The impact of blood flow restriction therapy on orthopaedic conditions of the upper extremity: a systematic review of randomized controlled trials

The upper extremities are necessary to independently perform everyday activities, engage with the environment and others and, importantly, work. Unfortunately, upper extremity (UE) conditions, resulting in pain and impairments, are common. Although returning to work is usually straightforward, for some it can be difficult and prolonged, impacting significantly on the worker, key stakeholders and society. This thesis utilized mixed methodology to explore factors influencing RTW following surgery for traumatic and non-traumatic UE conditions. Specifically, the overall aims were to: 1) identify gaps in the literature; 2) generate a list of factors influencing RTW; 3) explore stakeholders perspectives of barriers and the strategies to facilitate RTW; 4) determine the assessment tools used by health care providers (HCPs) to evaluate RTW barriers; 5) clarify a definition for delayed RTW; and 6) explore injured workers’ lived experiences to understand the context surrounding the factors and processes that may influence RTW. A scoping review identified gaps in the literature (Aim 1), generating the remaining thesis aims. A systematic review of prognostic studies for RTW following a common UE surgery, carpal tunnel release, was then conducted (Aim 2). This review revealed an inconsistent and low level of evidence for any studied prognostic factor for RTW or work disability. A three-round Delphi study determined expert opinion on the barriers and facilitators for RTW following surgery for non-traumatic UE conditions (Aim 2). Thirty-one experts completed all rounds. Strong consensus was achieved for these barriers: mood disorder; symptoms at more than one site; heavy UE work exertions; lack of flexible RTW arrangements; lack of supervisor support; and high pain catastrophising. Strong consensus was achieved for these facilitators: high motivation to RTW; high RTW and recovery self-efficacy; availability of modified duties; flexible RTW arrangements; positive coping skills; limited heavy UE work exertions; no catastrophic thinking; no fear avoidance to RTW, pain or activity; return to meaningful work duties; supportive RTW policies; supportive supervisor; and high job satisfaction. A cross-sectional study of 1011 RTW stakeholders (HCPs, employers, insurers and lawyers) was conducted. This study contained four sub-studies. In the first sub-study, a list of factors that stakeholders perceived influence RTW was generated (Aim 2). Highest agreement was found for: RTW self-efficacy; post-operative psychological status; supportive employer or supervisor; employer’s willingness to accommodate job modifications; worker’s recovery expectations; mood disorder diagnosis; post-operative pain level; and whether the job can be modified. Disagreements between stakeholder groups existed for a third of the factors. Further analysis of the 787 HCPs was conducted in sub-study two (Aim 2). This revealed that HCPs rated difficulty coping with the pain as the main RTW barrier. Few differences between the disciplines existed. In sub-study three, 621 of the stakeholders reviewed a hypothetical complex case to identify RTW barriers and strategies (Aim 3). Stakeholders identified similar RTW barriers but different strategies. More psychological and social barriers, than biological or demographic barriers, were identified. Employers and insurers identified similar strategies. However, the HCPs nominated more biological strategies. In sub-study four, the HCPs nominated 59 types of assessment tools/methods that they use to identify RTW barriers for workers with UE conditions in clinical practice (Aim 4). The most favoured method was clinical interviewing. Other commonly used tools were strength measurement, and the Orebro Musculoskeletal Screening Questionnaire. A definition for ‘delayed RTW’ was clarified by consulting 42 international experts (Aim 5). Experts were divided between definitions. Furthermore, two thirds of experts believed universal time-based cut-offs should not be used to delineate transition from an early to delayed RTW. To understand workers’ RTW experiences, a qualitative study was undertaken. Interviews with 34 workers generated two sub-studies (Aim 6). The first sub-study revealed that workers’ experiences of encounters with insurers, employers and HCPs were embedded within the structural context of the workers’ compensation system. These encounters were influenced by: stakeholders’ responses to conflicting organizational mandates; stakeholders’ responses to a system designed to ‘fit’ the average worker; and, the workers’ limited decision-making regarding treatments and RTW options. The second sub-study described the theme of ‘loss’ experienced by the workers and how loss influences the RTW process. The primary loss occurred when workers sustained the UE injury. Secondary, often snowballing, losses precipitated (e.g., related to work, relationships, self). Losses were intensified by workers’ compensation systems problems influencing how workers responded to their losses. Issues related to loss of control and trust were intensified by systems problems which impacted on work-related outcomes. This thesis’ findings contribute to understanding the factors influencing RTW for workers with UE conditions, from the workers’, employers’, HCPs’, insurers’, lawyers’ and international experts’ perspectives. Recommendations for a longitudinal study of prognostic factors for RTW (and long-term work disability) for workers with UE conditions are documented. Future research should also aim to understand the influence of workers’ compensation systems, and the complexities of stakeholder interactions to improve work disability outcomes.

Background:Disability following hand and upper extremity conditions is common. Patient-reported outcome measures (PROs) are used to capture patients’ status subjectively. This review has aimed to synthesis the literature regarding the extent and methodological quality of translation, cross-cultural adaptation, and psychometric properties of the hand and upper extremity disability PROs in the Persian language. Methods:Seven electronic databases (MEDLINE, EMBASE, Psychinfo, Scopus, ISI, Science direct, and Google Scholar) were searched until May 2020. Studies reporting cross-cultural adaptation and psychometric properties testing of the Persian validated disability PROs of the hand and upper extremity were identified. We appraised the eligible studies using Guidelines for the Process of Cross-cultural Adaptation of Self-report Measures and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist.Results: Out of 98 identified records, 22 studies on 17 PROs were reviewed. Most of the PROs (47%) were region-specific and the others were condition-specific (29%) and multi-region (24%). Most of the studies (67%) followed 80 to 100% of the recommended steps for cross-cultural adaptation and translation of a PRO. The evidence of internal consistency, test-retest reliability, and construct validity was available for all the PROs. Structural validity, measurement error, and responsiveness were evaluated for five, six, and four PROs, respectively. The overall risk of bias ranged from “inadequate” to “very good” for all studies. Conclusion: A reasonable number of PROs for the evaluation of hand and upper extremity disability are available in the Persian language. Although all of them are not of very good psychometric properties, they all have sufficient quality to be used in clinical settings.

The Effectiveness of Instrument-Assisted Soft Tissue Mobilization in Athletes, Participants Without Extremity or Spinal Conditions, and Individuals with Upper Extremity, Lower Extremity, and Spinal Conditions: A Systematic Review

Background: Arthritis leads to disabilities impacting patients’ physical and mental health. Objective: To synthesize the evidence on measurement properties of the patient-reported outcome measures (PROMs) for people with upper extremity arthritis. Design: Overview of systematic reviews (SRs). Methods: We performed an electronic search of 6 databases to retrieve SRs looking at any measurement property related to PROMs for people with upper extremity arthritis. Two authors rated the risk of bias (ROB) of the included SRs using AMSTAR. We extracted data on measurement properties from each SR. Results: From 6 included SRs, 6 PROMs (Arthritis Impact Measurement Scale [AIMS], AIMS-2, AIMS-Short Form, Cedars-Sinai Health-Related Quality of Life for Rheumatoid Arthritis (CSHQ-RA), Revised CSHQ-RA, and Influence of Rheumatic Disease on General Health and Lifestyle) were evaluated in 2 or more SRs. The ROB of the included SRs ranged from moderate to high. Low- to moderate-quality evidence was found of good construct and criterion validity, acceptable content validity, and good responsiveness of the AIMS. We found low- to moderate-quality evidence of good internal consistency, test-retest reliability, and construct validity of the CSHQ-RA. Conclusion: We found a moderate to high ROB in the included SRs on the upper extremity PROMs for patients with arthritis. More evidence was specific to upper extremity arthritis in measures not in common use versus well-validated measures used in upper extremity conditions and recommended in current core sets. These factors suggest an urgent need for additional research to improve the scope and quality of evidence before recommendations can be made specific to patients with arthritis. Registration Number: on PROSPERO CRD 42019137491

What is the effect of constraint-induced movement therapy on children with unilateral cerebral palsy? A Cochrane Review summary with commentary.

Quantifying the Burden of Unmet Upper Extremity Care Need in Low-Middle Income Countries: A Four-Country, Cluster-Randomized Study

Objective: The Musculoskeletal Health Questionnaire (MSK-HQ) is a standardized musculoskeletal outcomes measure for the health status of patients with various musculoskeletal conditions. The objective of this study was to investigate the patient reported outcomes using the MSK-HQ in an urban patient population that has a unique set of needs. Specifically, the patient population in the South Bronx, New York has defining demographic and clinical characteristics of low-income, English as a second language, and high rates of obesity. Moreover, patients in this community are at high risk for low rates of health literacy. This study aims to use the MSK-HQ to identify how living in an urban setting impacts patients’ access to affordable and quality care. Methods: Patients (n=83) at the BronxCare Health System Department of Orthopaedics outpatient clinics were surveyed using the Arthritis Research UK Musculoskeletal Health Questionnaire (MSK-HQ). The total number of patients were divided into 4 cohorts based on their musculoskeletal condition; spine (n=21), hand and upper extremity (n=29), sports medicine (n=17), and arthroplasty candidates (n=16). The MSK-HQ is a 15-item survey that assesses musculoskeletal disability and levels of physical activity. The minimum score of the questionnaire is 0 and maximum score is 56. A decrease in the total score indicates an decrease in Patient Reported Outcome Measures (PROMs). The patients were individually screened with the questionnaire. Those that declared English as a second language were screened with the aid of a telephone translator. Results: The mean age was 51.6 years old ± 14.1 years. There were 57 (70.37%) females and 24 (29.63%). The mean BMI was 31.0 ± 7.9. There were 12 (14.81%) patients that classified under normal weight conditions, 32 (39.51%) overweight, and 37 (45.68%) obese. The mean Patient Reported Outcome Measures (PROMs) for spine was 22.14, 31.46 for hand, 24.56 for sports, and 26.81 for arthroplasty candidates. The mean score for the patient’s understanding of condition and treatment for spine was 1.9 for spine, 2.36 for hand, 2.38 for sports, and 2.38 for arthroplasty candidates. Sex and the PROMs did not show correlation. There was a correlation between increasing BMI and decreasing PROMs for spine patients. However, there was no significant correlation between BMI and the PROMs of the other musculoskeletal conditions. The spine cohort exhibited the least understanding of their condition and treatment, suggesting a correlation between a patient’s health literacy and his or her overall PROMs. Health literacy did not correlate with English as a second language (ESL). The spine cohort demonstrated the lowest PROMs while the hand cohort had the highest PROMs. Conclusion: This is the first study to make use of the MSK-HQ in an urban setting within the United States. The unique clinical characteristics within this urban population include a mean BMI of obesity, as well as a large percentage of patients with English as a second language and low health literacy. The cohort of individuals that had the worst PROM were those treated for spine conditions, while patients treated for hand and upper extremity conditions had the best PROMs. A possible explanation for this finding is increased BMI within the spine cohort, as well as decrease in patient reported understanding of condition and current treatment. Additionally, as a translator was used for each patient who indicated ESL, there was no correlation found between health literacy, total score and ESL.

The aim of this study was to investigate whether there is evidence of bilateral upper limb strength deficits in individuals with unilateral lateral elbow tendinopathy (LET). The electronic databases Medline via Ovid, PubMed, and Scopus were searched from inception to March 2020. Included studies encompassed maximal strength outcomes of any upper limb and appendicular musculature in individuals with LET and an asymptomatic comparator. Study quality was rated using a modified version of the Epidemiological Appraisal Instrument. Hedges g effect sizes (ES) and 95% CIs were calculated for comparisons of maximal strength in the LET group and an asymptomatic control group. Meta-analysis using a random-effects model was performed when possible. Fourteen studies were included. Quality appraisal resulted in a mean Epidemiological Appraisal Instrument score of 46% (SD = 10%). Meta-analysis revealed strength deficits in shoulder abduction (pooled ES = -0.37 [95% CI = -0.62 to -0.12]) and shoulder external rotation (pooled ES = -0.55 [95% CI = -0.83 to -0.28]) of the symptomatic limb compared with an asymptomatic control group. Meta-analysis also revealed maximal strength deficits in the upper trapezius (pooled ES = -0.26 [95% CI = -0.49 to -0.02]) of the asymptomatic limb compared with an asymptomatic control group. There was also consistent evidence for strength deficits in the serratus anterior, lower trapezius, and wrist extensor muscles and deficits in grip strength of the symptomatic limb as well as strength deficits in the wrist extensor muscles of the asymptomatic limb in individuals with unilateral LET. In individuals with LET, there were maximal strength deficits in shoulder abduction, shoulder external rotation, serratus anterior and lower trapezius muscles, and wrist extension, as well as deficits in grip strength of the symptomatic limb compared with an asymptomatic control group. In addition, there appeared to be strength deficits in the upper trapezius muscle, wrist extension, and metacarpophalangeal joint flexion and extension, as well as deficits in grip strength of the asymptomatic limb in individuals with LET compared with an asymptomatic control group. These results suggest bilateral strength deficits. These findings highlight the importance of a thorough physical examination and appropriate strengthening intervention for the upper limb with a focus on shoulder and scapular stabilizers, in addition to forearm muscles, in individuals with LET. In people with tennis elbow, widespread strength deficits, including weakness of the shoulder, forearm, and wrist muscles, may exist. Interestingly, some of these weaknesses appear on both the affected and the unaffected sides in people with tennis elbow. A physical therapist can help strengthen these areas.

ChatGPT-3.5 and -4.0 Do Not Reliably Create Readable Patient Education Materials for Common Orthopaedic Upper- and Lower-Extremity Conditions

PurposeTo comprehensively evaluate clinical outcome reporting in hand surgery randomized controlled trials (RCTs), using Wide Awake Local Anesthesia with No Tourniquet (WALANT) studies as a model. MethodsThis PROSPERO-registered systematic review (CRD42023461653) adheres to PRISMA guidelines, focusing on RCTs evaluating WALANT in hand- and upper-limb surgery. A systematic search across five databases was conducted to include all eligible articles from inception until search date (April 1, 2023). Inclusion criteria encompassed WALANT RCTs in upper limb surgery, with exclusion criteria addressing non-RCTs and non-English studies. Data extraction covered study characteristics, patient demographics, procedures performed, and outcomes reported. The Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB-2) was employed for quality assessment. ResultsThe search identified 304 articles, after screening 11 were included for analysis, encompassing 889 patients in WALANT RCTs. Technical outcomes were most reported (73%), while functional was least commonly reported (36%). The analysis encompassed a heterogeneous patient cohort, with an average follow-up period of 41.3 days. Challenges in standardizing functional outcomes and patient-reported outcomes were identified. The RoB-2 indicated an overall low risk, affirming the methodological rigor of the included studies. ConclusionA significant diversity in outcome reporting and assessment tools was identified, emphasizing the challenges in standardization and outcome reporting across RCTs. While technical outcomes were prevalent, patient-reported and functional outcomes were often lacking. The study underscores the need for further research standardization to optimize patient care and advance evidence-based decision-making, as variability in outcomes reporting hinders the ability to draw consistent conclusions and comparisons across studies. Level of Evidence1a, Therapy / Prevention, Aetiology / Harm

Work-related upper limb and neck musculoskeletal disorders (MSDs) are one of the most common occupational disorders around the world. Although ergonomic design and training are likely to reduce the risk of workers developing work-related upper limb and neck MSDs, the evidence is unclear. To assess the effects of workplace ergonomic design or training interventions, or both, for the prevention of work-related upper limb and neck MSDs in adults. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, AMED, Web of Science (Science Citation Index), SPORTDiscus, Cochrane Occupational Safety and Health Review Group Database and Cochrane Bone, Joint and Muscle Trauma Group Specialised Register to July 2010, and Physiotherapy Evidence Database, US Centers for Disease Control and Prevention, the National Institute for Occupational Safety and Health database, and International Occupational Safety and Health Information Centre database to November 2010. We included randomised controlled trials (RCTs) of ergonomic workplace interventions for preventing work-related upper limb and neck MSDs. We included only studies with a baseline prevalence of MSDs of the upper limb or neck, or both, of less than 25%. Two review authors independently extracted data and assessed risk of bias. We included studies with relevant data that we judged to be sufficiently homogeneous regarding the intervention and outcome in the meta-analysis. We assessed the overall quality of the evidence for each comparison using the GRADE approach. We included 13 RCTs (2397 workers). Eleven studies were conducted in an office environment and two in a healthcare setting. We judged one study to have a low risk of bias. The 13 studies evaluated effectiveness of ergonomic equipment, supplementary breaks or reduced work hours, ergonomic training, a combination of ergonomic training and equipment, and patient lifting interventions for preventing work-related MSDs of the upper limb and neck in adults.Overall, there was moderate-quality evidence that arm support with alternative mouse reduced the incidence of neck/shoulder disorders (risk ratio (RR) 0.52; 95% confidence interval (CI) 0.27 to 0.99) but not the incidence of right upper limb MSDs (RR 0.73; 95% CI 0.32 to 1.66); and low-quality evidence that this intervention reduced neck/shoulder discomfort (standardised mean difference (SMD) -0.41; 95% CI -0.69 to -0.12) and right upper limb discomfort (SMD -0.34; 95% CI -0.63 to -0.06).There was also moderate-quality evidence that the incidence of neck/shoulder and right upper limb disorders were not reduced when comparing alternative mouse and conventional mouse (neck/shoulder RR 0.62; 95% CI 0.19 to 2.00; right upper limb RR 0.91; 95% CI 0.48 to 1.72), arm support and no arm support with conventional mouse (neck/shoulder RR 0.67; 95% CI 0.36 to 1.24; right upper limb RR 1.09; 95% CI 0.51 to 2.29), and alternative mouse with arm support and conventional mouse with arm support (neck/shoulder RR 0.58; 95% CI 0.30 to 1.12; right upper limb RR 0.92; 95% CI 0.36 to 2.36).There was low-quality evidence that using an alternative mouse with arm support compared to conventional mouse with arm support reduced neck/shoulder discomfort (SMD -0.39; 95% CI -0.67 to -0.10). There was low- to very low-quality evidence that other interventions were not effective in reducing work-related upper limb and neck MSDs in adults. We found moderate-quality evidence to suggest that the use of arm support with alternative mouse may reduce the incidence of neck/shoulder MSDs, but not right upper limb MSDs. Moreover, we found moderate-quality evidence to suggest that the incidence of neck/shoulder and right upper limb MSDs is not reduced when comparing alternative and conventional mouse with and without arm support. However, given there were multiple comparisons made involving a number of interventions and outcomes, high-quality evidence is needed to determine the effectiveness of these interventions clearly. While we found very-low- to low-quality evidence to suggest that other ergonomic interventions do not prevent work-related MSDs of the upper limb and neck, this was limited by the paucity and heterogeneity of available studies. This review highlights the need for high-quality RCTs examining the prevention of MSDs of the upper limb and neck.

Objective: Lateral elbow tendinopathy (LET) is a common clinical condition, and a wide array of physiotherapy treatments is used for treating LET. One of the most common physiotherapy modality is the ultrasound. Ultrasound is a dose response modality. The aim of the present article was to determine the effective ultrasound parameters in the management of (LET) and to provide recommendations based on this evidence. Methods: Randomized controlled trials (RCTs) identified by a search strategy in six databases were used in combination with reference checking. RCTs that included positive effects with ultrasound, description of ultrasound parameters in details, patients with LET, and at least one of the clinically relevant outcome measure were selected. The Pedro scale was used to analyse the results. Results: None RCTs fulfilled the criteria and therefore all the conducted trials were excluded in the review. Conclusions: Recommendations for the ultrasound parameters in the management of LET were based on animal studies and on studies in conditions similar to LET in clinical behavior and histopathological appearance. Further research with well-designed RCTs is needed to establish the absolute and relative effectiveness of this intervention with the recommended parameters for LET

Objective: The aim of the present review was to determine the effectiveness of iontophoresis in the management of lateral elbow tendinopathy (LET) and to provide recommendations based on this evidence. Background data: LET is a common clinical condition, and a wide array of physiotherapy treatments is used for treating LET. Methods: Randomized controlled trials (RCTs) identified by a search strategy in six databases were used in combination with reference checking. RCTs that included iontophoresis, patients with LET, and at least one of the clinically relevant outcome measures were selected. Aqualitative analysis of the selected studies was conducted using the Chalmers’ technique. Results: Four RCTs fulfilled the criteria and were included in the review. Although these studies had satisfactory methodology, shortcomings were not absent; conflicting results were revealed as to the effectiveness of iontophoresis for LET management. Conclusions: Iontophoresis need not be ruled out for LET as it is a dose-response modality, and the optimal treatment dose has obviously not yet have been discovered. Further research with well-designed RCTs is needed to establish the absolute and relative effectiveness of this intervention for LET.

Lateral elbow tendinopathy (LET) is a common musculoskeletal disorder caused by overuse, resulting in microtrauma to the extensor tendons. Because of its complex pathophysiology and high recurrence rate, LET poses significant treatment challenges. The effectiveness of extracorporeal shock wave therapy (ESWT) in treating LET remains controversial. To evaluate the therapeutic benefits of ESWT by comparing its effects to those of both placebo ESWT and conventional physical therapy. Systematic review; Level of evidence, 1. A systematic review of randomized controlled trials (RCTs) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The primary outcome measure was pain, assessed using the visual analog scale. Secondary outcome measures included maximal grip strength, Disabilities of the Arm, Shoulder and Hand score, Patient-Rated Tennis Elbow Evaluation (PRTEE) score, and Roles and Maudsley score. The risk of bias for each included study was assessed using the Cochrane risk of bias tool. Eleven RCTs were included, of which only 4 studies had a low risk of bias. Among these 4 studies, Aldajah et al (2022) demonstrated significant benefits of ESWT in pain reduction, muscle strength, and function. Guler et al (2018) observed improvements within the ESWT group, but no significant differences compared to placebo. Karaca et al (2022) found no significant differences in pain, grip strength, and PRTEE scores. Staples et al (2008) reported no statistically significant differences in pain and function between the ESWT and placebo groups. Although some studies report positive effects of ESWT, the evidence remains inconclusive. Future research should focus on optimizing ESWT protocols, addressing potential biases, and identifying patient subgroups that would benefit most from this treatment. ESWT may be a valuable adjunct to physical therapy in managing chronic LET.

Stroke is caused by the interruption of blood flow to the brain (ischemic stroke) or the rupture of blood vessels within the brain (hemorrhagic stroke) and may lead to changes in perception, cognition, mood, speech, health-related quality of life, and function, such as difficulty walking and using the arm. Activity limitations (decreased function) of the upper extremity are a common finding for individuals living with stroke. Mental practice (MP) is a training method that uses cognitive rehearsal of activities to improve performance of those activities. To determine whether MP improves outcomes of upper extremity rehabilitation for individuals living with the effects of stroke. In particular, we sought to (1) determine the effects of MP on upper extremity activity, upper extremity impairment, activities of daily living, health-related quality of life, economic costs, and adverse effects; and (2) explore whether effects differed according to (a) the time post stroke at which MP was delivered, (b) the dose of MP provided, or (c) the type of comparison performed. We last searched the Cochrane Stroke Group Trials Register on September 17, 2019. On September 3, 2019, we searched the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Web of Science, the Physiotherapy Evidence Database (PEDro), and REHABDATA. On October 2, 2019, we searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We reviewed the reference lists of included studies. We included randomized controlled trials (RCTs) of adult participants with stroke who had deficits in upper extremity function (called upper extremity activity). Two review authors screened titles and abstracts of the citations produced by the literature search and excluded obviously irrelevant studies. We obtained the full text of all remaining studies, and both review authors then independently selected trials for inclusion. We combined studies when the review produced a minimum of two trials employing a particular intervention strategy and a common outcome. We considered the primary outcome to be the ability of the arm to be used for appropriate tasks, called upper extremity activity. Secondary outcomes included upper extremity impairment (such as quality of movement, range of motion, tone, presence of synergistic movement), activities of daily living (ADLs), health-related quality of life (HRQL), economic costs, and adverse events. We assessed risk of bias in the included studies and applied GRADE to assess the certainty of the evidence. We completed subgroup analyses for time since stroke, dosage of MP, type of comparison, and type of arm activity outcome measure. We included 25 studies involving 676 participants from nine countries. For the comparison of MP in addition to other treatment versus the other treatment, MP in combination with other treatment appears more effective in improving upper extremity activity than the other treatment without MP (standardized mean difference [SMD] 0.66, 95% confidence interval [CI] 0.39 to 0.94; I² = 39%; 15 studies; 397 participants); the GRADE certainty of evidence score was moderate based on risk of bias for the upper extremity activity outcome. For upper extremity impairment, results were as follows: SMD 0.59, 95% CI 0.30 to 0.87; I² = 43%; 15 studies; 397 participants, with a GRADE score of moderate, based on risk of bias. For ADLs, results were as follows: SMD 0.08, 95% CI -0.24 to 0.39; I² = 0%; 4 studies; 157 participants; the GRADE score was low due to risk of bias and small sample size. For the comparison of MP versus conventional treatment, the only outcome with available data to combine (3 studies; 50 participants) was upper extremity impairment (SMD 0.34, 95% CI -0.33 to 1.00; I² = 21%); GRADE for the impairment outcome in this comparison was low due to risk of bias and small sample size. Subgroup analyses of time post stroke, dosage of MP, or comparison type for the MP in combination with other rehabilitation treatment versus the other treatment comparison showed no differences. The secondary outcome of health-related quality of life was reported in only one study, and no study noted the outcomes of economic costs and adverse events. Moderate-certainty evidence shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity activity. Moderate-certainty evidence also shows that MP in addition to other treatment versus the other treatment appears to be beneficial in improving upper extremity impairment after stroke. Low-certainty evidence suggests that ADLs may not be improved with MP in addition to other treatment versus the other treatment. Low-certainty evidence also suggests that MP versus conventional treatment may not improve upper extremity impairment. Further study is required to evaluate effects of MP on time post stroke, the volume of MP required to affect outcomes, and whether improvement is maintained over the long term.