferentes dominios, administrados por profesionales de la salud de diferentes antecedentes.Esta revisión es una actualización de una revisión Cochrane de MBR para LBP subaguda, que fue publicado en 2003 .Es parte de una serie de revisiones sobre MBR para el dolor musculoesquelético publicado por el Cochrane Back and Neck Group y el Cochrane Musculoskeletal Group. OBJETIVOS: Examinar la efectividad de MBR para LBP subaguda (dolor de una duración de seis a 12 semanas) en adultos, con énfasis en el dolor, discapacidad específica en la espalda y estado laboral. Métodos de búsqueda: Se buscaron ensayos relevantes en cualquier idioma mediante una búsqueda asistida por ordenador de CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO y dos registros de ensayos. Nuestra búsqueda es actual hasta el 13 de julio de 2016. CRITERIOS DE SELECCIÓN: Se incluyeron ensayos controlados aleatorios (ECA) de adultos con LBP subaguda. Se incluyeron estudios que investigaron un programa MBR en comparación con cualquier tipo de intervención de control. Definimos MBR como una intervención que incluía un componente físico (por ejemplo, farmacológico, fisioterapia) en combinación con un componente psicológico, social o ocupacional (o cualquier combinación de estos). También se requiere la participación de profesionales de la salud de por lo menos dos diferentes antecedentes clínicos con la formación adecuada para entregar el componente para el que eran responsables. Recopilación y análisis de datos: Se utilizaron procedimientos metodológicos estándar esperados por Cochrane. En particular, la extracción de datos y la evaluación del "riesgo de sesgo" fueron realizadas por dos personas, independientemente. Utilizamos la herramienta Cochrane para evaluar el riesgo de sesgo y el enfoque GRADE para evaluar la calidad general de la evidencia para cada resultado. PRINCIPALES RESULTADOS: En esta revisión se incluyeron un total de nueve ECA (981 participantes). Cinco estudios se realizaron en Europa y cuatro en América del Norte. El tamaño de las muestras osciló entre 33 y 351. La edad media entre los ensayos varió entre 32.0 y 43.7 años. Todos los estudios incluidos se consideraron con alto riesgo de sesgo de desempeño y alto riesgo de sesgo de detección debido a la falta de cegamiento y cuatro de los nueve estudios Sufrieron al menos una fuente adicional de sesgo posible. En el MBR comparado con el cuidado habitual para LBP subaguda, los individuos que recibieron MBR tuvieron menos dolor (cuatro estudios con 336 participantes, SMD -0,46; IC del 95%: -0,70 a -0,21; De la evidencia debido al riesgo de sesgo) y menos discapacidad (tres estudios con 240 participantes, SMD -0,44, IC del 95%: -0,87 a -0,01, baja calidad de evidencia debido al riesgo de sesgo e inconsistencia) De regreso al trabajo (tres estudios con 170 participantes, OR 3.19, IC del 95%: 1.46 a 6.98, muy baja calidad de la evidencia debido al grave riesgo de sesgo e imprecisión) y menos días de baja por enfermedad (dos estudios con 210 participantes; SMD -0,38 IC del 95% -0,66 a -0,10, baja calidad de evidencia debida t O riesgo de sesgo e imprecisión) a los 12 meses de seguimiento. Los tamaños del efecto para el dolor y la discapacidad fueron bajos en términos de significado clínico, mientras que los efectos para los resultados relacionados con el trabajo estaban en el rango moderado. Sin embargo, al comparar el MBR con otros tratamientos (es decir, intervención breve con características de un programa ligero de movilización y una calificación Programa de actividad, restauración funcional, intervención clínica breve incluyendo educación y asesoramiento sobre ejercicio y consejería psicológica), no se encontraron diferencias entre los grupos en cuanto al dolor (dos estudios con 336 participantes, SMD -0,14, IC del 95%: -0,36 a 0,07 , Evidencia de baja calidad debido a la imprecisión y el riesgo de sesgo), discapacidad funcional (dos estudios con 345 participantes, SMD -0,03, IC del 95%: -0,24 a 0,18, evidencia de baja calidad debido a imprecisión y riesgo de sesgo) (Dos estudios con 158 participantes, SMD -0,25 IC del 95%: -0,98 a 0,47, evidencia de muy baja calidad debido a serias imprecisiones, inconsistencia y riesgo de sesgo). El regreso al trabajo no se informó en ninguno de los estudios. Aunque buscamos eventos adversos en ambas comparaciones, ninguno de los estudios incluidos informó este resultado. Conclusiones de los autores: En promedio, las personas con LBP subaguda que reciben MBR harán mejor que si reciben atención habitual, pero no está claro si lo hacen mejor que las personas que reciben algún otro tipo de tratamiento. Sin embargo, la investigación disponible proporciona evidencia de baja a muy baja calidad, por lo que se necesitan ensayos adicionales de alta calidad antes de poder describir el valor de MBP para la práctica clínica.
La carga de dolor incapacitante y lesiones músculo-esquelético (trastornos musculoesqueléticos, MSD) se derivan de causas relacionadas con el trabajo en muchos lugares de trabajo sigue siendo considerable. Hay poco consenso sobre las intervenciones más apropiadas para los TME. Nuestro objetivo fue actualizar una revisión sistemática de las intervenciones basadas en el lugar de trabajo para la prevención y gestión de las extremidades superiores MSD (UEMSD). Seguimos un proceso de revisión sistemática desarrollada por el Instituto para el Trabajo y la Salud y una síntesis de las mejores pruebas adaptadas. 6 bases de datos electrónicas Se realizaron búsquedas (enero de 2008 hasta abril de 2013 inclusive) obteniéndose 9909 referencias no duplicados. 26 estudios de alta calidad y mediana calidad pertinentes a nuestra pregunta de investigación se combinaron con 35 a partir de la revisión original para sintetizar la evidencia en 30 categorías diferentes de intervención. Hubo una fuerte evidencia de una categoría de la intervención, el entrenamiento de resistencia, lo que lleva a la recomendación: La implementación de un programa de ejercicios de entrenamiento de resistencia basada en el lugar de trabajo puede ayudar a prevenir y controlar los síntomas y UEMSD. La síntesis también reveló pruebas moderadas para los programas de estiramiento, el uso del ratón y el antebrazo retroalimentación apoya en la prevención de UEMSD o síntomas. También hubo pruebas moderadas de ningún beneficio para la biorretroalimentación EMG, la formación en gestión estrés en el trabajo, y el ajuste de la estación de trabajo de oficina para UEMSD y los síntomas. Se proponen los mensajes tanto para éstas y otras categorías de intervención.
ANTECEDENTES CONTEXTO: En 2008, el Grupo de Dolor de cuello (NPTF) recomienda el ejercicio para el tratamiento del dolor de cuello y trastornos asociados al latigazo (WAD). Sin embargo, no hay evidencia disponible sobre la efectividad del ejercicio para el dolor cervical grado III o WAD. Además, había pruebas limitadas para contrastar la eficacia de diversos tipos de ejercicios.
PROPÓSITO: Para actualizar los resultados de la NPTF sobre la efectividad del ejercicio para el tratamiento del dolor de cuello y WAD de Grado I a III.
ESTUDIO DE DISEÑO / ESCENARIO: Revisión sistemática y síntesis de la mejor evidencia.
MUESTRA: Los estudios que compararon la efectividad del ejercicio de otras intervenciones conservadoras o ninguna intervención.
Medidas de resultado: Los resultados de interés incluyeron la recuperación autopercepción, la recuperación funcional, la intensidad del dolor, la calidad relacionada con la salud de la vida, los resultados psicológicos y / o eventos adversos.
MÉTODOS: Se realizaron búsquedas en bases de datos electrónicas ocho 2000-2013. Los estudios elegibles se evaluaron críticamente utilizando los criterios Scottish Intercollegiate Guidelines Network. Los resultados de los estudios científicamente admisibles se sintetizaron siguiendo principios síntesis de mejor evidencia.
Resultados: Se recuperaron 4.761 artículos, y 21 ensayos controlados aleatorios (ECA) se evaluaron críticamente. Diez ECA fueron científicamente admisible: nueve dolor de cuello investigado y uno dirigido WAD. Para el tratamiento del dolor reciente cuello de grado I / II, ejercicios sin supervisión de rango de movimiento, medicamentos antiinflamatorios no esteroideos y el acetaminofén o plomo terapia manual a resultados similares. Para el dolor reciente cuello de grado III, el fortalecimiento gradual supervisado es más efectivo que el consejo, pero conduce a resultados similares a corto plazo como un collarín cervical. Para el dolor de cuello persistente y WAD grado I / II, bajo la supervisión de qigong y fortalecimiento combinado, rango de movimiento, y ejercicios de flexibilidad son más eficaces que esperar lista. Además, bajo la supervisión de yoga Iyengar es más eficaz que el ejercicio en el hogar. Por último, supervisó el fortalecimiento de dosis alta no es superior a los ejercicios en casa ni de asesoramiento.
Conclusiones: Se encontró evidencia de que supervisó el qigong, yoga Iyengar, y programas combinados que incluyen el fortalecimiento, el rango de movimiento y flexibilidad son eficaces para el tratamiento del dolor de cuello persistente. No se encontró evidencia de que un programa de ejercicio supervisado es superior a otro. En general, la mayoría de los estudios informaron pequeños tamaños del efecto que sugieren que un pequeño efecto clínico se puede esperar que con el uso de ejercicio.
Antecedentes: El manejo de la enfermedad del manguito rotador a menudo incluye la terapia manual y el ejercicio, por lo general entregados juntos como componentes de una intervención de terapia física. Esta revisión forma parte de una serie de revisiones que forman una actualización de la revisión Cochrane, 'Intervenciones de fisioterapia para el dolor en el hombro'. OBJETIVOS: Sintetizar evidencia disponible sobre los beneficios y los daños de la terapia manual y el ejercicio, solo o en combinación, para el tratamiento de personas con enfermedad del manguito rotador. MÉTODOS DE BÚSQUEDA: Se realizaron búsquedas en el Registro Cochrane Central de Ensayos Controlados (CENTRAL; 2015, Número 3), Ovid MEDLINE (enero de 1966 a marzo de 2015), Ovid EMBASE (enero de 1980 a marzo de 2015), CINAHL Plus (EBSCO, enero de 1937 a marzo) 2015), ClinicalTrials.gov y los registros de ensayos clínicos de la ICTRP de la OMS hasta marzo de 2015, sin restricciones de idioma, y revisó las listas de referencias de artículos de revisión y ensayos recuperados para identificar ensayos potencialmente relevantes. Se incluyeron ensayos aleatorios y cuasialeatorios, incluyendo adultos con enfermedad del manguito rotador, y comparando cualquier terapia manual o intervención de ejercicio con placebo, ninguna intervención, otro tipo de terapia manual o ejercicio o cualquier otra intervención (por ejemplo, inyección de glucocorticoides) . Las intervenciones incluyeron movilización, manipulación y ejercicios supervisados o en casa. Los ensayos que investigan el efecto primario o complementario de la terapia manual y el ejercicio fueron las principales comparaciones de interés. Los principales resultados de interés fueron el dolor general, la función, el dolor al movimiento, la evaluación global del éxito del tratamiento, la calidad de vida y el número de participantes que experimentaron eventos adversos. Dos revisores seleccionaron de forma independiente los ensayos para su inclusión, extrajeron los datos, realizaron una evaluación del riesgo de sesgo y evaluaron la calidad del cuerpo de evidencia para los principales resultados utilizando el enfoque GRADE. Se incluyeron 60 ensayos (3620 participantes), aunque sólo 10 se refirieron a las principales comparaciones de interés. El riesgo general de sesgo fue bajo en tres, poco claro en 14 y alto en 43 ensayos. No pudimos realizar ningún metanálisis debido a la heterogeneidad clínica o el informe incompleto de los resultados. Un ensayo comparó la terapia manual y el ejercicio con placebo (terapia de ultrasonido inactiva) en 120 participantes con enfermedad crónica del manguito rotador (evidencia de alta calidad). A las 22 semanas, el cambio medio en el dolor total con placebo fue de 17,3 puntos en una escala de 100 puntos y 24,8 puntos con terapia manual y ejercicio (diferencia de medias ajustada (MD) 6,8 puntos, intervalo de confianza del 95% (IC) -0,70 a 14,30 puntos, diferencia absoluta de riesgo 7%, 1% menos a 14% más). El cambio medio en la función con placebo fue de 15,6 puntos en una escala de 100 puntos y de 22,4 puntos con terapia manual y ejercicio (MD ajustado 7,1 puntos, IC del 95% 0,30 a 13,90 puntos, diferencia de riesgo absoluto 7%, 1% a 14% más ). Cincuenta y siete por ciento (31/54) de los participantes informaron el éxito del tratamiento con la terapia manual y el ejercicio en comparación con el 41% (24/58) de los participantes que recibieron placebo (RR 1,39, IC del 95%: 0,94 a 2,03, riesgo absoluto El 31% (17%) de los participantes informaron eventos adversos con terapia manual y ejercicio, en comparación con el 8% (5/61) de los participantes que recibieron placebo (RR 3,77, 95% IC 1,49 a 9,54, diferencia de riesgo absoluto 23% (9% a 37% más) Sin embargo, los eventos adversos fueron leves (dolor a corto plazo después del tratamiento) .Cinco ensayos (pruebas de baja calidad) no encontraron diferencias importantes entre la terapia manual y Ejercicio comparado con la inyección de glucocorticoides con respecto al dolor general, la función, la abducción activa del hombro y la calidad de vida de cuatro semanas hasta 12 meses Sin embargo, el éxito del tratamiento global fue más común hasta 11 semanas en personas que recibieron inyecciones de glucocorticoides Un ensayo (prueba de baja calidad) sho No presentan diferencias importantes entre la terapia manual y el ejercicio y la descompresión artroscópica subacromial con respecto al dolor general, la función, el rango activo de movimiento y la fuerza a los seis y 12 meses o el éxito global del tratamiento a los cuatro a ocho años. Un ensayo (evidencia de baja calidad) encontró que la terapia manual y el ejercicio pueden no ser tan eficaces como la acupuntura y el asesoramiento dietético y el suplemento Phlogenzym con respecto al dolor general, la función, la abducción activa del hombro y la calidad de vida a las 12 semanas. No estamos seguros de si la terapia manual y el ejercicio mejoran la función que los fármacos antiinflamatorios no esteroides orales (AINE), o si la combinación de terapia manual y ejercicio con inyección de glucocorticoides proporciona un beneficio adicional en función de la inyección de glucocorticoides sola, Evidencia en estos dos ensayos.Cincuenta y dos ensayos investigaron los efectos de la terapia manual sola o el ejercicio solo, y la evidencia fue en su mayoría de muy baja calidad. Hubo poca o ninguna diferencia en los resultados importantes para el paciente entre la terapia manual sola y el placebo, ningún tratamiento, la ecografía terapéutica y la quinesioterapia, aunque la terapia manual sola fue menos eficaz que la inyección de glucocorticoides. El ejercicio solo condujo a menos mejoría en el dolor general, pero no la función, en comparación con la reparación quirúrgica para el desgarro del manguito rotador. Hubo poca o ninguna diferencia en los resultados importantes para el paciente entre el ejercicio solo y el placebo, el tratamiento de ondas de choque extracorpóreas radiales, la inyección de glucocorticoides, la descompresión subacromial artroscópica y el aparato ortopédico funcional. Además, la terapia manual o el ejercicio proporcionaron pocos o ningún beneficio adicional cuando se combinaron con otras intervenciones de terapia física, y un tipo de terapia manual o ejercicio rara vez fue más eficaz que otro. A pesar de identificar 60 ensayos elegibles, sólo un ensayo comparó una combinación de terapia manual y ejercicio que refleja la práctica actual común con el placebo. Se juzgó que era de alta calidad y no encontró diferencias clínicamente importantes entre los grupos en cualquier resultado. Los efectos de la terapia manual y el ejercicio pueden ser similares a los de la inyección de glucocorticoides y la descompresión subacromial artroscópica, pero esto se basa en pruebas de baja calidad. Los eventos adversos asociados con la terapia manual y el ejercicio son relativamente más frecuentes que el placebo, pero de naturaleza leve. Las nuevas combinaciones de terapia manual y ejercicio deben compararse con un placebo realista en ensayos futuros. Otros ensayos de terapia manual sola o ejercicio solo para la enfermedad del manguito rotador deben basarse en una sólida justificación y considerar si alteran o no las conclusiones de esta revisión.
Antecedentes: Desde la introducción de la escuela secundaria sueca en 1969, las escuelas de espalda se han utilizado con frecuencia para el tratamiento de las personas con dolor lumbar (LBP). Sin embargo, el contenido de las escuelas de nuevo ha cambiado y parece variar ampliamente hoy en día. En esta revisión definimos a la escuela de nuevo como un programa terapéutico dado a grupos de personas, que incluye tanto la educación como el ejercicio. Esta es una actualización de una revisión Cochrane publicada por primera vez en 1999 y actualizada en 2004. Para esta actualización de revisión, dividimos la revisión en dos revisiones distintas que separaron la LBP aguda de la crónica. OBJETIVOS: Evaluar la efectividad de las escuelas de espalda en el dolor y la discapacidad para las personas con LBP aguda o subaguda no específica. También examinamos el efecto sobre el estado de trabajo y los eventos adversos. MÉTODOS DE BÚSQUEDA: Se realizaron búsquedas en registros de CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, PubMed y dos ensayos clínicos hasta el 4 de agosto de 2015. También verificamos las listas de referencias de artículos y contactamos a expertos en el campo de la LBP. Criterios de selección Se incluyeron ensayos controlados aleatorios (ECA) o cuasi-ECA que informaron en la escuela secundaria de LBP aguda o subaguda no específica. Los resultados primarios fueron dolor y discapacidad. Los resultados secundarios fueron estado de trabajo y eventos adversos. La escuela de espalda tenía que ser comparada con otro tratamiento, un placebo (o farsa o control de la atención) o ningún tratamiento. RECOLECCIÓN Y ANÁLISIS DE DATOS: Utilizamos las pautas de los métodos actualizados de 2009 para esta revisión Cochrane. Dos revisores revisaron de forma independiente las referencias, evaluaron la calidad de los ensayos y extrajeron los datos. Establecemos el umbral para un bajo riesgo de sesgo, a priori, como seis o más de 13 criterios de validez interna y no hay defectos graves (por ejemplo, una tasa de abandono grande). Se clasificó la calidad de la evidencia en uno de los cuatro niveles (alto, moderado, bajo o muy bajo) usando el enfoque adaptado de Evaluación, Desarrollo y Evaluación de Recomendaciones (GRADE). Nos pusimos en contacto con los autores del estudio para obtener información adicional. Se recogieron los efectos adversos de la información de los ensayos. PRINCIPALES RESULTADOS: La actualización de búsqueda identificó 273 nuevas referencias, de las cuales ninguna cumplió con nuestros criterios de inclusión. Se incluyeron cuatro estudios (643 participantes) en esta revisión actualizada, que se incluyeron todos en la actualización anterior (2004). La calidad de la evidencia fue muy baja para todos los resultados. Como los datos eran demasiado heterogéneos clínicamente para ser agrupados, se describieron los resultados de los ensayos individuales. Los resultados indican que hay evidencia de muy baja calidad de que las escuelas de espalda no son más eficaces que un placebo (o simulacro de control de la atención) u otro tratamiento (terapias físicas, terapia miofascial, manipulación de las articulaciones, asesoramiento) sobre el dolor, la discapacidad, Eventos adversos a corto, mediano y largo plazo de seguimiento. Existe una evidencia de muy baja calidad que muestra una diferencia estadísticamente significativa entre las escuelas de espalda y un placebo (o control simulado o de atención) para el regreso al trabajo a corto plazo a favor de la escuela de espalda. La evidencia de muy baja calidad sugiere que la escuela secundaria agregada a un programa de cuidado de espalda es más efectiva que un programa de cuidado de espalda solo para la discapacidad en el seguimiento a corto plazo. Pruebas de muy baja calidad también indican que no hay diferencia en términos de eventos adversos entre la escuela de espalda y la terapia miofascial, la manipulación conjunta y la terapia combinada miofascial y manipulación conjunta. Conclusiones de los autores: Es incierto si las escuelas de espalda son eficaces para LBP aguda y subaguda no específica, ya que sólo hay evidencia de muy baja calidad disponible. Si bien los grandes estudios bien conducidos probablemente proporcionarán resultados más concluyentes, las escuelas de espalda no son intervenciones ampliamente utilizadas para la LBP aguda y subaguda y la investigación adicional en esta área puede no ser una prioridad.
Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve causing pain and numbness and tingling typically in the thumb, index and middle finger. It sometimes results in muscle wasting, diminished sensitivity and loss of dexterity. Splinting the wrist (with or without the hand) using an orthosis is usually offered to people with mild-to-moderate findings, but its effectiveness remains unclear.
OBJECTIVES:
To assess the effects (benefits and harms) of splinting for people with CTS.
SEARCH METHODS:
On 12 December 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov, and WHO ICTRP with no limitations. We checked the reference lists of included studies and relevant systematic reviews for studies.
SELECTION CRITERIA:
Randomised trials were included if the effect of splinting could be isolated from other treatment modalities. The comparisons included splinting versus no active treatment (or placebo), splinting versus another disease-modifying non-surgical treatment, and comparisons of different splint-wearing regimens. We excluded studies comparing splinting with surgery or one splint design with another. We excluded participants if they had previously undergone surgical release.
DATA COLLECTION AND ANALYSIS:
Review authors independently selected trials for inclusion, extracted data, assessed study risk of bias and the certainty in the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology.
MAIN RESULTS:
We included 29 trials randomising 1937 adults with CTS. The trials ranged from 21 to 234 participants, with mean ages between 42 and 60 years. The mean duration of CTS symptoms was seven weeks to five years. Eight studies with 523 hands compared splinting with no active intervention (no treatment, sham-kinesiology tape or sham-laser); 20 studies compared splinting (or splinting delivered along with another non-surgical intervention) with another non-surgical intervention; and three studies compared different splinting regimens (e.g. night-time only versus full time). Trials were generally at high risk of bias for one or more domains, including lack of blinding (all included studies) and lack of information about randomisation or allocation concealment in 23 studies. For the primary comparison, splinting compared to no active treatment, splinting may provide little or no benefits in symptoms in the short term (< 3 months). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) (scale 1 to 5, higher is worse; minimal clinically important difference (MCID) 1 point) was 0.37 points better with splint (95% confidence interval (CI) 0.82 better to 0.08 worse; 6 studies, 306 participants; low-certainty evidence) compared with no active treatment. Removing studies with high or unclear risk of bias due to lack of randomisation or allocation concealment supported our conclusion of no important effect (mean difference (MD) 0.01 points worse with splint; 95% CI 0.20 better to 0.22 worse; 3 studies, 124 participants). In the long term (> 3 months), we are uncertain about the effect of splinting on symptoms (mean BCTQ SSS 0.64 better with splinting; 95% CI 1.2 better to 0.08 better; 2 studies, 144 participants; very low-certainty evidence). Splinting probably does not improve hand function in the short term and may not improve hand function in the long term. In the short term, the mean BCTQ Functional Status Scale (FSS) (1 to 5, higher is worse; MCID 0.7 points) was 0.24 points better (95% CI 0.44 better to 0.03 better; 6 studies, 306 participants; moderate-certainty evidence) with splinting compared with no active treatment. In the long term, the mean BCTQ FSS was 0.25 points better (95% CI 0.68 better to 0.18 worse; 1 study, 34 participants; low-certainty evidence) with splinting compared with no active treatment. Night-time splinting may result in a higher rate of overall improvement in the short term (risk ratio (RR) 3.86, 95% CI 2.29 to 6.51; 1 study, 80 participants; number needed to treat for an additional beneficial outcome (NNTB) 2, 95% CI 2 to 2; low-certainty evidence). We are uncertain if splinting decreases referral to surgery, RR 0.47 (95% CI 0.14 to 1.58; 3 studies, 243 participants; very low-certainty evidence). None of the trials reported health-related quality of life. Low-certainty evidence from one study suggests that splinting may have a higher rate of adverse events, which were transient, but the 95% CIs included no effect. Seven of 40 participants (18%) reported adverse effects in the splinting group and 0 of 40 participants (0%) in the no active treatment group (RR 15.0, 95% CI 0.89 to 254.13; 1 study, 80 participants). There was low- to moderate-certainty evidence for the other comparisons: splinting may not provide additional benefits in symptoms or hand function when given together with corticosteroid injection (moderate-certainty evidence) or with rehabilitation (low-certainty evidence); nor when compared with corticosteroid (injection or oral; low certainty), exercises (low certainty), kinesiology taping (low certainty), rigid taping (low certainty), platelet-rich plasma (moderate certainty), or extracorporeal shock wave treatment (moderate certainty). Splinting for 12 weeks may not be better than six weeks, but six months of splinting may be better than six weeks of splinting in improving symptoms and function (low-certainty evidence).
AUTHORS' CONCLUSIONS:
There is insufficient evidence to conclude whether splinting benefits people with CTS. Limited evidence does not exclude small improvements in CTS symptoms and hand function, but they may not be clinically important, and the clinical relevance of small differences with splinting is unclear. Low-certainty evidence suggests that people may have a greater chance of experiencing overall improvement with night-time splints than no treatment. As splinting is a relatively inexpensive intervention with no plausible long-term harms, small effects could justify its use, particularly when patients are not interested in having surgery or injections. It is unclear if a splint is optimally worn full time or at night-time only and whether long-term use is better than short-term use, but low-certainty evidence suggests that the benefits may manifest in the long term.
