Rehabilitation following surgery for flexor tendon injuries of the hand

Susan E Peters; Bhavana Jha; Mark Ross

doi:10.1002/14651858.CD012479.pub2

Cochrane Database of Systematic Reviews

Rehabilitación después de la cirugía por lesiones del tendón flexor de la mano

Información

DOI:

https://doi.org/10.1002/14651858.CD012479.pub2 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

13 enero 2021see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Lesiones óseas, articulares y musculares

Copyright:

Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Susan E Peters

Correspondencia a: Brisbane Hand and Upper Limb Research Institute, Brisbane, Australia

[email protected]

[email protected]

Center for Work, Health and Wellbeing, Harvard TH Chan School of Public Health, Boston, USA
Bhavana Jha

Brisbane Hand and Upper Limb Research Institute, Brisbane, Australia

Sunshine Coast University Hospital, Queensland Health, Birtinya, Australia

Advanced Hand Clinic, Maroochydore, Australia
Mark Ross

Brisbane Hand and Upper Limb Research Institute, Brisbane, Australia

Department of Surgery, School of Medicine, The University of Queensland, Herston, Australia

Orthopaedic Department, Princess Alexandra Hospital, Woolloongabba, Australia

Contributions of authors

SP and BJ wrote the protocol. SP and BJ completed the searches, eligibility, risk of bias assessments and data extraction. SP completed the data analysis, and the GRADE tables. All authors contributed to, and approved, the final version of the review.

Contributions of the editorial base

Helen Handoll (Co‐ordinating Editor): edited the review; advised on methodology and review content; and approved the final version for publication.
Joanne Elliott (Managing Editor and Information Specialist): developed search strategies, coordinated the editorial process; advised on content; and edited the review.
Maria Clarke (Information Specialist): ran the search and edited the search methods section.

Sources of support

Internal sources

Harvard T.H. Chan School of Public Health, Center for Work, Health, and Well‐being, USA

Host institution for Dr. Susan E Peters
Brisbane Hand and Upper Limb Research Institute, Australia

Host institution for Professor Mark Ross
Sunshine Coast University Hospital, Queensland Health & Advanced Hand Clinic, Maroochydore, Queensland, Australia

Host institutions for Bhavana Jha

External sources

None, Other

Declarations of interest

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

Acknowledgements

We thank Helen Handoll and Joanne Elliott for their editorial feedback and support on this review. We also thank Maria Clarke for her help in running and reporting the searches. We are grateful to the external referees, Megan Blakeway, Christina Jerosch‐Herold and Jason Wong, for their helpful comments on the penultimate draft of the review. We thank Nicole Pitcher for her help with the plain language summary.

We thank the trial authors who took the time to respond to requests for further information about their trials, including Ali Kitis, K. Geetha, and Lars Adolfsson.

We are grateful to Hebatullah M. Abdulazeem and Martina Löwe for translation of articles.

This project was supported by the National Institute for Health Research via Cochrane Infrastructure funding to the Cochrane Bone, Joint and Muscle Trauma Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

Version history

Published

Title

Stage

Authors

Version

2021 Jan 13

Rehabilitation following surgery for flexor tendon injuries of the hand

Review

Susan E Peters, Bhavana Jha, Mark Ross

https://doi.org/10.1002/14651858.CD012479.pub2

2017 Jan 07

Rehabilitation following surgery for flexor tendon injuries of the hand

Protocol

Susan E Peters, Bhavana Jha, Mark Ross

https://doi.org/10.1002/14651858.CD012479

Differences between protocol and review

Types of interventions

We included the comparison of different doses for interventions, other than orthosis‐wearing regimen; e.g. ultrasound dose, frequency or amount of interventions in types of intervention.

Types of outcome measures

For our second primary outcome (active finger ROM using goniometric measurement), we allowed classification of ROM using a categorical outcome.

We modified our definitions for timing of outcome measurement by inserting a medium term period (3 to 6 months) before the long term period, which now starts at over six months instead of over three months.

Assessment of risk of bias in the included studies

Linked with our revised definitions of timing of follow‐up assessment, we limited the second group to up to six months, and added in a third group for outcomes measured for greater than six months.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Adolescent; Adult; Aged; Child; Female; Humans; Male; Middle Aged; Young Adult;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Diagram showing the flow of studies through the study selection process

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Study	Follow‐up	Active Median (IQR)	Active N (digits)	Control Median; IQR	Control N (digits)	Reported P value
Self‐reported function for ADL using a VAS (0 to 10; higher = better)
Rigo 2017	At 2 months	7.2 (3.0)	36	6.5 (3.1)	32	P = 0.204
	At 3 months	7.3 (3.6)	36	7.7 (3.0)	31	P = 0.850
	At 6 months	8.8 (1.5)	32	8.5 (3.5)	30	P = 0.942
	At 12 months	9.3 (1.2)	34	8.8 (2.0)	29	P = 0.113

Analysis 1.1

Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 1: Self‐reported function for ADL using a VAS (0 to 10; higher = better)

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Analysis 1.2

Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 2: Self‐reported function using VAS for ADLs (0 to 10; higher scores = better); secondary analyses

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Analysis 1.3

Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 3: Active finger range of motion (degrees)

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Analysis 1.4

Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 4: Finger range of movement ‐ Poor outcome

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Analysis 1.5

Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 5: Adverse events

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Analysis 1.6

Comparison 1: Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol), Outcome 6: Strength (% of the contralateral hand or digit)

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Analysis 2.1

Comparison 2: Early active flexion + active extension exercise regimen (+ modified Kessler suture surgical technique) versus passive flexion + active extension exercise regimen (+ grasping suture and external pull‐out knot surgical technique), Outcome 1: Adverse events

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Analysis 3.1

Comparison 3: Active exercise regimen versus immobilisation regimen, Outcome 1: Range of movement at 12+ months: poor outcome

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Analysis 3.2

Comparison 3: Active exercise regimen versus immobilisation regimen, Outcome 2: Adverse events

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Analysis 4.1

Comparison 4: Early place and hold progressed to tendon gliding exercise regimen versus early passive progressed to active exercise regimen, Outcome 1: Grip strength at 12 weeks (% difference between normal and affected hands)

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Analysis 5.1

Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 1: Function (self‐reported): DASH scores (0 to 100; higher score = more disability)

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Analysis 5.2

Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 2: Range of movement (Total Active Movement) (degrees)

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Analysis 5.3

Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 3: Range of movement (Strickland Criteria) at 8 weeks: Poor outcome

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Analysis 5.4

Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 4: Adverse events

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Analysis 5.5

Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 5: Function (observed): Jebsen Taylor at 52 weeks (seconds)

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Analysis 5.6

Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 6: Function (observed): Purdue pegboard at 52 weeks (pegs)

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Analysis 5.7

Comparison 5: Place and hold exercise regimen versus Controlled passive exercise regimen, Outcome 7: Satisfaction with hand function (0 to 10: complete satisfaction) at 6 months

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Analysis 6.1

Comparison 6: Unrestricted activity at 8 weeks post‐surgery versus unrestricted activity at 10 weeks, Outcome 1: Adverse event (tendon rupture)

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Analysis 7.1

Comparison 7: Exoskeleton versus physiotherapy, Outcome 1: Function (self‐reported): DASH scores (0 to 100; higher score = more disability)

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Analysis 7.2

Comparison 7: Exoskeleton versus physiotherapy, Outcome 2: Active finger range of motion of PIP joint (degrees)

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Analysis 7.3

Comparison 7: Exoskeleton versus physiotherapy, Outcome 3: Active finger range of motion of DIP joint (degrees)

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Analysis 7.4

Comparison 7: Exoskeleton versus physiotherapy, Outcome 4: Active finger range of motion (Total Active Movement) (degrees)

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Analysis 7.5

Comparison 7: Exoskeleton versus physiotherapy, Outcome 5: Adverse events

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Analysis 7.6

Comparison 7: Exoskeleton versus physiotherapy, Outcome 6: Strength at 18 weeks

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Analysis 8.1

Comparison 8: Continuous passive motion device versus controlled passive progressed to active exercise regimen (Modified Kleinert), Outcome 1: Active finger range of motion (degrees)

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Analysis 8.2

Comparison 8: Continuous passive motion device versus controlled passive progressed to active exercise regimen (Modified Kleinert), Outcome 2: Range of movement at > 6 months (Strickland criteria) ‐ poor outcome

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Analysis 8.3

Comparison 8: Continuous passive motion device versus controlled passive progressed to active exercise regimen (Modified Kleinert), Outcome 3: Adverse event

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Analysis 9.1

Comparison 9: Ultrasound versus control, Outcome 1: Improvement in active range of movement (Difference between 3 and 12 weeks; Total Active Motion measured in degrees)

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Analysis 9.2

Comparison 9: Ultrasound versus control, Outcome 2: Active finger range of motion (Strickland classification) at 3 months ‐ Poor outcome

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Analysis 9.3

Comparison 9: Ultrasound versus control, Outcome 3: Adverse events

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Analysis 10.1

Comparison 10: Low‐level laser therapy versus placebo control, Outcome 1: Active finger range of motion (Total active motion (degrees)) at 12 weeks

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Analysis 10.2

Comparison 10: Low‐level laser therapy versus placebo control, Outcome 2: Range of movement at 12 weeks: poor outcome

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Analysis 10.3

Comparison 10: Low‐level laser therapy versus placebo control, Outcome 3: Adverse events

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Analysis 10.4

Comparison 10: Low‐level laser therapy versus placebo control, Outcome 4: Grip strength at 12 weeks (% lost using uninjured hand as comparison)

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Analysis 11.1

Comparison 11: Motor imagery versus control, Outcome 1: Strength (kg)

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Summary of findings 1. Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen for rehabilitation following surgery for flexor tendon injuries of the hand

Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Addition of active flexion exercises to controlled passive exercise regimen for rehabilitation following surgery for flexor tendon injuries of the hand
Patient or population: participants undergoing rehabilitation following surgery for flexor tendon injuries of the hand^a Setting: orthopaedic surgery department (Norway) Intervention: active flexion exercises commenced at one day post‐surgery plus standard hand therapy using modified Kleinert regimen Comparison: standard hand therapy using modified Kleinert regimen started at one day post‐surgery
Outcomes	Early controlled passive exercise regimen (modified Kleinert protocol)	Early active flexion plus early controlled passive exercise regimen	Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Functional assessment using a patient reported outcome measure: assessed with a VAS of ADL (0 to 10; higher score = better function) Follow‐up: 6 months	Study population		‐	62 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,c,d	The study reporting this outcome reported median and interquartile ranges. It found no evidence of a difference between the two groups (reported P = 0.942). It is very unlikely that a difference of 0.3 on an 11 point scale is clinically important.
	See comment. Median 8.5, IQR 3.5	See comment. Median 8.8, IQR 1.5	‐	62 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,c,d
Functional assessment using a patient reported outcome measure: assessed with a VAS of ADL (0 to 10; higher score = better function) Follow‐up: 12 months	Study population		‐	63 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW^b,c,d	The study reporting this outcome reported median and interquartile ranges. It found no evidence of a difference between the two groups (reported P = 0.113). It is very unlikely that a difference of 0.5 on an 11 point scale is clinically important
	See comment. Median 8.8, IQR 2.9	See comment. Median 9.3, IQR 1.2	‐	63 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW^b,c,d
Active finger range of motion assessed with: goniometer (degrees) Follow‐up: 6 months	Study population		‐	63 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,c	This difference is not meaningful and could have been due to error in measurement: for goniometric measurement, the minimal detectable difference is between 12 and 30 degrees with a standard error of measurement ranging from 4 to 11 degrees per joint (Reissner 2019).
	Mean AROM in the control group was 134 degrees	MD 3 degrees higher (14.00 lower to 20.00 higher)	‐	63 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,c
Active finger range of motion assessed with: goniometer (degrees) Follow‐up: 12 months	Study population		‐	63 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,c	This difference is not meaningful and could have been due to error in measurement: for goniometric measurement, the minimal detectable difference is between 12 and 30 degrees with a standard error of measurement ranging from 4 to 11 degrees per joint (Reissner 2019).
	Mean AROM in the control group was 140 degrees	MD 9 degrees higher (7.04 lower to 25.04 higher)	‐	63 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,c
Adverse events: participants incurring one or more adverse events Follow‐up: 12 months	Study population		RR 0.58 (0.23 to 1.44)	69 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,e	The 15 adverse events comprised 3 tendon ruptures, 6 wound dehiscence, 1 complex regional pain syndrome and 5 transitory swelling and tenderness of the tendon sheaf.
	282 per 1000	164 per 1000 (65 lower to 406 higher)	RR 0.58 (0.23 to 1.44)	69 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,e
Adverse event (tendon rupture) Follow‐up: 12 months	Study population		RR 1.73 (0.16 to 18.20)	69 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,e	All three tendon ruptures (4.3%) underwent secondary surgery.
Adverse event (tendon rupture) Follow‐up: 12 months	31 per 1000	54 per 1000 (5 to 569)	RR 1.73 (0.16 to 18.20)	69 fingers (1 RCT)	⊕⊝⊝⊝ VERY LOW ^b,e
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). ADL: activities of daily living; AROM: active range of motion; CI: confidence interval; IQR: interquartile range; MD: mean difference; RCT: randomised controlled trial; RR: risk ratio; VAS: visual Analogue Scale
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.
^aThe majority (68%) were zone II flexor tendon repairs; the rest being zone I and III. ^bDowngraded two levels due to very serious risk of bias reflecting performance and detection bias (no blinding) and unit of analysis errors since the data were provided for fingers not participants. ^cDowngraded one level due to serious imprecision reflecting the small sample size. ^dDowngraded one level due to serious indirectness reflecting the reflecting the uncertain nature of the outcome. ^eDowngraded two levels due to very serious imprecision reflecting the small number of events.

Summary of findings 1. Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen for rehabilitation following surgery for flexor tendon injuries of the hand

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Summary of findings 2. Active exercise regimen compared with an immobilisation regimen following surgery for flexor tendon injuries of the hand

Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Active exercise regimen compared with an immobilisation regimen following surgery for flexor tendon injuries of the hand
Patient or population: participants undergoing rehabilitation following surgery for flexor tendon injuries of the hand^a Setting: specialist hand clinic (Brazil) Intervention: active exercise regimen commenced within one day post‐surgery for 3 weeks, all wore a dorsal splint Comparison: immobilisation in a dorsal splint for 3 weeks
Outcomes	Immobilisation regimen for three weeks	Active exercise regimen commenced within one day post‐surgery	Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Functional assessment using a patient reported outcome measure Follow‐up: 3 to 6 months	See comment.	See comment.	Not estimable	‐	See comment.	Outcome was not reported
Functional assessment using a patient reported outcome measure Follow‐up: more than 6 months	See comment.	See comment.	Not estimable	‐	See comment.	Outcome was not reported
Range of movement Follow‐up: 3 to 6 months	See comment.	See comment.	Not estimable	‐	See comment.	Outcome was not reported
Range of movement assessed with poor outcome (Strickland criteria) Follow‐up: 12 to 36 months	Study population		RR 0.08 (0.00 to 1.43)	84 (1 RCT)	⊕⊝⊝⊝ VERY LOW^b,c,d	Poor outcome is < 25% of normal. The 7 (15%) cases of poor range of finger movement were all in the immobilisation group
	149 per 1000	12 per 1000 (0 to 213)	RR 0.08 (0.00 to 1.43)	84 (1 RCT)	⊕⊝⊝⊝ VERY LOW^b,c,d
Adverse events: participants incurring one or more adverse events	See comment.	See comment.	Not estimable	84 (1 RCT)	See comment	Outcome was not reported. Only tendon rupture and indication for tenolysis data provided; see below.
Adverse events requiring (or indicated for) surgery	Study population		RR 0.64 (0.24 to 1.70)	84 (1 RCT)	⊕⊝⊝⊝ VERY LOW^b,e	All five cases of tendon rupture (13.5% of 37) needing surgical repair occurred after 2 weeks in the active mobilisation group and all 10 cases of range of motion deficiency (21.3% of 47) indicating scar adhesion and need for tenolysis occurred in the immobilisation group.
Adverse events requiring (or indicated for) surgery	213 per 1000	137 per 1000 (52 to 363)	RR 0.64 (0.24 to 1.70)	84 (1 RCT)	⊕⊝⊝⊝ VERY LOW^b,e
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group (in this table, this is directly based on the study population) and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect
^aAll were zone II flexor tendon repairs. ^bDowngraded two levels for very serious risk of bias reflecting detection bias (no blinding of outcome assessors), potential selection bias and attrition bias. ^cDowngraded one level for serious indirectness reflecting the unsatisfactory nature of the outcome. ^dDowngraded one level because of low number of events and wide confidence intervals for this outcome. ^eThese complications reflect the anticipated complications of early active mobilisation (early re‐rupture) and immobilisation (scar adhesions and contractures). It is uncertain whether tenolysis was actually done for those participants with range of motion deficit in the immobilisation group.

Summary of findings 2. Active exercise regimen compared with an immobilisation regimen following surgery for flexor tendon injuries of the hand

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Summary of findings 3. Place and hold exercise regimen versus controlled passive exercise regimen following surgery for flexor tendon injuries of the hand

Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Place and hold exercise versus controlled passive exercise following surgery for flexor tendon injuries of the hand
Patient or population: participants undergoing rehabilitation following surgery for flexor tendon injuries of the hand^a Setting: specialist hand clinics (Iran and USA) and a specialist rehabilitation department (Egypt) Intervention: place and hold exercise regimen^b Comparison: controlled passive exercise regimen^c
Outcomes	Controlled passive exercise regimen	Place and hold exercise regimen	Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Functional assessment using a patient reported outcome measure: assessed with DASH questionnaire (0 to 100; higher scores = worse disability) Follow‐up: 6 months	Study population		Not estimable	26 (1 RCT)	⊕⊝⊝⊝ VERY LOW^d,e	The study reporting this outcome reported median and interquartile ranges, finding no evidence of a difference between the two groups (reported P = 0.62).
	See comment. Median 15, IQR 10 to 30	See comment. Median 23, IQR 2 to 26	Not estimable	26 (1 RCT)	⊕⊝⊝⊝ VERY LOW^d,e
Functional assessment using a patient reported outcome measure: assessed with DASH questionnaire (0 to 100; higher scores = worse disability) Follow up: 12 months	Study population		‐	89 (1 RCT)	⊕⊝⊝⊝ VERY LOW^d,f	These differences are not clinically important. The recommended minimal clinically important difference for DASH is 15 (DASH/QuickDASH).
	Mean DASH score was 3.1	Mean DASH score was 1.1 lower (2.77 lower to 0.57 higher)	‐	89 (1 RCT)	⊕⊝⊝⊝ VERY LOW^d,f
Range of movement Follow‐up: 3 to 6 months	See comment.	See comment.	Not estimable	‐	See comment.	Outcome was not reported
Range of movement (degrees) Follow‐up: 12 months	Study population		‐	89 (102 digits) (1 RCT)	⊕⊝⊝⊝ VERY LOW^d,g
Range of movement (degrees) Follow‐up: 12 months	Mean ROM was 128 degrees	Mean ROM was 28 degrees higher (18.87 higher to 37.13 higher)	‐	89 (102 digits) (1 RCT)	⊕⊝⊝⊝ VERY LOW^d,g
Adverse events: participants incurring one or more adverse events	See comment.	See comment.	Not estimable	84 (1 RCT)	See comment.	This outcome was not reported by the three trials testing this comparison. Only tendon rupture (see next) was commonly reported. One trial (26 participants), reporting by tendon or digit (36 digits), also reported on scar adherence (reported only in the controlled passive group), flexion contracture at the DIP and PIP joints and tendon lag; very low certainty evidence for all individual complications.
Adverse events requiring (or indicated for) surgery	Study populations^h		RR 0.81 (0.19 to 3.50)	196 tendons (3 RCTs)	⊕⊝⊝⊝ VERY LOW^d,i	These data were limited to tendon rupture. We considered that all 7 tendon ruptures (3.6% of 196 tendons) would have required surgery.^j
Adverse events requiring (or indicated for) surgery	40 per 1000	33 per 1000 (8 to 140)	RR 0.81 (0.19 to 3.50)	196 tendons (3 RCTs)	⊕⊝⊝⊝ VERY LOW^d,i
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group (in this table, this is directly based on the study population) and the relative effect of the intervention (and its 95% CI). CI: confidence interval; DASH: Disabilities of the Arm, Shoulder and Hand; DIP: distal interphalangeal; IQR: interquartile range; PIP: proximal interphalangeal; RCT: randomised controlled trial; ROM: range of movement; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect
^aThe majority were zone II flexor tendon repairs; one of the three studies making this comparison also included 7 zone I injuries and 7 zone III injuries. ^bAll exercises started at 3 days from surgery. The place and hold exercise regimens varied among the three studies. In two studies, the exercises were carried out with a dorsal orthosis and in one study, the dorsal orthosis was removal when doing the exercises ^cAll exercises started at 3 days from surgery. The controlled passive exercise regimens varied among the three studies. However, rubber band traction was common to all three. ^dDowngraded two levels for very serious risk of bias reflecting lack of blinding (performance and detection bias) ^eDowngraded one level for serious imprecision. ^fDowngraded one level for serious imprecision, also reflecting the potential 'ceiling' effect as the mean values were very low and thus cannot discriminate between the two groups. ^gDowngraded one level for serious imprecision as the data are presented for tendons not participants. ^hControl group risk was devised from the summed data from the three studies. These results were not available for participants rather than tendons. ⁱDowngraded two levels for very serious imprecision reflecting a very low number of events and wide confidence interval for this outcome. ^jWe did not include the 14 cases of scar adherence (70% of 20 tendons) reported in the controlled passive group of one trial because the outcome was not defined and no details of the extent or consequences were provided.

Summary of findings 3. Place and hold exercise regimen versus controlled passive exercise regimen following surgery for flexor tendon injuries of the hand

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Table 1. Number of records retrieved by each search strategy

Database	Period Searched	Date Searched	Number of hits
Cochrane Bone, Joint and Musculoskeletal Trials (BJMT) Specialised Register	18 June 2019	18 June 2019	26
CENTRAL	August 2020, Issue 8	11 August 2020	208
MEDLINE	January 1946 to August 2020	10 August 2020	462
Embase	January 1980 to June 2019	18 June 2019	227
CINAHL PLUS	January 1937 to June 2019	18 June 2019	63
AMED	January 1985 to August 2020	10 January 2017	75
ClinicalTrials.gov		11 August 2020	79
WHO International Clinical Trials Registry Platform (ICTRP)		18 June 2019	138

Table 1. Number of records retrieved by each search strategy

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Table 2. Summary of study settings and participant characteristics

Study	Country	Setting	Recruited Participants; Digits; Tendons	Final follow‐up Participants; Digits; Tendons	Zones	Age (years) Mean (Range)	Male	Female
Abdel Sabour 2018	Egypt	Rehabilitation Department	33; NR; 45	26; NR; 36	I‐III	26.8 (15‐60)^a	21^a	5^a
Adolfsson 1996	Sweden	NR	96; 106; NR	82; 91; 118	II	37^a	54^a	28^a
Farzad 2014	Iran	Hand therapy clinic	54; 64; 108	54; 64; 108	II	28.5 (13‐50)	37	17
Geetha 2014	India	Hospital	106; 139; NR	100; 131; NR	II	G1: NR (10‐45)^a G2: 35 (22‐50)^a	89^a	11^a
Gelberman 1991	USA	Multi‐centre hospital	51; 60; 102^b	51; 60; 102	II	29.4^a	NR	NR
Gulke 2018	Germany	Physiotherapy clinic	62; NR;NR	59; NR; NR	II	29.5 (18‐60)	44	18
Hagberg 2000	Sweden	NR	100; 108; NR	NR; NR; NR	II	NR	NR	NR
Kneafsey 1994	UK	Plastic surgery centre	112; NR; NR	80; NR; NR	I‐III	NR	NR	NR
Ozkan 2004	Turkey	Hand surgery centre	25; 41; NR	23; 39; NR	I‐V	24 (7‐43)	15	10
Poorpezeshk 2018	Iran	Plastic surgery centre	97; 114; 114	77; 92; 92	I‐III	27^a	60^a	17^a
Rigo 2017	Norway	Orthopaedic surgery centre	53; 73; 73	45; 63; 63	I‐III	38.7 (18‐72)^c	36^c	14^c
Scavenius 2000	Denmark	Hand surgery centre	39; 39; 39	33; 33; 33	I‐II	NR	NR	NR
Silva 2003	Brazil	Hand surgery centre	84; NR; 152	NR; NR; NR	II	34 (18‐66)	NR	NR
Stenekes 2009	Netherlands	Plastic surgery centre	28; NR; NR	25; NR; NR	All	33.5^a	18^a	7^a
Trumble 2010	USA	Multi‐centre hand surgery centre	103; 119; 238	89; 102; 204	II	29 (15‐51)^a	63^a	30^a
Uday Raj 2018	India	Plastic surgery centre	30; NR; NR	30; NR; NR	V	NR	NR	NR
Vialaneix 2003	France	NR	35; NR; NR	NR; NR NR	II	35	NR	NR
NR: Not reported; G1: Group 1; G2: Group 2 ^aOnly reported at follow‐up (not at baseline) ^bParticipants were only eligible if they were available for the 6 month follow‐up. Thus, this number is likely to have been much higher than reported here. ^cExcludes 3 participants who experienced tendon ruptures after randomisation.

Table 2. Summary of study settings and participant characteristics

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Table 3. Outcome matrix showing the outcomes reported for the individual trials

Study ID	Function: patient‐reported	Active ROM	Adverse event	Passive ROM	Strength	Return to work	Function: objective measure	Satisfaction
Abdel Sabour 2018	X	X	X					X
Adolfsson 1996	X	X	X		X	X
Farzad 2014		X	X
Geetha 2014		X	X		X
Gelberman 1991		X	X
Gulke 2018	X	X	X		X			X
Hagberg 2000		X	X
Kneafsey 1994		X			X
Ozkan 2004		X	X		X
Poorpezeshk 2018			X	X				X
Rigo 2017	X	X	X		X
Scavenius 2000		X	X		X
Silva 2003		X	X
Stenekes 2009	X	X			X
Trumble 2010	X	X	X			X	X	X
Uday Raj 2018		X	X		X
Vialaneix 2003		X	X			X

Table 3. Outcome matrix showing the outcomes reported for the individual trials

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Table 4. Outcome classifications using active ROM

Classification system	Outcome (% motion achieved)	Excellent	Good	Fair or satisfactory	Poor	Failure
Strickland‐Glogovac (Strickland 1980)	% active PIP + DIP ROM (active flexion ‐ extension deficit) compared to contralateral side or 175 degrees*	85% to 100%	70% to 84%	50% to 69%	0% to 49%	Not applicable
Strickland‐Glogovac (Strickland 1980)	ROM (in degrees)	> 150	125 to 149	90 to 124	< 90	Not applicable
Strickland or Modified Strickland (Strickland 1985)	% active PIP + DIP ROM (active flexion ‐ extension deficit) compared to contralateral side or 175 degrees*	75% to 100%	50% to 74%	24% to 49%	0% to 24%	Not applicable
Strickland or Modified Strickland (Strickland 1985)	ROM (in degrees)	> 132	88 to 131	45 to 87	< 44	Not applicable
Tang*** (Tang 2007)	% active PIP + DIP ROM compared to contralateral side or 175 degrees*	90% to 100%	70% to 89%	50% to 69%	30% to 49%	< 30%
IFSSH (Silva 2003)	% Total active motion compared to total passive motion**	75% to 100%	50% to 74%	24% to 49%	0% to 24%	Not applicable
Total Active Motion (ASSH 1976)	% active MCP + PIP + DIP ROM (active flexion ‐ extension deficit) compared to contralateral side	Normal	> 75%	50% to 75%	< 50%	< pre‐surgery
DIP: distal interphalangeal; IFFSH: International Federation of Societies for Surgery of the Hand; MCP: metacarpophalangeal; ROM: range of movement; PIP: proximal interphalangeal The sum of active ROM of the PIP and DIP joints is calculated in degrees. This is done by adding the flexion achieved at the PIP and DIP joints and subtracting any extension deficits from the total. Motion is reported as a % of the contralateral side. It is assumed that 175 degrees is the sum of motion of the normal PIP and DIP joints of the unaffected side. % motion achieved = ((PIP + DIP flexion) ‐ (PIP + DIP extension deficit)) X 100 divided by 175. * % motion achieved = (Total active motion X 100) divided by Total passive motion. ***According to Tang, the excellent and good scores are further divided into plus and minus sub‐grades based on their grip strength and quality of motion (investigator’s subjective judgement of the coordination, visual arc and speed of motion).

Table 4. Outcome classifications using active ROM

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Comparison 1. Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Self‐reported function for ADL using a VAS (0 to 10; higher = better) Show forest plot	1		Other data	No numeric data

1.2 Self‐reported function using VAS for ADLs (0 to 10; higher scores = better); secondary analyses Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.2.1 ADL VAS at 2 months (0=worst; 10=best)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.2.2 ADL VAS at 3 months (0=worst; 10=best)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.2.3 ADL VAS at 6 months (0=worst; 10=best)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.2.4 ADL VAS at 12 months (0=worst; 10=best)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.3 Active finger range of motion (degrees) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.3.1 Total Active Movement at 1 month (degrees)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.3.2 Total Active Movement at 2 months (degrees)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.3.3 Total Active Movement at 3 months (degrees)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.3.4 Total Active Movement at 6 months (degrees)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.3.5 Total Active Movement at 12 months (degrees)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.4 Finger range of movement ‐ Poor outcome Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.4.1 Strickland classification at 1 month	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.2 Strickland classification at 2 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.3 Strickland classification at 3 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.4 Strickland classification at 6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.5 Strickland classification at 12 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.6 Tang classification at 1 month	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.7 Tang classification at 2 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.8 Tang classification at 3 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.9 Tang classification at 6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.10 Tang classification at 12 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.5 Adverse events Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.5.1 Tendon rupture	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.5.2 Complex Regional Pain Syndrome	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.5.3 Wound dehiscence	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.5.4 Transitory swelling + tenderness	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.5.5 Any adverse event	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.6 Strength (% of the contralateral hand or digit) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.6.1 Grip Strength at 3 months (% of the contralateral hand)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.6.2 Grip Strength at 6 months (% of the contralateral hand)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.6.3 Grip Strength at 12 months (% of the contralateral hand)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.6.4 Pinch Strength at 3 months (% of the contralateral digit)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.6.5 Pinch Strength at 6 months (% of the contralateral digit)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.6.6 Pinch Strength at 12 months (% of the contralateral digit)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 1. Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol)

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Comparison 2. Early active flexion + active extension exercise regimen (+ modified Kessler suture surgical technique) versus passive flexion + active extension exercise regimen (+ grasping suture and external pull‐out knot surgical technique)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Adverse events Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1.1 Tendon ruptures	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.1.2 Scar adhesions requiring surgery (Tenolysis)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 2. Early active flexion + active extension exercise regimen (+ modified Kessler suture surgical technique) versus passive flexion + active extension exercise regimen (+ grasping suture and external pull‐out knot surgical technique)

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Comparison 3. Active exercise regimen versus immobilisation regimen

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Range of movement at 12+ months: poor outcome Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.1.1 IFSSH criteria	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.1.2 Strickland criteria	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.2 Adverse events Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.2.1 Tendon ruptures	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.2.2 Movement restrictions indicating need for tenolysis	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.2.3 Secondary surgery (actual or indicated)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 3. Active exercise regimen versus immobilisation regimen

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Comparison 4. Early place and hold progressed to tendon gliding exercise regimen versus early passive progressed to active exercise regimen

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Grip strength at 12 weeks (% difference between normal and affected hands) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 4. Early place and hold progressed to tendon gliding exercise regimen versus early passive progressed to active exercise regimen

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Comparison 5. Place and hold exercise regimen versus Controlled passive exercise regimen

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Function (self‐reported): DASH scores (0 to 100; higher score = more disability) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1.1 DASH at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
5.1.2 DASH at 52 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
5.2 Range of movement (Total Active Movement) (degrees) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.2.1 At 8 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
5.2.2 At 52 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
5.3 Range of movement (Strickland Criteria) at 8 weeks: Poor outcome Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5.4 Adverse events Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.4.1 Tendon rupture	3	196	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.19, 3.50]
5.4.2 Scar adherence	1	36	Risk Ratio (M‐H, Fixed, 95% CI)	0.04 [0.00, 0.66]
5.4.3 Flexion contracture of the DIP joint	1	36	Risk Ratio (M‐H, Fixed, 95% CI)	0.12 [0.02, 0.88]
5.4.4 Flexion contracture of the PIP joint	1	36	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.15, 1.48]
5.4.5 FDS tendon lag	1	36	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.06, 0.98]
5.4.6 FDP tendon lag	1	36	Risk Ratio (M‐H, Fixed, 95% CI)	0.17 [0.04, 0.62]
5.5 Function (observed): Jebsen Taylor at 52 weeks (seconds) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.6 Function (observed): Purdue pegboard at 52 weeks (pegs) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.7 Satisfaction with hand function (0 to 10: complete satisfaction) at 6 months Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 5. Place and hold exercise regimen versus Controlled passive exercise regimen

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Comparison 6. Unrestricted activity at 8 weeks post‐surgery versus unrestricted activity at 10 weeks

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
6.1 Adverse event (tendon rupture) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 6. Unrestricted activity at 8 weeks post‐surgery versus unrestricted activity at 10 weeks

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Comparison 7. Exoskeleton versus physiotherapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
7.1 Function (self‐reported): DASH scores (0 to 100; higher score = more disability) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7.1.1 DASH at 12 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.1.2 DASH at 18 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.2 Active finger range of motion of PIP joint (degrees) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7.2.1 PIP joint range of motion at 6 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.2.2 PIP joint range of motion at 12 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.2.3 PIP joint range of motion at 18 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.3 Active finger range of motion of DIP joint (degrees) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7.3.1 DIP joint range of motion at 6 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.3.2 DIP joint range of motion at 12 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.3.3 DIP joint range of motion at 18 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.4 Active finger range of motion (Total Active Movement) (degrees) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7.4.1 TAM at 6 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.4.2 TAM at 12 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.4.3 TAM at 18 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.5 Adverse events Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7.5.1 Tendon rupture	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
7.5.2 CRPS (complex regional pain syndrome)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
7.6 Strength at 18 weeks Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

7.6.1 Grip strength (kg)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
7.6.2 Pinch strength (kg)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 7. Exoskeleton versus physiotherapy

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Comparison 8. Continuous passive motion device versus controlled passive progressed to active exercise regimen (Modified Kleinert)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
8.1 Active finger range of motion (degrees) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

8.1.1 TAM at > 6 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
8.2 Range of movement at > 6 months (Strickland criteria) ‐ poor outcome Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8.3 Adverse event Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8.3.1 Tendon rupture at >6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
8.3.2 Infection at >6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 8. Continuous passive motion device versus controlled passive progressed to active exercise regimen (Modified Kleinert)

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Comparison 9. Ultrasound versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
9.1 Improvement in active range of movement (Difference between 3 and 12 weeks; Total Active Motion measured in degrees) Show forest plot	1	131	Mean Difference (IV, Fixed, 95% CI)	26.47 [19.70, 33.24]

9.1.1 1MHz; 0.7W/cm2 increased to 1w/cm2	1	50	Mean Difference (IV, Fixed, 95% CI)	31.50 [19.94, 43.06]
9.1.2 1 MHz; 0.3w/cm2 increased to 1.0w/cm2	1	40	Mean Difference (IV, Fixed, 95% CI)	23.80 [11.89, 35.71]
9.1.3 3Mhz; 0.5w/cm2 increased to 0.7w/cm2	1	41	Mean Difference (IV, Fixed, 95% CI)	23.90 [12.20, 35.60]
9.2 Active finger range of motion (Strickland classification) at 3 months ‐ Poor outcome Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9.3 Adverse events Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9.3.1 Tendon rupture at 3 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
9.3.2 Wound dehiscence <3 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 9. Ultrasound versus control

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Comparison 10. Low‐level laser therapy versus placebo control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
10.1 Active finger range of motion (Total active motion (degrees)) at 12 weeks Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

10.2 Range of movement at 12 weeks: poor outcome Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10.2.1 Strickland scoring system at 12 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
10.3 Adverse events Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10.3.1 Tendon rupture	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
10.3.2 Wound infection	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
10.4 Grip strength at 12 weeks (% lost using uninjured hand as comparison) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 10. Low‐level laser therapy versus placebo control

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Comparison 11. Motor imagery versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
11.1 Strength (kg) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

11.1.1 Grip strength (kg) at 12 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
11.1.2 Pinch strength (kg) at 12 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 11. Motor imagery versus control

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