Proprioception of the wrist joint: a review of current concepts and possible implications on the rehabilitation of the wrist

Evaluation of proprioception in denervated and healthy wrist joints

We recruited 25 patients after complete wrist denervation and 60 healthy adults to investigate conscious and unconscious proprioception of the wrist. Ipsi- and contralateral joint-position sense, force sense, and wrist reflexes were measured. The latter were triggered by a trapdoor, recording electromyographic signals from the extensor carpi radialis brevis, extensor carpi ulnaris, flexor carpi radialis, and flexor carpi ulnaris muscles. No significant differences were found for joint position sense, force sense, and wrist reflexes between both groups, except for reflex time of the flexor carpi ulnaris after denervation of the left wrist as compared with the left flexor carpi ulnaris in controls or in right operated wrists. At a mean follow-up of 32 months (range 8 to 133), we found no proprioceptive deficit of the conscious proprioceptive qualities of joint position sense, force sense, and the unconscious proprioceptive neuromuscular control of wrist reflex time for most muscles after complete wrist denervation. We conclude from this study that complete wrist denervation does not affect the proprioceptive senses of joint position, force sense, and reflex time of the wrist.

Similar effects of two different external supports on wrist joint position sense in healthy subjects: A randomized clinical trial

The hand is one of the most injured organs. Proprioceptive rehabilitation decreases the incidence of injury while using external supports can increase proprioception. The aim of this study was to investigate the effects of taping and elastic bandaging on wrist joint position sense (proprioception) in healthy individuals. Sixty-eight healthy students were included in our study and randomized into two groups. External supports were to apply to the dominant hand for 24hours in both groups. Joint position sense was evaluated with an angle reproduction test before applying the external support and 20 minutes after and then 24hours later with the external support and after removing it. There were significant improvements in joint position sense 20 minutes after applying the external support and 24hours later (P<0.05). Although a significant decrease in joint position sense was observed after removing the external support compared to while wearing it (P<0.05), there was a significant improvement in the joint position sense relative to the pre-study assessment (P<0.05). In between group comparisons, the only significant difference was observed 20 minutes after the external support was applied: the taping group had better results in joint flexion position sense than the bandaging group (P<0.05), but in the other assessments there were no significant differences between two groups (P>0.05). It was found that two different types of external support can improve the wrist joint's position sense in healthy subjects. These procedures can be used as a supplemental treatment in wrist rehabilitation.

A novel staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex injury: A case report

STUDY DESIGN

Case report.

INTRODUCTION

Studies have highlighted the sensory innervations and stabilizing role of forearm muscles on wrist joint and implications to wrist sensorimotor rehabilitation. This case explored the novel incorporation of dart-throwing motion and proprioceptive neuromuscular facilitation in wrist sensorimotor rehabilitation.

PURPOSE OF THE STUDY

To describe and evaluate a staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex (TFCC) injury.

METHODS

The patient participated in the staged program for 9 sessions over a 3-month period. Treatment involved neuromuscular strengthening at the wrist and movement normalization of the upper extremity. Outcome measures were grip strength, visual analog scale, joint position sense, Quick Disabilities of the Arm, Shoulder and Hand, and patient-rated wrist evaluation.

RESULTS

The patient showed improvement in all outcome measures. Most outcomes exceeded the established minimal clinically important difference values.

DISCUSSION

The results suggest that dart-throwing motion and proprioceptive neuromuscular facilitation are beneficial in rehabilitation of TFCC injury.

CONCLUSIONS

This is the first study that incorporated dart-throwing motion and proprioceptive neuromuscular facilitation in the sensorimotor rehabilitation of TFCC injury and yielded promising results. There is a need to further evaluate the program in prospective randomized controlled trial recruiting a larger group of patients with TFCC injury.

Therapy Considerations for Getting Athletes to Return to Play

During the protective phase of treatment, therapy for hand and wrist injuries in athletes is similar to the plan of care provided to all patients. The nuances in the care provided to athletes become apparent during the transition to the postprotective phase of rehabilitation when the focus has shifted to return to play. Therapy following a sports injury should address the individual needs of the athletes in their everyday lives as well as the specificity of their training and sports-specific activities. The factors that influence return to play are discussed.

Surgical Techniques for the Treatment of Acute Carpal Ligament Injuries in the Athlete

The treatment of athletes with carpal ligament injuries provides many challenges. Our initial goals remain to make a timely and accurate diagnosis, provide treatment options, and create an environment for shared decision making. To optimize outcomes and facilitate return to play, early surgical intervention may be warranted. This article reviews common carpal ligament injury patterns in the athlete with a focus on both classic and newer surgical techniques.

Arterialized Posterior Interosseous Nerve Graft for Digital Neuroma

Painful neuromas are not uncommon following nerve injury, and are especially bothersome in the hand, with severe cases resulting in significant disability. Outcomes of neuroma surgery are unpredictable regardless of technique. It is recognized that optimal soft tissue environment influences nerve healing more than the specific nerve graft technique, and it is in this context, we present a novel technique of transferring a posterior interosseous nerve graft along with vascularized synovial and fat tissue based on a branch of the posterior interosseous artery to provide healthy soft tissue for nerve healing of neuroma in continuity about the hand and digits.

Short-term effect of delayed-onset muscle soreness on trunk proprioception during force reproduction tasks in a healthy adult population: a crossover study

PURPOSE

The aim of this study was to evaluate the effects of lumbar muscle delayed-onset muscle soreness (DOMS) on the ability of the trunk muscles to reproduce different levels of force.

METHODS

Twenty healthy adults (10 males and 10 females) were recruited for this study. Force reproduction in trunk extension and flexion was assessed at 50 and 75% of participants' maximal isometric voluntary contraction in flexion and extension before and after a lumbar muscle DOMS protocol. Trunk proprioception was evaluated and compared between these conditions using different variables such as constant errors (CE), absolute errors (AE), variable errors (VE) and time to peak force (TPF). For each variable, repeated measure ANOVAs were conducted.

RESULTS

AE were higher when participants had to reach the target post-DOMS protocol in extension compared to flexion and in the presence of higher demand of force (p = 0.02). For VE, results showed that participants were more variable in extension than in flexion when the required force was higher (p = 0.04). CE variable was higher when participants had to reach the force target in extension compared to flexion under the effect of DOMS (p = 0.02). Results also showed that participants took less time to reach the force target post-DOMS protocol in extension (0.62 ± 0.20 s) and in flexion (0.53 ± 0.19 s) than pre-DOMS protocol in extension (0.55 ± 0.15) and in flexion (0.50 ± 0.20) (p < 0.001).

CONCLUSION

Lumbar muscle DOMS affects trunk proprioception during force reproduction tasks especially in trunk extension and at higher force.

An Anatomical Study to the Branching Pattern of the Posterior Interosseous Nerve on the Dorsal Side of the Hand

Partial denervation of the wrist can benefit patients with chronic wrist pain. A complication of partial denervation is loss of proprioception and hypesthesia on the dorsal side of the hand. Our aim is to evaluate whether the sensory branches of the posterior interosseous nerve could contribute to the loss of proprioception and sensation. The branching pattern of the posterior interosseous nerve was studied in 20 cadaveric hands. The terminal branches of the posterior interosseous nerve reached the metacarpophalangeal joints in three specimens (15%), the midshaft of the metacarpals in three specimens (15%), carpometacarpal joints in 11 specimens (55%), and the scapholunate joint in three specimens (15%). The finding that terminal branches of the posterior interosseous nerve can reach the metacarpals and the metacarpophalangeal joints indicates that the posterior nerve may contribute to the proprioception and sensation of the dorsal side of the hand. Clin. Anat., 33:678-682, 2020. © 2019 Wiley Periodicals, Inc.

Neuromuscular Properties of the Human Wrist Flexors as a Function of the Wrist Joint Angle

The joint angle dependence of voluntary activation and twitch properties has been investigated for several human skeletal muscles. However, although they play a key role for hand function and possess a unique neural control compared to muscles surrounding other joint complexes, little is known about the wrist flexors innervated by the median nerve. Therefore, isometric voluntary and electrically evoked contractions of the wrist flexors were analyzed at three wrist joint angles (extension: -30°, neutral: 0°, flexion: 30°) to quantify the joint angle dependence of (i) voluntary activation (assessed via peripheral nerve stimulation and electromyography [EMG]), (ii) unpotentiated twitch torques, and (iii) potentiated twitch torques. Maximum voluntary torque was lower in extension compared to neutral and flexion. Although voluntary activation was generally high, data indicate that voluntary activation of the wrist flexors innervated by the median nerve was lower and the antagonist·agonist^-1 EMG ratio was higher with the wrist joint in flexion compared to extension. Peak twitch torque, rate of twitch torque development, and twitch half-relaxation time increased, whereas electromechanical delay decreased from flexion to extension for the unpotentiated twitch torques. Activity-induced potentiation partly abolished these differences and was higher in short than long wrist flexors. Different angle-dependent excitatory and inhibitory inputs to spinal and supraspinal centers might be responsible for the altered activation of the investigated wrist muscles. Potential mechanisms were discussed and might have operated conjointly to increase stiffness of the flexed wrist joint. Differences in twitch torque properties were probably related to angle-dependent alterations in series elastic properties, actin-myosin interaction, Ca²⁺ sensitivity, and phosphorylation of myosin regulatory light chains. The results of the present study provide valuable information about the contribution of neural and muscular properties to changes in strength capabilities of the wrist flexors at different wrist joint angles. These data could help to understand normal wrist function, which is a first step in determining mechanisms underlying musculoskeletal disorders and in giving recommendations for the restoration of musculoskeletal function after traumatic or overuse injuries.

Three-dimensional geometric morphometric analysis of the distal radius insertion sites of the palmar radiocarpal ligaments in hominoid primates

OBJECTIVES

To identify anatomic differences in the insertion sites of the palmar radiocarpal ligaments in different species of hominoid primates that may be related to their different types of locomotion.

MATERIALS AND METHODS

We have used three-dimensional geometric morphometrics (3D GM) to analyze the distal radius ligament insertion sites in 31 Homo sapiens, 25 Pan troglodytes, 31 Gorilla gorilla, and 15 Pongo pygmaeus. We have also dissected the radioscaphocapitate (RSC), long radiolunate (LRL) and short radiolunate (SRL) ligaments in six H. sapiens and five P. troglodytes to obtain quantitative values that were then compared with the results of the 3D GM analysis.

RESULTS

H. sapiens had a relatively larger insertion site of the RSC + LRL ligament than the other hominoid primates. P. pygmaeus and P. troglodytes had a relatively large SRL ligament insertion site with a palmar orientation. In G. gorilla, the two ligament insertion sites were relatively smaller and the SRL insertion site had an ulnopalmar orientation.

DISCUSSION

The morphological differences observed can be related to the types of locomotion used by the different species and to quantitative data obtained from the dissection of ligaments in H. sapiens and P. troglodytes. 3D GM analysis of ligament insertion sites can help in interpreting the types of locomotion used by extinct hominoid primates through the analysis of preserved fossilized fragments of the distal radius.

Effects of mirror therapy on muscle activity, muscle tone, pain, and function in patients with mutilating injuries: A randomized controlled trial

BACKGROUND

This study assessed the effectiveness of mirror therapy (MT) on muscle elasticity, pain, and function in patients with mutilating injuries.

METHODS

Thirty patients with impaired function due to mutilating injuries were assigned randomly to experimental or control group. The experimental group (n = 15) received MT (30 minutes a day, 3 days a week for 4 weeks) and conventional physical therapy after each MT session while the control group (n = 15) only received conventional physical therapy.

RESULTS

There were significant differences in pain and hand function within each group (pre-intervention vs post-intervention) and between groups (experimental vs control) (P < .05). However, there was no significant difference in muscle elasticity between groups (P > .05).

CONCLUSION

Although MT cannot result in significant changes in muscle elasticity in a clinical setting, it does have positive effects by reducing pain and improving hand function. Thus, MT can be effective for patients with impaired function due to mutilating injuries.

Postoperative Treatment of Distal Radius Fractures Using Sensorimotor Rehabilitation

Background  Sensorimotor and specifically proprioception sense has been used in rehabilitation to treat neurological and joint injuries. These feedback loops are not well understood or implemented in wrist treatment. We observed a temporary sensorimotor loss, following distal radius fractures (DRF) that should be addressed postsurgery. Purpose  The purpose of this prospective therapeutic study was to compare the outcomes of patients following surgery for DRF treated using a sensorimotor treatment protocol with those patients treated according to the postoperative standard of care. Patients and Methods  Patients following surgery for DRF sent for hand therapy were eligible for the study. Both the evaluation and treatment protocols included a comprehensive sensorimotor panel. Patients were randomized into standard and standard plus sensorimotor postoperative therapy and were evaluated a few days following surgery, at 6 weeks, and 3 months postsurgery. Results  Sixty patients following surgery were randomized into the two treatment regimens. The initial evaluation was similar for both groups and both demonstrated significant sensorimotor deficits, following surgery for DRF. There was documented sensorimotor and functional improvement in both groups with treatment. The clinical results were better in the group treated with the sensorimotor-proprioception protocol mostly in the wrist; however, not all of the differences were significant. Conclusion  Patients after surgery for DRF demonstrate significant sensorimotor deficits which may improve faster when utilizing a comprehensive sensorimotor treatment protocol. However, we did not demonstrate efficacy of the protocol in treating proprioceptive deficits. Further study should include refinement of functional outcome evaluation, studying of the treatment protocol, and establishment of sensorimotor therapeutic guidelines for other conditions. Level of Evidence This is a level II, therapeutic study.

Lateral epicondylalgia: A primary nervous system disorder

Lateral epicondylalgia (LE) is the most common chronic painful condition affecting the elbow in the general population. Although major advances have been accomplished in recent years in the understanding of LE, the underlying physiopathology is still a reason for debate. Differences in clinical presentation and evolution of the symptoms among patients, suggest the need for revisiting the current knowledge about subjacent mechanisms that attempt to explain pain and functional loss. Previous models have suggested that the condition is mainly a degenerative tendinopathy, associated with changes in pain pathways and the motor system. The hypothesis of this work is that LE is the clinical manifestation of a primary nervous system disorder, characterized by an abnormal increase in neuronal activity and a subsequent loss of homeostasis, which secondarily affects the musculoskeletal tissues of the elbow-forearm-hand complex. A new model for LE is presented, supported by an in-deep analysis of basic sciences, epidemiological and clinical studies.

The Effect of Triangular Fibrocartilage Complex Tear on Wrist Proprioception

PURPOSE

This study examined the influence of triangular fibrocartilage complex (TFCC) deep fiber tears on wrist proprioception.

METHODS

The study involved 48 subjects: 24 with deep fiber TFCC tears and 24 with healthy wrists. A specially created sensor measured wrist proprioception in 3 axes of movement. Absolute differences between target and subject-reproduced angles were compared in injured and healthy wrists and in injured and contralateral patient wrists. A greater difference in reproduced angles was deemed to reflect a lesser ability to approximate a target angle.

RESULTS

In wrists with TFCC injuries, 40° pronation and 60° pronation showed significantly greater differences between target and subject-reproduced angles compared with those in the control wrists. In wrists with TFCC injuries, 40° pronation demonstrated significantly greater differences between target and subject-reproduced angles than did those in patients' contralateral wrists. Proportions of outliers with absolute differences greater than 6° were significantly higher in 60° supination and 40° pronation in wrists with TFCC injuries.

CONCLUSIONS

Deep TFCC fiber detachment may lead to decreased wrist proprioception in 60° and 40° forearm rotation.

CLINICAL RELEVANCE

Deep TFCC fiber tear may contribute to decreased wrist rotational positioning sense and may have biomechanical importance in distal radioulnar joint stability.

Optimal management of scapholunate ligament injuries

Scapholunate ligament (SLL) injuries are a common cause of wrist pain and instability. Treatment of SLL injuries requires intricate understanding of wrist anatomy and biomechanics. Mindful physical exam and appropriate diagnostic studies can orient the surgeon to the defined stage of injury. Review of the literature on each treatment by stage can prepare the upper extremity surgeon to provide the best evidence-based care. The optimal management of SLL injuries should result in a stable, painless wrist.

Coactivation index of children with congenital upper limb reduction deficiencies before and after using a wrist-driven 3D printed partial hand prosthesis

Background

Co-contraction is the simultaneous activation of agonist and antagonist muscles that produces forces around a joint. It is unknown if the use of a wrist-driven 3D printed transitional prostheses has any influence on the neuromuscular motor control strategies of the affected hand of children with unilateral upper-limb reduction deficiencies. Thus, the purpose of the current investigation was to examine the coactivation index (CI) of children with congenital upper-limb reduction deficiencies before and after 6 months of using a wrist-driven 3D printed partial hand prosthesis.

Methods

Electromyographic activity of wrist flexors and extensors (flexor carpi ulnaris and extensor digitorum) was recorded during maximal voluntary contraction of the affected and non-affected wrists. Co-contraction was calculated using the coactivation index and was expressed as percent activation of antagonist over agonist. Nine children (two girls and seven boys, 6 to 16 years of age) with congenital upper-limb deficiencies participated in this study and were fitted with a wrist-driven 3D printed prosthetic hand. From the nine children, five (two girls and three boys, 7 to 10 years of age) completed a second visit after using the wrist-driven 3D printed partial hand prosthesis for 6 months.

Results

Separate two-way repeated measures ANOVAs were performed to analyze the coactivation index and strength data. There was a significant main effect for hand with the affected hand resulting in a higher coactivation index for flexion and extension than the non-affected hand. For wrist flexion there was a significant main effect for time indicating that the affected and non-affected hand had a significantly lower coactivation index after a period of 6 months.

Conclusion

The use of a wrist-driven 3D printed hand prosthesis lowered the coactivation index by 70% in children with congenital upper limb reduction deficiencies. This reduction in coactivation and possible improvement in motor control strategies can potentially improve prosthetic rehabilitation outcomes.

Length Changes in Scapholunate Interosseous Ligament With Resisted Wrist Radial and Ulnar Inclination

PURPOSE

To investigate the changes in length of the scapholunate interosseous ligament (SLIL) when the wrist is resisting horizontal lateral load and the forearm is in full pronation in vivo.

METHODS

We obtained computed tomography scans of the wrists of 6 volunteers in 3 situations: 0° position (0° extension and 0° ulnar inclination) and full forearm pronation without force, and in the same position but with resisted ulnar and radial deviation. Nine zones of 3 subregions of the SLIL were measured and analyzed with computer modeling.

RESULTS

Changes in length of the palmar SLIL with resisted ulnar deviation were significantly greater than those without an applied lateral load. In contrast, the changes in length of the dorsal SLIL with resisted radial deviation were statistically greater than those in the 0° position without loading. However, no significant differences in the changes in length of the proximal SLIL were found in any of 3 situations, except the dorsal zone with resisted radial deviation.

CONCLUSIONS

Application of lateral load has an effect on the separation of the palmar and dorsal insertions of the SLIL. The palmar subregion of the SLIL was more highly strained with wrist-resisted ulnar deviation. Conversely, the dorsal subregion of the SLIL was under greater tension with wrist-resisted radial deviation.

CLINICAL RELEVANCE

For patients undergoing nonsurgical treatment of SLIL tears, a sudden contraction of ulnar or radial deviation agonist muscles may be harmful and contribute to SL instability.

Test–retest reliability of wrist joint position sense in healthy adults in a clinical setting

Introduction

Proprioceptive assessments of the wrist inform clinical decision making. In wrist rehabilitation, joint position sense has emerged as one way of assessing conscious proprioception with varying methods and minimal psychometric analysis reported. The purpose of this study was to standardise the wrist joint position sense test method for clinical use and to determine its test–retest reliability in a healthy population.

Methods

Four wrist positions (20° and 45° flexion, 20° and 45° extension) were measured twice in a random order, by a single rater, using a universal goniometer on the same day. The absolute error in degrees between each position and reposition was calculated. For relative reliability analysis, the intraclass correlation coefficient (3,1) was calculated. For absolute reliability the standard error of the measurement was calculated and Bland–Altman plots visually inspected.

Results

Fifty-five healthy volunteers (mean age 31.1 SD±10.25 years) were assessed. The mean absolute error, summarised for all positions for test and retest, was 3.98°. The intraclass correlation coefficients were poor to fair (0.07–0.47), and standard error of the measurement was 2° (rounded) for all positions. The limits of agreement were fairly narrow, and the Bland–Altman plots showed random distribution of errors for each position, therefore the measurement error was clinically acceptable.

Conclusions

The active wrist joint position sense test using goniometry demonstrated poor to fair test–retest reliability and acceptable measurement error in healthy volunteers. The wrist joint position sense angle of 20° flexion was the most reliable.

[Mediocarpal instability of the wrist]

Typical lesions of the carpal ligaments are mostly found after a fall on the wrist in hyperextension or as complex injuries after severe trauma, e. g. after a fall from a significant height, motorcycle accident or as accompanying lesions in multiple trauma. The typical mechanisms, patterns and diagnostic algorithms are well known for the common ligamentous injuries (e.g. scapholunate, lunotriquetral and perilunate); therefore, consistent diagnostic procedures and adequate therapy are increasingly performed after such lesions, e. g. by early ligament repair or by ligament reconstruction through augmentation. Within appropriate operative treatment, accompanying fractures are also treated and instabilities are addressed by transfixation of joints by Kirschner wires. If followed by immobilization with a cast or stable brace, healing can be achieved in most cases; however, more problems occur if ligamentous lesions or instabilities are not clearly due to a trauma mechanism and more the result of laxity or hypermobile situations due to a congenital predisposition. In such cases, wrist pain is often described and misdiagnosed as the result of overload or tenovaginitis.

Scapholunate interosseous ligament dysfunction as a source of elbow pain syndromes: Possible mechanisms and implications for hand surgeons and therapists

Elbow pain syndromes are common upper extremity musculoskeletal disorders, and they are usually associated with repetitive occupational exposure. Ligaments are often one of the sources of musculoskeletal disorders because of their mechanical and neurological properties. The wrist ligaments are some of the ligaments most vulnerable to occupational exposure. Since most occupational tasks require wrist extension for handling tools and loading, the scapholunate interosseous ligament (SLIL) bears greater strain during loading, which results in creep deformation and hysteresis. Ligamentous creep may result in diminished ability to detect signal changes during joint movements, which impairs neuromuscular control established by ligamentomuscular reflex arcs elicited from mechanoreceptors in the ligaments. Changes in muscle activation patterns of forearm muscles due to diminished ligamentomuscular reflexes may initiate a positive feedback loop, leading to musculoskeletal pain syndromes. The relationship between elbow pain syndromes and SLIL injury will be presented through two hypotheses and relevant pain mechanisms: 1. Repetitive tasks may cause creep deformation of the SLIL, which then impairs ligamentomuscular reflexes, leading to elbow pain disorders. 2. Lateral epicondylalgia may increase the risk of SLIL injury through the compensation of the lower extensor carpi radialis muscle activity by higher extensor carpi ulnaris muscle activity, which may alter carpal kinematics, leading to SLIL degeneration over time. The differential diagnosis is usually complicated in musculoskeletal pain disorders. The failure of treatment methods is one of the issues of concern for many researchers. A key element in developing treatment strategies is to understand the source of the disorder and the nature of the injury. We proposed that the differential diagnosis include SLIL injuries when describing elbow pain syndromes, particularly, lateral epicondylalgia.

Responsiveness of the active wrist joint position sense test after distal radius fracture intervention

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

The active wrist joint position sense (JPS) test has been determined to be a clinically useful test for assessing wrist sensorimotor (SM) status after distal radius fracture (DRF). Its responsiveness is yet to be determined.

PURPOSE OF THE STUDY

Primary study aim was to determine the active wrist JPS test responsiveness to detect change in wrist SM status at 8 and 12 weeks after DRF treatment intervention. Secondary aims were to compare group (nonsurgical, surgical, high, and low pain) test responsiveness; compare pain-level group participants test scores; determine the relationship between test minimal clinically important difference (MCID) value and function; compare functional outcomes across assessment times; and determine the Patient Global Impression of Change Scale intrarater reliability.

METHODS

A total of 33 male and female participants were tested at baseline, 8, and 12 weeks after nonsurgical (n = 13) and surgical (n = 20) DRF treatment interventions. Distribution-based analysis encompassed both group- (ie, effect size, standardized response mean) and individual-based (ie, minimum detectable change) statistical indices. Anchor-based analysis determined the MCID value by linking test scores to the Patient Global Impression of Change Scale.

RESULTS

The active wrist JPS test is highly responsive based on effect size (8 weeks = 1.53 and 12 weeks = 2.36) and standardized response mean (8 weeks = 1.57 and 12 weeks = 2.14). Statistically significant minimum detectable change values were 4.28° and 4.94° at 8 and 12 weeks, respectively. Clinically meaningful MCID values were 5.00° and 7.09° at 8 and 12 weeks, respectively. Between treatment type and pain-level group responsiveness levels were not significantly different. High-pain participants demonstrated significantly greater JPS deficit. Test MCID values and function were significantly associated.

DISCUSSION

This is the first study to determine the active wrist JPS test responsiveness as reflected by its group- and individual-based statistical indices following DRF surgical and non-surgical interventions among low- and high-pain level participants. The statistical analysis approach, which was used to determine the aforementioned variables of the active wrist JPS test, is consistent with current research. This study's strengths included its design, methodology, and statistical approach. The study findings must be interpreted, however, within the content of several methodological limitations.

CONCLUSIONS

The active wrist JPS test was determined to be highly responsive to detect wrist SM status change at 8 and 12 weeks regardless of treatment type or pain level. Clinicians can use this test with confidence to measure clinically meaningful SM impairment after DRF treatment.

LEVEL OF EVIDENCE

2b.

Robotic finger perturbation training improves finger postural steadiness and hand dexterity

The purpose of the study was to understand the effect of robotic finger perturbation training on steadiness in finger posture and hand dexterity in healthy young adults. A mobile robotic finger training system was designed to have the functions of high-speed mechanical response, two degrees of freedom, and adjustable loading amplitude and direction. Healthy young adults were assigned to one of the three groups: random perturbation training (RPT), constant force training (CFT), and control. Subjects in RPT and CFT performed steady posture training with their index finger using the robot in different modes: random force in RPT and constant force in CFT. After the 2-week intervention period, fluctuations of the index finger posture decreased only in RPT during steady position-matching tasks with an inertial load. Purdue pegboard test score improved also in RPT only. The relative change in finger postural fluctuations was negatively correlated with the relative change in the number of completed pegs in the pegboard test in RPT. The results indicate that finger posture training with random mechanical perturbations of varying amplitudes and directions of force is effective in improving finger postural steadiness and hand dexterity in healthy young adults.

Lunotriquetral Ligament Reconstruction Utilizing a Palmaris Longus Autograft

Injury to the lunotriquetral ligament can result in midcarpal instability, with resultant alterations in normal wrist kinematics and subsequent arthrosis. We performed a previously undescribed technique of lunotriquetral ligament reconstruction in two patients utilizing a palmaris longus tendon autograft. Average age at presentation was 24 years old with a mean follow up of 10 months. Average range of motion was 62.5° of flexion and 57.5° of extension. Total arc of motion was 83% of the contralateral uninvolved extremity. Average grip strength was 31 kg which was 91% of the contralateral extremity. Average Quick Disability of Arm, Shoulder and Hand score was 12.5 and Modern Activity Subjective Survey of 2007 was 1.5. No complications were noted.

Arthroscopic Scapholunate Ligament Reconstruction, Volar and Dorsal Reconstruction

Arthroscopic scapholunate volar and dorsal ligament reconstruction achieves an anatomic reconstruction, avoids an open approach and capsular detachment, and provides a strong construct for early mobilization. Clinical results are discussed. Detailed "surgical tips" and technical modifications are provided.

A new clinical test for sensorimotor function of the hand - development and preliminary validation

BACKGROUND

Sensorimotor disturbances of the hand such as altered neuromuscular control and reduced proprioception have been reported for various musculoskeletal disorders. This can have major impact on daily activities such as dressing, cooking and manual work, especially when involving high demands on precision and therefore needs to be considered in the assessment and rehabilitation of hand disorders. There is however a lack of feasible and accurate objective methods for the assessment of movement behavior, including proprioception tests, of the hand in the clinic today. The objective of this observational cross- sectional study was to develop and conduct preliminary validation testing of a new method for clinical assessment of movement sense of the wrist using a laser pointer and an automatic scoring system of test results.

METHODS

Fifty physiotherapists performed a tracking task with a hand-held laser pointer by following a zig-zag pattern as accurately as possible. The task was performed with left and right hand in both left and right directions, with three trials for each hand movement. Each trial was video recorded and analysed with a specifically tailored image processing pipeline for automatic quantification of the test. The main outcome variable was Acuity, calculated as the percent of the time the laser dot was on the target line during the trial.

RESULTS

The results showed a significantly better Acuity for the dominant compared to non-dominant hand. Participants with right hand pain within the last 12 months had a significantly reduced acuity (p < 0.05), and although not significant there was also a similar trend for reduced Acuity also for participants with left hand pain. Furthermore, there was a clear negative correlation between Acuity and Speed indicating a speed-accuracy trade off commonly found in manual tasks. The repeatability of the test showed acceptable intra class correlation (ICC_2.1) values (0.68-0.81) and standard error of measurement values ranging between 5.0-6.3 for Acuity.

CONCLUSIONS

The initial results suggest that the test may be a valid and feasible test for assessment of the movement sense of the hand. Future research should include assessments on different patient groups and reliability evaluations over time and between testers.

El papel de la propiocepción y el control neuromuscular en las inestabilidades del carpo

La congruencia articular, la integridad ligamentaria y la compresión de las superficies articulares ocasionada por la contracción muscular se han considerado históricamente los tres pilares básicos para la estabilidad del carpo. En los últimos años se ha propuesto un nuevo factor para explicar los mecanismos de estabilización carpiana, la propiocepción y el control neuromuscular. La propiocepción en la muñeca se origina en órganos sensoriales localizados en los ligamentos y cápsulas articulares (los mecanorreceptores). La estimulación de los mismos inicia un reflejo involuntario que provoca una respuesta muscular selectiva dirigida a proteger la zona de la muñeca donde se ha originado la señal aferente. En este trabajo de revisión se pretende dar a conocer el concepto de propiocepción y control neuromuscular, el papel que tienen en la estabilidad del carpo y las posibles aplicaciones en la práctica clínica.

El papel de la rehabilitación tras las reparaciones de las inestabilidades de muñeca

De las patologías de muñeca más frecuentes en la consulta del cirujano de la mano, las inestabilidades carpianas ocupan un lugar importante junto con el dolor en la vertiente ulnocarpiana cuya causa más frecuente son las lesiones del complejo fibrocartílago triangular, que en ocasiones van a condicionar una inestabilidad de la articulación radiocubital distal. Analizando los datos anatómicos y biomecánicos que diponemos de la muñeca y tomando como punto de partida los escasos protocolos rehabilitadores de las inestabilidades escafolunares y lunopiramidales que existen en la bibliografía, se exponen los programas rehabilitadores específicos para cada una de ellas. Se describen también los protocolos existentes para la rehabilitación tras las reparaciones del complejo fibrocartílago triangular y exponemos los protocolos con los que trabajamos en la actualidad.

Definimos también la importancia de la reeducación propioceptiva en este tipo de lesiones y describimos un programa detallado de introducción progresiva de determinados ejercicios encaminados a ello.

The effects of age and amplitude on wrist proprioceptive acuity

This study examined wrist proprioception in a cross-sectional sample of 44 children aged between 8-to 14-years and a control group of 10 neurologically and physically healthy adults. Using a 3-degrees of freedom robotic device, participants performed an ipsilateral joint position matching task in which target amplitude (40% or 80% functional range of motion [fRoM]) and degrees-of-freedom (Flexion/Extension [FE], Radial/Ulnar deviation [RUD], Pronation/Supination [PS]) were manipulated. Results indicated that proprioceptive function became more accurate and consistent over the developmental spectrum, but that the ability to utilize proprioceptive feedback did not reach adult levels till the age of 10-11 years. Furthermore, proprioceptive acuity was influenced by target amplitude, such that movements were more accurate for the 80% fROM compared to the 40% fROM target for both the RUD and PS DoFs, independently of age. The present results provide critical information about the typical development of wrist proprioception that will enable clinicians to chart the course of development and dysfunction in neurological disorders in children, and help establish protocols for the robotic diagnosis and assessment of neurodevelopmental disorders.

Carpal Ligaments: A Functional Classification

Recent laboratory research has disclosed that carpal ligaments exhibit different kinetic behaviors depending on the direction and point of application of the forces being applied to the wrist. The so-called helical antipronation ligaments are mostly active when the wrist is axially loaded, whereas the helical antisupination ligaments constrain supination torques to the distal row. This novel way of interpreting the function of the carpal ligaments may help in developing better strategies to treat carpal instabilities.

Rehabilitation of distal radioulnar joint instability

Distal radioulnar joint (DRUJ) instabilities are common and often combined with other injuries of the interosseous membrane and/or the proximal radioulnar joint. Once they are diagnosed and the treatment is chosen, physiotherapists have limited choices due to the lack of validated protocols. The benefits of proprioception and neuromuscular rehabilitation have been brought to light for the shoulder, knee and ankle joints, among others. However, no program has been described for the DRUJ. The purpose of this article is to study the muscular elements responsible for active DRUJ stability, and to propose a proprioceptive rehabilitation program suited to this condition.

A Protocol for Evaluation and Rehabilitation of Distal Radius Fractures Using Sensorimotor Input: A Case Series

BACKGROUND

Proprioception and sensorimotor input are used to treat neurological and joint injuries. Following distal radius fractures (DRF) there is a temporary loss of proprioception that should be addressed. We created a protocol for evaluation, and a treatment plan following wrist surgery that is based on proprioceptive and sensorimotor input. We describe a series of patients undergoing surgery for DRF that were evaluated and treated with these protocols.

METHODS

Both evaluation and treatment protocols included comprehensive sensorimotor procedures performed with eyes open and closed. These included Semmes- Weinstein, static and moving 2-point discrimination, vibration, temperature testing, Moberg pick-up- test, stereognosis and proprioception.

RESULTS

A series of twelve patients was evaluated and treated with the protocol following surgical treatment for DRF. Patients demonstrated significant sensorimotor deficits, which improved utilizing the comprehensive sensorimotor treatment protocol.

CONCLUSIONS

Further study is necessary to validate the results of this pilot series. Use of proprioception and sensorimotor input may improve outcomes of rehabilitation following DRF.

Rehabilitation for scapholunate injury: Application of scientific and clinical evidence to practice

In this article, the development of a rehabilitation approach is describe using scapholunate injury as a model. We demonstrate how scientific and clinical evidence is applied to a treatment paradigm and modified based on emerging evidence. Role of the scapholunate interosseous ligament within the pathomechanics of the carpus, along with the progression of pathology, and specific rehabilitation algorithms tailored to the stage of injury. We review the recent and current evidence on the kinematics of wrist motion during functional activity, role of the muscles in providing dynamic stability of the carpus, and basic science of proprioception. Key relevant findings in each of these inter-related areas are highlighted to demonstrate how together they form the basis for current wrist rehabilitation. Finally, we make recommendations for future research to further test the efficacy of these approaches in improving functional outcomes.

Proprioception retraining for a patient with chronic wrist pain secondary to ligament injury with no structural instability

STUDY DESIGN

Case report.

INTRODUCTION

Previously published studies demonstrate the importance of the sensory innervation of the carpal ligaments and the implication for the sensorimotor control of the wrist. In addition, this case considers key rehabilitation concepts to include the dart-throwing motion and the stabilizing effect of the forearm muscles.

PURPOSE OF THE STUDY

To describe the rehabilitation program for a patient with chronic wrist pain, diagnosed with a partial tear of the dorsal intercarpal ligament and a sprain of the scapholunate ligament of the right wrist.

METHODS

The patient participated in a staged treatment plan over a 3-month period (20 sessions), which began with a focus on proprioceptive awareness and joint position sense retraining. The treatment progressed to strengthening of specific muscles to enhance stability of the wrist joint. The patient completed the Quick Disabilities of the Arm, Shoulder and Hand and the patient-rated wrist evaluation on initial evaluation, re-evaluation at ninth session, and discharge at 20th session.

RESULTS

Raw scores in the Quick Disabilities of the Arm, Shoulder and Hand and the patient-rated wrist evaluation improved from 33 and 61.5 on initial evaluation to 18 and 17.5 on discharge, respectively.

CONCLUSIONS

Sensorimotor techniques including proprioceptive retraining may improve pain, neuromuscular control, and functional outcomes in patients with chronic wrist pain due to ligament injury. The effectiveness of proprioceptive retraining needs to be evaluated in a well-designed randomized controlled trial recruiting this patient population.

LEVEL OF EVIDENCE

5.

Rehabilitation strategies for wrist sensorimotor control impairment: From theory to practice

This clinical review discusses the organization, neuroanatomy, assessment, clinical relevance, and rehabilitation of sensorimotor (SM) control impairment after wrist trauma. The wrist SM control system encompasses complex SM pathways that control normal wrist active range of motion and mediate wrist joint neuromuscular stability for maintaining joint function. Among various known assessment methods of wrist SM control impairment, the active wrist joint position sense test is determined to be a clinically meaningful and responsive measure for wrist SM control impairment after wrist fracture. Wrist trauma may involve significant soft tissue injury (ie, skin, ligament, muscle), which could disrupt the generation and transmission of adequate proprioceptive input from wrist mechanoreceptors, thus leading to significant joint SM impairment. Various clinical examples of wrist trauma (eg, distal radius fracture, scapholunate joint injury) along with known prognostic factors (eg, pain) that may influence wrist SM control impairment recovery are discussed to illustrate this point. This article proposes promising rehabilitation strategies toward restoring wrist joint conscious and unconscious SM control impairments, integrating current research evidence with clinical practice. These strategies require more rigorous evaluation in clinical trials.

LEVEL OF EVIDENCE

5.

Early controlled mobilization using dart-throwing motion with a twist for the conservative management of an intra-articular distal radius fracture and scapholunate ligament injury: A case report

This case describes an early controlled mobilization (ECM) approach that uses dart-throwing motion (DTM) with a twist orthoses as an alternative to immobilization for conservative management of a minimally displaced and intra-articular distal radius styloid fracture with an associated scapholunate ligament injury in a 47-year-old female health care administrator (JP). Pain-free active DTM began at day 10 (5 times/d) with a dynamic DTM with a twist orthosis worn during the day from weeks 3 to 6. At 6 weeks, JP had pain-free functional mobility and strength with minimal limitation in household and occupational activities, returning to her normal sporting activities by 3 months. ECM led to rapid return of normal functioning in the short term with no apparent impact on intermediate outcomes at 8 months. This case allows hand therapists to consider a similar ECM approach for the management of similar injuries in their patients.

LEVEL OF EVIDENCE

Level 5 and case report.

Orthotic intervention incorporating the dart-thrower's motion as part of conservative management guidelines for treatment of scapholunate injury

STUDY DESIGN

Case series.

INTRODUCTION

This paper describes conservative guidelines for the management of scapho-lunate interosseous ligament (SLIL) injury including fabrication of an orthosis that restricts active wrist movement to the dart-throwers (DTM) plane.

PURPOSE OF THE STUDY

The dart throwers' orthosis (DTO) was designed as a response to biomechanical studies suggesting that restraining motion to the DTM would off-load a deficient SLIL.

METHODS

After six weeks of wearing the DTO, the 5 patients in this case series initiated an exercise program that incorporated wrist proprioceptive training and specific muscle strengthening.

DISCUSSION

The DTO was designed to incorporate controlled movement in order to better integrate the secondary wrist stabilizers in wrists that had a deficient SLIL. The orthosis and the exercise program harnessed proprioceptive influences using active motion within the DTM plane, and stimulated mechanoreceptors so as to enhance stability.

RESULTS

All patients demonstrated improvement in subjective and objective outcomes including self-reported pain and function.

CONCLUSIONS

Orthotic intervention that controls motion within the DTM, combined with an appropriate proprioceptive rehabilitation program, may provide a viable conservative treatment option for patients with a similar clinical presentation.

LEVEL OF EVIDENCE

4.

Robot-assisted assessment of wrist proprioception: does wrist proprioceptive acuity follow Weber's law?

Proprioception is essential for planning and controlling limb posture and movement. In our recent work, we introduced a standardized robot-aided method for measuring proprioceptive discrimination thresholds at the wrist to obtain reliable and accurate measures of proprioceptive acuity. Weber's law defines discrimination thresholds as a constant ratio between the just noticeable difference and the reference or standard stimulus. Reporting Weber's fractions thus provides the possibility of comparing results with the reports of others collected worldwide. This work aims to determine that Weber's Law holds for proprioceptive discrimination thresholds and to provide Weber's fraction for wrist joint proprioception. To this end, eight healthy subjects experienced two passive wrist movements of different amplitude and verbally indicated which was larger. An adaptive psychophysical procedure established the amplitude of the largest stimulus according to participants' responses. This comparison stimulus was then compared to a standard stimulus amplitude of 10°, 20°, 30° or 40°. The discrimination thresholds for each standard stimulus were established at the 75% correct response level. The obtained thresholds followed Weber's Law indicating that larger amplitudes were associated with higher discrimination thresholds. Based on a linear regression function the overall Weber's fraction, defined as the slope of the line, was computed to be 0.09. This result expands the present limited knowledge on wrist proprioception showing that its proprioceptive acuity follows Weber's law.

Early outcomes of ‘The Birmingham Wrist Instability Programme’: A pragmatic intervention for stage one scapholunate instability

Introduction

Scapholunate instability is commonly caused by a fall on an outstretched hand resulting in structural pathology and pain. In recent years, dynamic stability mechanisms have been described that may aid in the non-operative management of this patient group. Limited evidence exists regarding the clinical application of stability mechanisms for scapholunate instability, and there is a void of reproducible structured exercise regimes.

Method

A service evaluation was conducted over 16 months to assess patient outcomes following an evidence-based treatment protocol in the conservative management of stage one scapholunate instability. Pain-free grip, maximal grip, grip strength ratio, Euro-Qol five dimensions questionnaire (EQ-5D), Visual Analogue Scale (VAS) and Quick Disability of Arm, Shoulder and Hand questionnaire (Quick-DASH) scores were compared between baseline and final follow-up.

Results

Six consecutive patients (seven wrists) were included with five patients (six wrists) completing treatment. Mean grip strength ratio improved by 45%, mean VAS improved by 5.5 points, mean Quick-DASH improved by 33.96% and EQ-5D improved by 0.187 quality-adjusted life years. Where established, all outcomes exceeded minimal clinically important difference values.

Discussion

The Birmingham Wrist Instability Programme can yield clinically important results for patients with stage one scapholunate instability in the short term based on a small service evaluation. The findings support the need for further research to evaluate the rehabilitation programme in a larger group of patients over the longer term.

Robot-aided developmental assessment of wrist proprioception in children

BACKGROUND

Several neurodevelopmental disorders and brain injuries in children have been associated with proprioceptive dysfunction that will negatively affect their movement. Unfortunately, there is lack of reliable and objective clinical examination protocols and our current knowledge of how proprioception evolves in typically developing children is still sparse.

METHODS

Using a robotic exoskeleton, we investigated proprioceptive acuity of the wrist in a group of 49 typically developing healthy children (8-15 years), and a group of 40 young adults. Without vision participants performed an ipsilateral wrist joint position matching task that required them to reproduce (match) a previously experienced target position. All three joint degrees-of-freedom of the wrist/hand complex were assessed. Accuracy and precision were evaluated as a measure of proprioceptive acuity. The cross-sectional data indicating the time course of development of acuity were then fitted by four models in order to determine which function best describes developmental changes in proprioception across age.

RESULTS

First, the robot-aided assessment proved to be an easy to administer method for objectively measuring proprioceptive acuity in both children and adult populations. Second, proprioceptive acuity continued to develop throughout middle childhood and early adolescence, improving by more than 50% with respect to the youngest group. Adult levels of performance were reached approximately by the age of 12 years. An inverse-root function best described the development of proprioceptive acuity across the age groups. Third, wrist/forearm proprioception is anisotropic across the three DoFs with the Abduction/Adduction exhibiting a higher level of acuity than those of Flexion/extension and Pronation/Supination. This anisotropy did not change across development.

CONCLUSIONS

Proprioceptive development for the wrist continues well into early adolescence. Our normative data obtained trough this novel robot-aided assessment method provide a basis against which proprioceptive function of pediatric population can be compared. This may aid the design of more effective sensorimotor intervention programs.

[Hand rehabilitation after distal radius fracture]

Distal radius fractures (DRF) are common. Good outcomes are the result of appropriate initial treatment (immobilization, external fixation, percutaneous pinning or open reduction and internal fixation) and rehabilitation adapted to this treatment. When started immediately, rehabilitation of DRF prevents complications due to immobilization, surgery and a non-controlled healing process. Splints play an important role at all stages of rehabilitation.

Preliminary analysis of non-dominant proprioceptive acuity and interlimb asymmetry in the human wrist

Proprioception provides information about limb configuration which are essential for planning and controlling its posture and movement. Asymmetries in the way dominant and non-dominant limbs exploit proprioceptive information have been previously evaluated, with contradictory results due to the difference in the employed methodology. A measure of proprioceptive acuity that does not reflect the influence of one limb on the other consists in the evaluation of the psychophysical threshold. This metric, evaluated separately for each limb and involving only passive movements, reflects a reliable measure of proprioceptive acuity. The aim of this work is to first evaluate the proprioceptive acuity of the non-dominant wrist joint in flexion/extension and adduction/abduction and to compare these results to the acuity of the dominant wrist. Data were collected during a unidirectional 2-alternative-forcedchoice test performed by six right-handed subjects. We found acuity of 1.31°, 1.26°, 1.33° and 1.63° respectively for abduction, adduction, extension and flexion of the non-dominant wrist. Acuity of the dominant wrist was assessed for five of the subjects for abduction and flexion and resulted lower (mean values were respectively 1.64° and 2.14°). The preliminary results suggest a leading role of the non-dominant wrist in the processing of the proprioceptive feedback.

Multiplanar wrist joint proprioception: The effect of anesthetic blockade of the posterior interosseous nerve or skin envelope surrounding the joint

STUDY DESIGN

Randomized clinical trial.

PURPOSE

Contribution of the posterior interosseous nerve (PIN) and surrounding skin envelope to wrist proprioception is a topic of debate and the primary focus of this research.

METHODS

We performed a double-blinded, placebo control study in which subjects underwent baseline multiplanar testing of wrist proprioception. They were randomized to receive either anesthetic blockade of the PIN within the fourth dorsal compartment, or circumferential topical anesthetic blockade of skin surrounding the wrist. Corresponding opposite wrists underwent placebo intervention with saline injection or inert ultrasound gel. Subjects repeated proprioceptive testing.

RESULTS

Eighty subjects, 45 male and 35 female, mean age 33 years (range, 19-64 years), completed testing. The percentage of measurements falling outside a ±18° range did not differ between pre-treatment and post-treatment PIN blockade or for circumferential skin anesthesia.

CONCLUSIONS

Wrist proprioception appears to be a multifactorial phenomenon. Surgeons may sacrifice the PIN without concern for effect on joint proprioception.

LEVEL OF EVIDENCE

Level I.

The effect of individual isometric muscle loading on the alignment of the base of the thumb metacarpal: a cadaveric study

Stability of the thumb carpometacarpal joint relies upon equilibrium between its ligaments, muscular support and joint congruity. We wanted to identify the muscles important in preventing or increasing dorsoradial subluxation of this joint. In ten cadaveric hands, a Fastrak® motion tracking device was used to assess the effects of individual isometric muscle loading on the base of the thumb metacarpal relative to the radius and to the base of the middle finger metacarpal. We found that the first dorsal interosseous muscle caused the least dorsoradial translation and highest distal migration of the base of the first metacarpal, whereas abductor pollicis longus was the primary destabilizer, increasing dorsoradial misalignment. The findings show different impacts of these muscles on joint alignment and stability, which suggests that treatment should be targeted to enhance the action of the primary stabilizing muscle, the first dorsal interosseous muscle.

A study to investigate the intra-rater and inter-rater reliability of goniometric measurements of dart throwers motion of asymptomatic wrists

Introduction

This study investigated the intra-rater and inter-rater reliability of measuring dart throwers motion of asymptomatic wrists with a handheld manual goniometer typical of that used in the clinical setting.

Method

Working in pairs, each rater took three repeated measures of radial extension and of ulnar flexion of both wrists using a goniometer positioned on the radiodorsal aspect of the radius proximally and the second metacarpal distally. Both raters and subjects were blinded, and measurements were read by an independent observer. Subjects were of varied age, gender and with no history of wrist pathology. Subjects rated how difficult they found the dart throwers motion to perform using a 5-point Likert scale.

Results

Measurements were collected from both wrists of 37 subjects (74 wrists). The intraclass correlation coefficient for intra-rater measurements of radial extension was 0.89 (95% CI 0.86–0.92) and for ulnar flexion was 0.92 (95% CI 0.90–0.94). Standard deviation for radial extension was 4.2° and for ulnar flexion 3.6°. The intraclass correlation coefficient for inter-rater measurements of radial extension was 0.83 (95% CI 0.74–0.89) and for ulnar flexion was 0.81 (95% CI 0.72–0.88). Subjects rated the movement more difficult to perform with the non-dominant side (P=0.006), and standard deviation was greater when the subject found dart throwers motion difficult to perform. No significant associations were found (P<0.05) to suggest that reliability is influenced by hand dominance, gender, age, level of perceived difficulty or data collection site.

Discussion

Our study confirms good reliability when using this method to measure dart throwers motion. It is suggested that dart throwers motion can be measured to compare different subjects and monitor change; however, studies need to be undertaken with a symptomatic population.

Targeted brain activation using an MR-compatible wrist torque measurement device and isometric motor tasks during functional magnetic resonance imaging

Dedicated pairs of isometric wrist flexion tasks, with and without visual feedback of the exerted torque, were designed to target activation of the CBL and BG in healthy subjects during functional magnetic resonance imaging (fMRI). Selective activation of the cerebellum (CBL) and basal ganglia (BG), often implicated in movement disorders such as tremor and dystonia, may help identify pathological changes and expedite diagnosis. A prototyped MR-compatible wrist torque measurement device, free of magnetic and conductive materials, allowed safe execution of tasks during fMRI without causing artifacts. A significant increase of activity in CBL and BG was found in healthy volunteers during a constant torque task with visual feedback compared to a constant torque task without visual feedback. This study shows that specific pairs of motor tasks using MR-compatible equipment at the wrist allow for targeted activation of CBL and BG, paving a new way for research into the pathophysiology of movement disorders.

Management of lunotriquetral instability: a review of the literature

Lunotriquetral ligament injury is a relatively common cause of ulnar-sided wrist pain. Injury ranges from partial stable ligament tears to extensive perilunate instability. Clinical decision-making largely depends on the chronicity, instability and cause of the ligament injury. Conservative treatment is generally regarded as first choice of treatment of mild lunotriquetral instability; however, outcome studies on conservative treatment are lacking. Temporary arthroscopic pinning and/or debridement are minimally invasive procedures of preference. In the case of more dissociative injury, surgical interventions may be performed. The literature suggests that soft tissue reconstruction is an effective procedure in this group. Arthrodesis of the lunotriquetral joint is associated with high rates of non-union (up to 57%) and the indications for surgery should therefore be very clear. Methodological issues make it hard to draw firm conclusions from the data. Studies on the effectiveness of conservative management and prospective comparative studies will further improve clinical decision-making in lunotriquetral instability.

LEVEL OF EVIDENCE

N/A.

Conservative management of midcarpal instability

Midcarpal instability is a complex condition that can present in various forms, from mild pain to debilitating subluxation. Once diagnosed, treatment guidelines for hand therapy are limited by the scarcity of high-level evidence. Evidence does exist for use of proprioceptive awareness and neuromuscular rehabilitation for instability of the knee, shoulder and ankle joint, but studies of similar programmes for the wrist joint have not been published. The purpose of this review is to examine the evidence supporting current concepts in the non-operative management of midcarpal instability, and to provide recommendations for the management of this condition with hand therapy.