PICO
Patient/Population
Patients with type 2 diabetic polyneuropathy (n=40)
Intervention
- Hand exercises
- Conventional physical therapy
Comparison
- Conventional physical therapy
Outcomes
Proprioception
Handgrip strength
Function
Translatability: (3/3) Easy
Comments: Adding hand exercises program (proprioceptive training and strength training) to conventional physical therapy is necessary to restore wrist proprioception and improve strength and hand function.
Limitations: Lack of follow-up to determine the long term effects; the choice of the patients at first was represented as a convenient sample rather than a random sample of the whole population; the physiotherapist was not blinded.
Appraisals:
PEDro Scale – (7/10) Blind subjects: No; Blind therapists: No; Intention-to-treat analysis: No. (by PEDro – confirmed)
BTB
Intervention – 1
- Hand exercises
Dose
- 30 min per session
- Rest periods as needed for each patient
Periodicity
- 3 days a week 4 four weeks
Local/Technic:
A – Proprioceptive exercise (Thabet et al; Hincapie)
- “Isometric exercise: Patient was instructed to sit with forearm pronated and hand resting flat on the table placed in front of him then the physical therapist apply manual resistance on hand dorsal-radial side (for extensor carpi radialis) while forearm supinated and hand resting on the table and manual resistance applied on palm (for flexor carpi ulnaris and flexor carpi radialis) (each movement repeated 10 times, and hold for 5 seconds).
- Rhythmic stabilization: The patient was instructed to position his wrist in different angles of wrist flexion/extension and hold this isometric contraction. Then manual perturbation applied by the therapist (3 s for 10 times ) for coactivation of agonists and antagonists. The physical therapist provides enough resistance to cause the patient to react, but not enough to break the isometric contraction. As the patient progresses, length of time of rhythmic stabilization increases, and therapist resistance increases.
- Duplicating position: Patient’s wrist was moved passively to a position within its available range of motion, then returned it to its resting position. Again, therapist emphasize the affected positions. Then, the patient was instructed to actively repeat the movement, first with his eyes open, then closed. If the patient misses the position, he opens his eyes and actively moves to the desired position. Perform 10 to 20 repetitions of varying positions and held that position for three seconds.
- Dart-throwing motion with weight placed in hand: The patient was instructed to start with 1 lb dumbbell and progress according to his tolerance, 2 sets of 10 repetitions.
- Throwing into rebounder: The patient was instructed to throw and catch medicine ball with forearm in pronation, 2 sets of 10 repetition. Patient starts with 1 lb medicine ball and progress according to his tolerance.
- A controlled weight-bearing exercise: The patient was standing facing the wall. Then patient was instructed to press a soft ball against the wall. The same exercise can be performed while the patient was standing in front of table and press on a soft ball placed on the table.
- The Wobble Board Balance exercise: The patient was instructed to assume the quadruped position on the floor with their upper body positioned over a wobble board. Elbow joint should be kept straight and shoulder joint should be flexed to approximately 90. Patient’s upper body weight was positioned over the upper limbs. The patients rocked their wrist in the following directions; flexion, extension, and radial and ulnar deviation for 30 seconds while maintaining their balance. This exercise was performed first with eyes open, then closed. Perform 5 to 10 repetitions.”
B) Strength training as described by Thorat and Ganvir:
- “Squeeze ball exercise: Each patient was instructed to sit and squeeze ball and wait for 10 seconds count.
- Spring Hand Dynamometer: Each patient was instructed to sit and spring and press hand dynamometer placed in his hand and wait for 10 seconds.
- Rubber band exercise: I] Each patient was instructed to sit with shoulder in neutral position and both elbow and finger (metacarpo phalangeal joint) were flexed . Rubber band was wrapped around the patient’s fingers and patient was asked to perform fingers extension. II] The patient was asked to sit with shoulder in neutral position, elbow flexed and forearm pronated then rubber band was wrapped around his fingers and the patient was asked to do abduction of the fingers.”
Intervention – 2
- Conventional physical therapy
Dose
- 30 min per session
Periodicity
- 3 days a week 4 four weeks.
Local/Technic:
- Active range of motion exercises for wrist joint including wrist flexion, wrist extension, ulnar deviation and radial deviation .
- Stretching exercises for flexors of the wrist: The exercises were done according to the patient’s tolerance for thirty seconds and rest for thirty seconds.
- Strength exercises: Graduated active resistive exercises; Isometric hooks exercises; Pinching clothespin with each finger: Patient was instructed to take clothespin and practice pinching it with different fingers.
- Exercises to facilitate the function of hand including reaching, grasping, carrying, release different objects. The patient was instructed to sit and perform these exercises after demonstrating it. These exercises were in form of the following as described by Thabet et al.: Grasping a cube: Each patient was instructed to grasp cubes placed in box within his hand reach; Transferring cube: Each patient was instructed to pick up cubes then put cubes in the physical therapist’s hand; Releasing cube: Each patient was instructed to release or drop the cubes placed in his hand into a container placed in front of him; Stacking coins: Each patient was asked to stacking coins on top of each other; Turning pages: Each patient was asked to open a thick large book placed on a table and turn pages; Writing activities.
Citation: Rehab N., Abdelmageed, S., Abu El Kasem, S., & Tawfik, R. (n.d.). EFFECT OF HAND EXERCISES PROGRAM ON WRIST PROPRIOCEPTION, GRIP STRENGTH AND HAND FUNCTION IN PATIENTS WITH TYPE 2 DIABETIC POLYNEUROPATHY: A RANDOMIZED CONTROLLED TRIAL. Turkish Journal of Physiotherapy and Rehabilitation,32(3). https://turkjphysiotherrehabil.org/pub/pdf/321/32-1-1022.pdf