Resea ch
Exe cises using a ouchsc een able applica ion imp o ed unc ional abili y mo e
han an exe cise p og am p esc ibed on pape in people a e su gical ca pal
unnel elease: a andomised ial
Jesús Blanque o
a
, Ma ía Dolo es Co és-Vega
a
, Ma ía Ángeles Ga cía-F asque
b
,
Pablo Rod íguez Sánchez-Laulhé
c
, Ma ía Isabel Nie o Díaz de los Be na dos
b
, Alejand o Sue o-Pineda
c
a
Physio he apy Depa men , Uni e si y o Se ille;
b
Hand Su ge y Di ision, Vi gen Maca ena Uni e si y Hospi al;
c
Andalusian Public Founda ion o he Managemen o Heal h
Resea ch o Se ille FISEVI, Se ille, Spain
KEY WORDS
Ca pal unnel synd ome
Exe cise he apy
Feedback senso y
Mobile applica ions
ABSTRACT
Ques ion: In people who ha e unde gone su gical ca pal unnel elease, do senso imo o -based exe cises
pe o med on he ouchsc een o a able de ice imp o e ou comes mo e han a con en ional home
exe cise p og am p esc ibed on pape ? Design: Randomised, pa allel-g oup ial wi h concealed
alloca ion, assesso blinding, and in en ion- o- ea analysis. Pa icipan s: Fi y pa icipan s wi hin 10
days o su gical ca pal unnel elease. In e en ion: Each pa icipan was p esc ibed a 4-week home exe cise
p og am. Pa icipan s in he expe imen al g oup ecei ed he ReHand able applica ion, which adminis e ed
and moni o ed exe cises ia he ouchsc een. The con ol g oup was p esc ibed a home exe cise p og am on
pape , as is usual p ac ice in he public hospi al sys em. Ou come measu es: The p ima y ou come was
unc ional abili y o he hand, epo ed using he sho ened o m o he Disabili ies o he A m, Shoulde and
Hand (QuickDASH) ques ionnai e. Seconda y ou comes we e g ip s eng h, pain in ensi y measu ed on a
10-cm isual analogue scale, and dex e i y measu ed wi h he Nine-Hole Peg Tes . Ou comes we e measu ed
by a blinded assesso a baseline and a he end o he 4-week in e en ion pe iod. Resul s: A Week 4,
unc ional abili y imp o ed significan ly mo e in he expe imen al g oup han he con ol g oup (MD –21,
95% CI –33 o –9) on he QuickDASH sco e (0 o 100). Al hough he mean es ima es o e ec on he seconda y
ou come also all a ou ed he expe imen al g oup, none eached s a is ical significance: g ip s eng h (MD
5.6 kg, 95% CI –0.5 o 11.7), pain (MD –1.4 cm, 95% CI –2.9 o 0.1), and dex e i y (MD –1.3 seconds, 95% CI –3.7
o 1.1). Conclusion: Use o he ReHand able applica ion o ea ly ehabili a ion a e ca pal unnel elease is
mo e e ec i e in he eco e y o unc ional abili y han a con en ional home exe cise p og am. I emains
unclea whe he he e a e any benefi s in g ip s eng h, pain o dex e i y. T ial egis a ion:
ACTRN12618001887268. [Blanque o J, Co és-Vega MD, Ga cía-F asque MÁ, Sánchez-Laulhé PR, Nie o
Díaz de los Be na dos MI, Sue o-Pineda A (2019) Exe cises using a ouchsc een able applica ion
imp o ed unc ional abili y mo e han an exe cise p og am p esc ibed on pape in people a e su gical
ca pal unnel elease: a andomised ial. Jou nal o Physio he apy 65:81–87]
© 2019 Aus alian Physio he apy Associa ion. Published by Else ie B.V. This is an open access a icle unde
he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
In oduc ion
Ca pal unnel synd ome is a ocal and comp essi e neu opa hy in
which aised p essu e in he ca pal canal esul s in median
ne e comp ession and impai ed ne e pe usion, leading o
discom o and pa aes hesia in he hand.
1,2
Conse a i e ea men s
a e ecommended as ini ial managemen , whe eas su ge y is
gene ally ecommended in e ac o y cases.
2
Ca pal unnel decomp ession is he accep ed su gical ea men
when conse a i e measu es ail,
1
wi h he a e o su gical
in e en ion a e ini ial conse a i e managemen being be ween 57
and 66%.
2
Open ca pal unnel elease is he s anda d su gical
echnique.
1
Howe e , he me hod o pos -su gical ehabili a ion ha
should be used is con o e sial.
3
Pos -su gical immobilisa ion,
despi e a lack o scien ific e idence epo ing i s alue
3–5
and he
exis ence o Le el 1 e idence o i s lack o benefi ,
6
is s ill employed
by app oxima ely hal o su geons, al hough he numbe o
p o essionals ad oca ing o i is dec easing annually.
6
Se e al g oups
o au ho s ha e ound ha he e is no beneficial e ec ob ained om
pos ope a i e immobilisa ion compa ed o so d essing allowing
mo emen a e ca pal unnel elease.
7–9
O he s udies ha e epo ed
ha ea ly mobilisa ion esul s in an imp o emen in pain, g ip and
pinch s eng h,
10
as well as a educ ion in he ime o e u n o
ac i i ies o daily li ing and wo k,
10,11
compa ed o immobilisa ion. In
ligh o his e idence, he Eu opean guidelines
12
s a e ha exe cises
should be conside ed o he pos ope a i e pe iod.
Jou nal o Physio he apy 65 (2019) 81–87
h ps://doi.o g/10.1016/j.jphys.2019.02.008
1836-9553/© 2019 Aus alian Physio he apy Associa ion. Published by Else ie B.V. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/
licenses/by-nc-nd/4.0/).
jou nal homepage: www.else ie .com/loca e/jphys
A sys ema ic e iew iden ified ha home exe cise p og ams ha e
simila e ec s as ace- o- ace ehabili a ion on unc ion, dex e i y
and s eng h a e ca pal unnel elease.
4
In one o he e iewed
s udies, P o inciali e al compa ed a mul imodal ehabili a ion
p og am agains a 2-week home exe cise p og am in a sample o
100 pa icipan s; no significan be ween-g oup di e ences we e
ound in he Bos on Ca pal Tunnel Ques ionnai e, Jebsen-Taylo es ,
and 9-Hole Peg Tes a e 3 mon hs o ollow-up.
13
Pome ance e al
compa ed, in a sample o 150 pa icipan s, he ea men by a
hand he apis agains a home exe cise p og am; hey ound no
significan di e ences in pain, g ip and pinch s eng h o he Dis-
abili ies o he A m, Shoulde and Hand (DASH) ques ionnai e a e
3 and 6 mon hs o ollow-up.
14
They also made an obse a ion
abou he ela i e cos -e ec i eness o home exe cise p og ams and
ace- o- ace ehabili a ion, concluding ha he la e seems o be
unjus ified o uncomplica ed pa ien s wi h con en ional sho
incisions.
14
Ca pal unnel synd ome is no jus a pe iphe al p oblem; i has a
cen al in ol emen , which ehabili a ion (including home exe cise
p og ams) ough o add ess. This cen al in ol emen is cha ac e ised
by co ical eo ganisa ion caused by ch onic median ne e
dys unc ion and al e ed soma osenso y a e ence.
15
In people wi h
ca pal unnel synd ome, his impac s senso imo o in eg a ion and
mo o pe o mance,
16,17
esul ing in defici s in dex ous manipula ion
and finge o ce dis ibu ion con ol.
18,19
Those abili ies a e basic o
ac i i ies o daily li ing, ela ing di ec ly o he impai men o
unc ionali y and quali y o li e in people wi h ca pal unnel
synd ome.
Some ecen p elimina y s udies ha e shown ha an exe cise
applica ion (app) on a able de ice can imp o e dex e i y and
co icospinal d i e o spinal mo oneu ons.
20,21
This s udy is pa o a
la ge body o esea ch ha has s udied he e ec i eness o a
senso imo o app oach o he eco e y o hand auma pa hologies,
h ough he enhancemen o neu omuscula con ol and he e ec a
co ical le el.
22
The e o e, one way o expand his field o knowledge
is h ough a new senso imo o modali y ia a able ouchsc een
using he ReHand app. ReHand is an app specifically de eloped o
he auma app oach o he w is , hand and finge s h ough exe cises
ha a e pe o med on he ouchsc een. The app has been de eloped
by and unde he supe ision o heal hca e p o essionals, including
su geons, physio he apis s and occupa ional he apis s, so he
unc ionali ies seek o mee he needs ha hese p o essionals
iden ified h ough hei pa ien s in p ac ice.
The e o e, he esea ch ques ion o his andomised ial was:
In people who ha e unde gone su gical ca pal unnel elease, do
senso imo o -based exe cises pe o med on he ouchsc een o a
able de ice imp o e ou comes mo e han a con en ional home
exe cise p og am p esc ibed on pape ?
Me hod
Design
An assesso -blinded, pa allel-g oup, andomised con olled ial
was unde aken in people who had unde gone su gical ca pal unnel
elease. The s udy was conduc ed om No embe 2018 o Janua y
2019. Pa icipan s we e andomly alloca ed o an expe imen al g oup
o a con ol g oup using a compu e -gene a ed, concealed alloca ion
schedule. All pa icipan s ecei ed a 4-week home exe cise p og am.
Pa icipan s in he expe imen al g oup we e alloca ed a p og am ha
included senso imo o -based exe cises pe o med using a able
ouchsc een. Pa icipan s in he con ol g oup ecei ed a home
exe cise p og am con en ionally p o ided on pape o ehabili a ion
a e ca pal unnel elease in he public heal hca e sys em. Da a we e
collec ed by a blinded assesso p io o andomisa ion and 4 weeks
la e .
Pa icipan s, he apis s, cen es
People aged be ween 18 and 65 yea s old who had unde gone
su gical ca pal unnel elease we e consecu i ely sc eened a Vi gen
Maca ena and Vi gen del Rocio Uni e si y Hospi als, Se ille, Spain.
Two expe ienced hand su geons pe o med sc eening agains hese
inclusion c i e ia: diagnosis o ca pal unnel synd ome was based on
his o y, examina ion, and ne e conduc ion s udies; open ca pal
unnel elease wi h a s anda d su gical app oach was no mo e han
10 days p io o he baseline measu emen ; and a able de ice was
accessible o he pe son o he s udy pe iod. Po en ial pa icipan s
we e excluded i hey had: a his o y o neu ological, psychia ic o
cogni i e diso de ; o a plan o ecei e physio he apy du ing he
4-week s udy pe iod.
A e confi ma ion o eligibili y and comple ion o he baseline
measu emen s, an independen esea che andomly alloca ed
pa icipan s ia a compu e -gene a ed, andom alloca ion schedule
wi hou knowledge o he baseline measu emen esul s. This
esea che also: explained how o ca y ou he andomly alloca ed
in e en ion; asked he pa icipan no o e eal his in e en ion o
any o he s udy’s in es iga o s; answe ed any ques ions om he
pa icipan ; and p o ided elephone suppo . In addi ion, his
independen esea che o e saw he weekly moni o ing o he
pa icipan s. Since i was no possible o blind pa icipan s, e o s
we e made o keep pa icipan s unawa e o he de ails o he
in e en ion being alloca ed o he opposi e g oup. Fo his eason,
he wo in e en ions we e desc ibed in he in o ma ion shee as
home-based exe cise p og ams wi h di e ing o ma s.
In e en ions
Pa icipan s in bo h g oups we e ad ised o ca y ou hei
alloca ed exe cise in e en ion au onomously a home, comple ing
one session a day on a leas 5 days a week, o 4 weeks. The exe cise
p og am las ed app oxima ely 25 minu es pe session. The
di e ences be ween he wo g oups we e he exe cise p og am
employed and how adhe ence o ea men was measu ed.
Expe imen al g oup
Pa icipan s in he expe imen al g oup pe o med he home
exe cise p og am using he ReHand able app. This app was
de eloped unde he guidance o se e al heal hca e p o essionals
(su geons, physio he apis s and occupa ional he apis s) o use on
And oid and iOS able s o enhance, h ough con olled ac i e wo k,
he dex e i y and unc ionali y o he w is , hand and finge s a e
auma ic inju y. ReHand has a ange o specific exe cises o hese
pu poses, which can be configu ed in o an exe cise p og am
acco ding o he pa hology and p og ess o he pa ien . All o he
exe cises a e pe o med on he able ouchsc een (Figu e 1). Fo he
expe imen al g oup, a specific p og am was designed o
ehabili a ion a e ca pal unnel elease consis ing o exe cises o
mobili y, co-o dina ion and dex e i y o he hand, w is and finge s,
as desc ibed in de ail in Table 1. The exe cises a e pe o med by
making aps and mo emen s while ouching he ouchsc een and
guided by eedback, he eby enabling senso imo o -based, con olled,
ac i e exe cise. To assis use s o unde s and each exe cise on he app,
i gi es bo h s ep-by-s ep eal- ime ins uc ions and a ideo
demons a ion o he exe cise being pe o med. The explana ion o
his in e en ion o he pa icipan s andomised o he expe imen al
g oup included: a 5-minu e demons a ion o how o use he ReHand
app on a able ; in o ma ion abou how o download he app om
And oid and iOS sou ces; p o ision o a use name and passwo d; and
elephone suppo .
Da a we e ans e ed om he app o a web managemen panel,
which allowed moni o ing o adhe ence o he p esc ibed exe cise
p og am. In his g oup, his sys em was used by he esea che in
cha ge o moni o ing. Those pa icipan s who did no use he app in
he fi s 5 days we e elephoned o ensu e ha hey we e no
expe iencing echnical di ficul ies.
82 Blanque o e al: Table -based exe cise a e ca pal unnel elease
Con ol g oup
The pa icipan s o his g oup ecei ed a home exe cise p og am
on pape . This p og am is con en ionally used in he public hospi al
sys em o ea ly ehabili a ion a e ca pal unnel elease. The
exe cises a e ocused on mobili y o he en i e uppe limb, wi h
g ea e emphasis on hose exe cises ela ing o he hand. These
exe cises a e de ailed in Table 2. A esea che moni o ed he exe cises
pe o med by he pa icipan h ough a weekly elephone call.
Ou come measu es
Baseline measu es we e collec ed be ween 7 and 10 days a e
su ge y and p io o andom alloca ion o a s udy g oup. Final
measu es we e collec ed 4 weeks la e , a he end o he in e en ion
pe iod. All measu es we e assessed in each pa icipan indi idually
and ace- o- ace. The measu emen s we e made by a single
physio he apis wi h ex ensi e clinical expe ience, who was blinded
o each pa icipan ’s alloca ed g oup. Pa icipan s we e also blind o
alloca ion du ing he baseline measu emen s and subsequen ly hey
we e ins uc ed no o e eal o he assesso he g oup o which hey
belonged.
P ima y ou come
Changes in sel - epo ed unc ional abili y we e measu ed on he
DASH ques ionnai e, which is conside ed o be one o he main
measu emen s in ca pal unnel esea ch.
3
The DASH ques ionnai e
has been shown o be eliable and alid, and has been success ully
ansla ed in o Spanish.
3,23
Func ional abili y was measu ed h ough
he sho ened o m o he DASH ques ionnai e (QuickDASH), which
has a disc iminan abili y, c oss-sec ional eliabili y and es - e es
eliabili y simila o he DASH ques ionnai e,
24
which u he
demons a es i s alidi y and p ac ical u ili y in people who ha e
unde gone ca pal unnel elease.
25
Seconda y ou comes
G ip s eng h measu emen was pe o med using a hyd aulic g ip
dynamome e
a
. Pa icipan s we e sea ed com o ably up igh , wi h
bo h ee on he g ound, shoulde s adduc ed and neu ally o a ed,
elbow flexed a 90 deg, o ea m in neu al o a ion, and w is
be ween 0 deg and 30 deg do siflexion and be ween 0 deg and 15 deg
ulna de ia ion. Th ee successi e ials we e eco ded o each es ,
wi h 30 seconds o es be ween each measu emen . The a e age o
he h ee measu emen s was used in he analysis. This p ocedu e has
been well documen ed as eliable.
26
Pain se e i y was assessed on a isual analogue scale o 0 o 10 cm,
whe e a sco e o 0 equa ed o ‘no pain’and 10 equa ed o he ‘mos
se e e pain’.
The Nine-Hole Peg Tes is one o he mos commonly used ools o
assessing dex e i y.
27
The es uses a squa e boa d wi h nine holes, wi h a
con aine holding nine pegs a ached o i . The pa icipan mus pick up
one peg a a ime and pu i in o a hole un il all he holes a e filled in any
o de . Then, he pa icipan mus emo e all he pegs one a a ime and
e u n hem o hecon aine . S anda dins uc ions o he es we egi en
along wi h a b ie demons a ion.
28
Pa icipan s pe o med a b ie
p ac ice es p io o he ac ual es .
Assesso blinding was e alua ed a he end o he ial by asking
he assesso i any o he pa icipan s had indica ed o which g oup
hey had been alloca ed.
Da a analysis
The in en ion- o- ea p inciple was used o da a analysis. Mean
sco es, SDs and be ween-g oup di e ences (95% CIs) we e calcula ed
o all ou comes a baseline and a he end o he 4-week in e en ion
pe iod. The be ween-g oup di e ences and hei espec i e 95% CIs
we e calcula ed using linea mixed models wi h g oup, ime and g oup-
e sus- ime in e ac ion e ms. The confidence le el adop ed was 5%
and s a is ical analyses we e pe o med using comme cial so wa e
b
.
Resul s
Flow o pa icipan s
O 72 sc eened subjec s, 50 me he selec ion c i e ia and
comple ed he s udy. The flow o pa icipan s is de ailed in Figu e 2.
The mean age o he pa icipan s was 50 yea s (SD 8), o whom nine
(18%) we e men and 41 (82%) we e women. The mean age o he
pa icipan s in he expe imen al g oup was 51 yea s (SD 8), o whom
h ee we e male and 22 we e emale. The mean age o pa icipan s in
he con ol g oup was 49 yea s (SD 7), o whom six we e male and 19
we e emale. The g oups had simila baseline sco es on all he
ou come measu es. Baseline demog aphic and clinical cha ac e is ics
o pa icipan s a e p esen ed in Table 3.
Compliance wi h he s udy p o ocol
All pa icipan s we e alloca ed he ea men in line wi h hei
andom alloca ion. All pa icipan s unde wen baseline and final
Table 1
Desc ip ion o expe imen al in e en ion (app-based exe cises) o ehabili a ion a e ca pal unnel elease.
Exe cise (each epe i ion o he exe cise las s 25 seconds) Repe i ions
1. Pinch exe cise wi h he index finge , pe o ming a con olled mo emen in a painless ange guided by eedback 4
2. Pinch exe cise wi h he middle finge , pe o ming a con olled mo emen in a painless ange guided by eedback 4
3. Pinch exe cise wi h he ing finge , pe o ming a con olled mo emen in a painless ange guided by eedback 4
4. Flexion-ex ension exe cise o he index finge , pe o ming a con olled mo emen in a painless ange guided by eedback 4
5.Flexion-ex ension exe cise o he middle finge , pe o ming a con olled mo emen in a painless ange guided by eedback 4
6. Hand-eye co-o dina ion exe cise, making aps on he sc een wi h each finge as he ci cles change colou 4
7. Hand opened and finge s ex ended, w is s abilisa ion and li le finge in con ac wi h he able sc een. Con olled w is
flexion-ex ension mo emen in painless ange guided by eedback
4
8. Closed fis holding a s ylus, w is s abilisa ion and s ylus in con ac wi h he able sc een. Con olled w is flexion-
ex ension mo emen in painless ange guided by eedback
4
Figu e 1. Example o pe o mance o an exe cise in he expe imen al in e en ion.
Resea ch 83
measu es. No pa icipan s e ealed hei g oup alloca ion o he
assesso .
E ec o in e en ion
A Week 4, unc ional abili y imp o ed significan ly mo e in he
expe imen al g oup han he con ol g oup (MD –21, 95% CI –33 o
–9) on he QuickDASH sco e (0 o 100). Summa y da a a e p esen ed
in Table 4 and indi idual-pa icipan da a a e p esen ed in Table 5 on
he eAddenda.
Al hough he mean es ima es o e ec on he seconda y
ou come also all a ou ed he expe imen al g oup, none eached
s a is ical significance: g ip s eng h (MD 5.6kg, 95% CI –0.5 o 11.7),
pain (MD –1.4 cm, 95% CI –2.9 o 0.1), and dex e i y (MD –1.3 seconds,
95% CI –3.7 o 1.1). Summa y da a a e p esen ed in Table 4
and indi idual-pa icipan da a a e p esen ed in Table 5 on he
eAddenda.
Discussion
The main finding o his s udy was ha an exe cise p og am
adminis e ed ia an app on a able p oduced a significan ly g ea e
imp o emen in sel - epo ed unc ional abili y han an exe cise
p og am p esc ibed on pape . This esul sugges s ha he inno a i e
o ma o ehabili a ion h ough mo emen s and aps on dynamic
ouchsc een a ge s migh p o ide mo e e ec i e ehabili a ion a e
ca pal unnel elease han he esul s ob ained wi h a home exe cise
p og am p esc ibed on pape .
I is impo an o conside whe he he e ec obse ed on he
p ima y ou come is likely o be clinically wo hwhile. The p o ocol o
his s udy did no p ospec i ely nomina e he smalles e ec on he
p ima y ou come ha would make using he app (as opposed o
using he pape handou ) o ca y ou he home p og am wo hwhile.
I seems easonable o assume ha his smalles wo hwhile e ec
would be ma ginal, gi en ha he cos s, isks and incon eniences o
he expe imen al and con ol in e en ions in he s udy we e no
e y di e en . Specifically, apps a e gene ally ela i ely inexpensi e,
he isk o ad e se e ec s was low in bo h g oups (nei he g oup
epo ed any ad e se e en s), and he ime and e o in ol ed in
pe o ming he exe cises was e y simila in bo h g oups. One ac o
ha would inc ease he cos o he expe imen al in e en ion would
be p o iding a able o pa ien s who do no ha e one. Howe e ,
many pa ien s al eady ha e a leas empo a y access o a able and
an ins i u ion may be able o loan a able wi h he expe imen al app
loaded on i o successi e pa ien s a e ca pal unnel elease.
The e o e, he au ho s conside ha he mean es ima e o he e ec
(21 poin s ex a benefi on he 100-poin QuickDASH om using he
app ins ead o he pape handou ) would make using he app
wo hwhile. A guably, e en he lowe end o he confidence in e al
Table 2
Desc ip ion o con ol in e en ion (home exe cise p og am) con en ionally used in public heal h se ices.
Exe cise Se s Repe i ions
1. Make a fis and hen ex end he finge s 315
2. Wi h he hand opened and finge s ex ended, maximally ex end he w is 3 15
3. Wi h he hand opened and finge s ex ended, maximally abduc he finge s 3 15
4. Con ac each finge ’s pad wi h he humb pad 315
5. Wi h a (semi-) closed fis , flex and ex end he w is 315
6. Wi h he hand opened and finge s ex ended, de ia e he hand owa ds adius and ulna 3 15
7. Wi h a semi-closed fis , pe o m o a ing mo emen s o he fis 315
8. S anding o si ing in a chai , ex end he elbow so ha he uppe limb hangs beside he body 3 10
9. F om he p e ious posi ion, slowly aise he uppe limb o he ho izon al plane wi h he elbow in ex ension 3 10
10. F om he p e ious posi ion, flex he elbow and ouch he same shoulde wi h you finge s 3 10
Con ol g oup
•con en ional home
exe cise p og am
p esc ibed on
pape
•≥ 5 days pe week
•4 weeks
Sc eened (n = 72)
Measu ed unc ional abili y, pain, dex e i y and g ip s eng h
Randomised (n = 50)
(n = 25) (n = 25)
Excluded (n = 22)
•> 10 days since su ge y (n = 18)
•his o y o neu ological diso de (n = 2)
•declined (n = 2)
Week 0
Expe imen al g oup
•senso imo o -based
exe cises pe o med
on he ouchsc een
o a able de ice a
home
•≥ 5 days pe week
•4 weeks
Week 4
Measu ed unc ional abili y, pain, dex e i y and g ip s eng h
(n = 25) (n = 25)
Los o ollow-up (n = 0) Los o ollow-up (n = 0)
Figu e 2. Design and flow o pa icipan s h ough he ial.
84 Blanque o e al: Table -based exe cise a e ca pal unnel elease
(ie, 9 poin s ex a imp o emen om using he app) migh be
conside ed wo hwhile by some pa ien s, especially hose who
al eady ha e a able .
I is also impo an o conside whe he he esul s on he p ima y
and seconda y ou comes a e belie able and consis en wi h o he
esea ch. The belie abili y o he p ima y ou come is well suppo ed
by he obus ness o he s udy’s me hods, which included concealed
alloca ion, assesso blinding, comple e ollow-up and in en ion- o-
ea analysis. The s a is ically significan esul on he p ima y
ou come is unlikely o be a Type-I e o (ie, a chance finding) because
i was p ospec i ely egis e ed and only ou s a is ical es s we e
conduc ed in o al. I is no able ha he p ima y ou come was a
subjec i e measu e and he benefi was no also demons a ed on
ano he objec i e measu e, which aises he possibili y o a ‘poli e
pa ien ’e ec . Howe e , pa icipan s we e kep unawa e o
he opposi e g oup’s in e en ion, which should ha e minimised he
po en ial o such an e ec . Fu he mo e, u he insigh abou
he seconda y ou comes can be ob ained by conside ing each one
indi idually.
The g ip s eng h da a a e qui e consis en wi h exis ing e idence.
In he p esen s udy, g ip s eng h inc eased om 17.4 o 25.9 kg in
he con ol g oup. This alue in he con ol g oup a e 4 weeks o
in e en ion co esponds o da a obse ed by Pome ance e al,
14
whe e, a e 4 weeks o home he apy exe cises, a g ip s eng h o
24 kg was obse ed. The mean be ween-g oup di e ence in change in
g ip s eng h in he p esen s udy was 5.6 kg in a ou o he
expe imen al g oup. While his esul was non-significan , he
confidence in e al includes he possibili y ha he ue mean e ec
could be o e 11 kg. This could be pa ly explained by conclusions
d awn by Kama h e al,
29
whe eby he imp o emen in g ip s eng h
was g ea es om he en h day o he hi d mon h a e he
ope a ion. Ou hypo hesis was ha he senso imo o -based,
con olled and ea ly wo k ha ReHand allows migh accele a e he
eco e y o s eng h. Ea ly eco e y o s eng h may also be ela ed o
he enhancemen o o he measu es, such as unc ional abili y and
pain, aligning wi h findings om p e ious s udies. Fo example,
Pome ance e al ound an a e age DASH and sel - epo ed pain sco es
o 18 and 1 poin s, espec i ely, a e 6 mon hs o home exe cises
a e ca pal unnel elease.
14
This p og ession o he DASH sco e
aligns wi h he esul s ob ained in he cu en con ol g oup,
whe e his unc ional sco e imp o ed om 66 o 53 poin s du ing
1 mon h o con en ional exe cises, sugges ing ha a simila
e olu ion o Pome ance e al would be ollowed a 6 mon hs.
Howe e , he less a ou able end o he confidence in e al mus also
be conside ed. This negligible ad e se e ec (ie, 0.5 kg less
imp o emen in g ip s eng h) is eassu ing because, e en in he
wo s -case scena io, i shows ha he imp o emen in he p ima y
ou come was ob ained wi hou subs an ial de imen o he eco e y
o g ip s eng h.
The nex seconda y ou come was dex e i y assessed using he
Nine-Hole Peg Tes , which (like g ip s eng h) was non-significan ,
had a mean es ima e ha a ou ed he expe imen al ea men ,
and had a confidence in e al ha only ex ended a ela i ely small
way in o he de imen al ange (ie, a wo s , 1 second less
imp o emen on a es ha akes 20 seconds on a e age). I is
he e o e possible, bu unce ain, ha he imp o emen in
sel - epo ed unc ional abili y migh be due o imp o ed dex e i y
(which would be plausible, gi en ha many o he i ems on he
QuickDASH con ain a dex e i y componen ). We sugges ha any
amelio a ion o c i ical hand a iables, such as pain, weakness o
educed unc ional abili y, could a ise om enhancemen o he
senso imo o sys em a bo h pe iphe al and cen al le els, achie ing
g ea e and mo e con olled abili y o fi e mo o uni s, op imising
ec ui men o he muscles in ol ed. Manual dex e i y is ela ed o
he op imal de elopmen and unc ion o he co icospinal sys em.
30
The majo con ibu o o he co icospinal sys em in p ima es is he
p ima y mo o co ex, which is ela ed di ec ly o p ima y soma o-
senso y co ex. Thus, al e a ion in he p ima y soma osenso y co ex
condi ions he pe o mance o he p ima y mo o co ex.
31
To assess
his ela ionship, cohe ence be ween co ical ac i i y eco ded by
elec oencephalog aphy and muscula ac i i y eco ded by elec o-
myog aphy has been used elsewhe e, p o iding da a on he s a us o
he in o ma ion sen om he mo o co ex and i s ansmission o
he spinal mo oneu ons du ing muscle ac i a ion.
32
P e ious s udies
ha e shown ha he pe o mance o asks ha equi e g ea a en ion
and p ecision
33
and a e influenced by p ac ice
34
(such as he ac i i ies
included in he able app) influences his cohe ence, gene a ing
changes a he co icospinal le el ha eflec an op imisa ion in he
senso imo o in eg a ion be ween he co ex and he muscle,
34
achie ing imp o emen s in mo o pe o mance.
35
This was one o
he esul s ob ained by La sen e al
21
h ough able -based mo o
p ac ice (3 310 minu es) wi h he non-dominan hand in 16 heal hy
emales. Thus, i is p oposed ha h ough pe o ming his ype o
ask, communica ion be ween he mo o co ex and mo oneu ons can
be acili a ed, inducing and s eng hening synap ic plas ici y be ween
bo h ne wo ks and a highe cohe ence.
35
A significan e ec on
dex e i y will be necessa y o demons a e he ele ance o his
mechanism, which could be he ocus o u u e esea ch. In he
mean ime, i can be assumed ha he imp o emen in sel - epo ed
unc ional abili y may o may no come om imp o ed dex e i y,
bu i ce ainly does no come a he expense o subs an ial de imen
o dex e i y.
The emaining seconda y ou come is pain, which has a
undamen al ole in his co ical synch ony. As one o he main
gene a o s o he al e a ions in he p ima y soma osenso y co ical
ep esen a ions,
36
pain c ea es a edis ibu ion o ac i i y wi hin a
muscle
37
and changes he mechanical beha iou o he mo emen .
38
This sugges s ha con olled painless ac i i ies (such as hose
implemen ed in ReHand h ough p e ious pain- ee mo emen
calib a ion) a e app op ia e because hey seek o a oid he
Table 4
Mean (SD) o g oups, mean (SD) di e ence wi hin g oups, and mean (95% CI) di e ence be ween g oups.
Ou come G oups Di e ence wi hin g oups Di e ence be ween g oups
Week 0 Week 4 Week 4 minus Week 0 Week 4 minus Week 0
Exp (n = 25) Con (n = 25) Exp (n = 25) Con (n = 25) Exp Con Exp minus Con
Func ional abili y (QuickDASH) (0 o 100) 73 (14) 66 (24) 39 (24) 53 (24) –34 (18) –13 (24) –21 (–33 o –9)
Pain (VAS) (0 o 10) 5.1 (2.6) 4.8 (2.9) 4.0 (2.7) 5.0 (3.2) –1.2 (2.8) 0.2 (2.3) –1.4 (–2.9 o 0.1)
Dex e i y (NHPT) (s) 22.7 (3.9) 23.4 (5.3) 18.1 (2.3) 20.1 (4.7) –4.6 (3.6) –3.3 (4.6) –1.3 (–3.7 o 1.1)
G ip s eng h (kg) 17.6 (12.0) 17.4 (14.7) 31.6 (12.7) 25.9 (13.1) 14.1 (12.2) 8.5 (8.9) 5.6 (–0.5 o 11.7)
Con = con ol g oup, Exp = expe imen al g oup, VAS = isual analogue scale, NHPT = Nine-Hole Peg Tes , QuickDASH = sho ened o ma o he Disabili ies o he A m, Shoulde , and
Hand ques ionnai e.
Table 3
Baseline cha ac e is ics o pa icipan s (n = 50).
Cha ac e is ics Exp
(n = 25)
Con
(n = 25)
Age (y ), mean (SD) 51 (8) 49 (7)
Gende , n emale (%) 22 (88) 19 (76)
Func ional abili y (QuickDASH) (0 o 100), mean (SD) 73 (14) 66 (24)
Pain (VAS) (0 o 10), mean (SD) 5.1 (2.6) 4.8 (2.9)
Dex e i y (NHPT) (s), mean (SD) 22.7 (3.9) 23.4 (5.3)
G ip s eng h (kg), mean (SD) 17.6 (12.0) 17.4 (14.7)
Con = con ol g oup, Exp = expe imen al g oup, NHPT = Nine-Hole Peg Tes ,
QuickDASH = sho ened o m o he Disabili ies o he A m, Shoulde , and Hand
ques ionnai e, VAS = Visual Analogue Scale.
Resea ch 85

mechanisms ha cause al e a ion o he senso imo o sys em and
p o ide a s imulus o e u n o he ini ial pa e n. The e o e, a
significan educ ion o pain in he expe imen al g oup would be
expec ed o ha e con ibu ed o imp o emen in unc ional abili y.
Again, howe e , he esul was non-significan , he mean es ima e
a ou ed he expe imen al g oup, and he confidence in e al
excluded all bu he mos i ial o de imen al e ec s (ie, 0.1 poin s
less imp o emen on he 10-poin isual analogue scale). The e o e,
o summa ise all he seconda y ou come esul s: i is unknown
whe he he imp o emen in sel - epo ed unc ional abili y migh
ha e been due o imp o emen s in pain, dex e i y and/o s eng h,
bu i is clea ha he significan benefi on he p ima y ou come was
achie ed wi hou subs an ial de imen o eco e y on he h ee
seconda y ou comes.
Ano he possible explana ion o he p esence o an e ec on he
p ima y ou come bu no elsewhe e could be g ea e a iabili y in
he seconda y ou comes. Fo example, he undamen al ac ion he
Nine-Hole Peg Tes en ails g apping small objec s. This ac ion
in ol es wo mo emen s: a con olled and p ecise mo emen o he
index finge and humb o pe o m he pinch, and ano he ac ion
anspo ing he execu ing hand.
39
In people wi h ca pal unnel
synd ome, he diso ganisa ion a he cen al le el
16
may cause an
al e a ion in he unc ion o he en i e uppe limb, which would
co espond o an inc ease in he anspo a iabili y o he execu ing
hand.
40
In he p esen s udy, he in e en ion o he con ol g oup
in ol ed a se ies o exe cises no only a he w is , hand and finge (as
in he expe imen al g oup) bu also a he elbow and shoulde le el.
This can ha e an e ec on he kinema ics o he en i e uppe limb in
he con ol g oup, since co-o dina ed mo emen s o he en i e uppe
limb (including he elbow and shoulde ) a e in ol ed in hand
anspo in he Nine-Hole Peg Tes . Fu he mo e, he e was
conside able imp o emen in he expe imen al g oup ( om 22.7 o
18.1 seconds) and in he con ol g oup ( om 23.4 o 20.1 seconds),
which b ough he pa icipan s –especially hose in he expe imen al
g oup –close o he no ma i e alues o 19 seconds in men and 17.7
seconds in women.
27
This may ha e caused a ceiling e ec in he
expe imen al g oup bu no in he con ol g oup.
Some limi a ions o his s udy mus be acknowledged. No
measu emen s we e made du ing he ea men pe iod o a a
pos -in e en ion ollow-up. Such measu es would ha e helped o
e eal he e olu ion o any benefi s, and whe he hey we e
sus ained. They may ha e also helped o disce n whe he and when
he ou come measu es o he con ol g oup eached hose o he
expe imen al g oup. Ano he limi a ion was he absence o
cos -u ili y a iables. These could ha e indica ed he e ec s o he
expe imen al in e en ion on he consump ion o heal h esou ces
based on he quali y o li e epo ed by he pa icipan s.
In summa y, ou da a sugges ha a home p og am pe o med
using he able -based ReHand app in ea ly ehabili a ion a e
su gical ca pal unnel elease appea s o be mo e e ec i e in he
eco e y o he unc ional abili y han a con en ional home p og am
p esc ibed on pape . Fu u e esea ch should seek o cla i y he e ec s
on he seconda y ou comes, which appea p omising bu emain
unce ain due o imp ecision a ound he be ween-g oup es ima es.
Fu u e esea ch could also in es iga e possible e ec on o he
a iables, such as he p op iocep i e sys em, quali y o li e o
consump ion o esou ces, as well as he e ec on o he
high-incidence auma pa hologies such as dis al adius ac u es.
Wha was al eady known on his opic: Ca pal unnel syn-
d ome causes discom o and pa aes hesia in he hand. Conse -
a i e ea men s a e ecommended as ini ial managemen .
Su ge y is gene ally ecommended in se e e and e ac o y cases.
The bes me hod o pos -su gical ehabili a ion is unknown.
Wha his s udy adds: Use o a able app o ea ly ehabili-
a ion a e ca pal unnel elease is mo e e ec i e in he eco e y
o unc ional abili y han a con en ional pape -based home
exe cise p og am. I emains unclea whe he he e ec is
accompanied by any bene i s in g ip s eng h, pain o dex e i y.
Foo no es:
a
Baseline, I ing on, NY, USA.
b
SPSS, IBM Co po a ion,
A monk, NY, USA.
eAddenda: Table 5 can be ound online a h ps://doi.o g/10.1016/j.
jphys.2019.02.008.
E hics app o al: The Vi gen Maca ena and Vi gen del Rocio Uni-
e si y Hospi als E hics Commi ee app o ed his s udy. All applicable
ins i u ional and go e nmen al egula ions conce ning he use o
human olun ee s we e ollowed. All pa icipan s ga e w i en
in o med consen be o e da a collec ion began.
Compe ing in e es s: Andalusian Heal h Se ice (SAS) has a
collabo a ion ag eemen conce ning he ReHand solu ion, and may
benefi financially i his esea ch gene a es a success ul ma ke ing
alue ela ed o ReHand. The e ms o his ag eemen ha e been
e iewed and app o ed by Andalusian Heal h Se ice in acco dance
wi h i s policy on Financial Conflic o In e es . Alejand o Sue o and
Jesús Blanque o we e he ini ia o s o he p ojec and ounded a spin-
o .
Sou ce(s) o suppo : This s udy was suppo ed by he Inno a ion
P ojec s G an #0143-2017 o he Heal h Council o Andalusian
Go e nmen . This s udy is pa o an ac i i y ha has ecei ed
unding om he Eu opean Ins i u e o Inno a ion and Technology
(EIT). This body o he Eu opean Union ecei es suppo om he
Eu opean Union’s Ho izon 2020 esea ch and inno a ion p og am.
Acknowledgemen s: We hank o he en i e ReHand esea ch
eam, and o he enginee ing eam ha de eloped ‘ReHand’: José
Manuel López, An onio Ga cía and Nie es Sánchez-Laulhé.
P o enance: No in i ed. Pee e iewed.
Co espondence: Ma ía Dolo es Co és-Vega, Physio he apy
Depa men , Uni e si y o Se ille, Se ille, Spain. Email: mdco [email p o ec ed]
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