Long-Term Functional Results of a Wrist Exercise Program for Patients with Palmar Midcarpal Instability

Effects of Wrist Stability Training Combined with Grip Strength Exercise on Pain and Function in Patients with Nonspecific Chronic Wrist Pain

Background and Objectives: Non-specific chronic wrist pain is wrist pain that occurs without a specific cause, such as trauma, and may limit the range of motion of the joints of the wrist and hand, affecting muscle strength, grip strength, and function. This study aimed to determine the effects of grip-strengthening exercises combined with wrist stability training on pain and function in patients with non-specific chronic wrist pain. Materials and Methods: The subjects of the study were 31 patients with wrist pain. To determine the effect of grip-strengthening exercises combined with wrist stability training, 15 participants participated in grip-strengthening exercises combined with wrist stability training and 16 control subjects participated. The experimental group participated in wrist-stability training. Grip-strengthening exercises combined with wrist stability training were performed for 20 min/day twice a week for 4 weeks, and relaxation massage and conservative physical therapy were performed for 20 min/day twice a week for 4 weeks. The control group received relaxation massage and conservative physical therapy for 40 min/day twice a week for 4 weeks. A visual pain scale was used to evaluate the degree of pain before and after treatment, and a patient-rated wrist evaluation was used to evaluate wrist function. Results: The results showed that the visual score significantly decreased in the time effect before and after the intervention in both groups (p < 0.001), patient-rated wrist evaluation significantly decreased (p < 0.001), and grip strength and muscle strength significantly increased (p < 0.001). The results of this study showed that grip-strengthening exercises combined with wrist stability training were effective in improving pain, function, grip strength, and muscle strength in patients with non-specific chronic wrist pain. Conclusions: Grip-strengthening exercises combined with wrist stability training can be used as an effective intervention method to improve pain, function, grip strength, and muscle strength, emphasizing the need for wrist exercise interventions in patients with non-specific chronic wrist pain in the future.

Exercise-based intervention as a nonsurgical treatment for patients with carpal instability: A case series

BACKGROUND

Although the important roles of proprioception and neuromuscular control in carpal instabilities under laboratory conditions have been recognized, only a few studies have translated this knowledge into a routine clinical practice.

PURPOSE

This study aimed to evaluate the results of a personalized rehabilitation in patients with carpal instability on functionality and pain intensity.

STUDY DESIGN

This was a case series study.

METHODS

This case series included 39 adults (mean age: 38.2 ± 14.0 years; 16/23 females/males) diagnosed with carpal instability (radial or ulnar) with indication for orthopedic treatment. The disabilities of the arm, shoulder, and hand questionnaire was used to assess upper limb functionality. Pain perception was assessed using a visual analog scale. Exercise-based physiotherapy interventions were performed according to the clinical needs of the patients for at least 6 weeks (2-3 sessions per week). For the treatment of radial instability (n = 13), strengthening exercises of the abductor pollicis longus, extensor carpi radialis longus, flexor carpi radialis, and pronator quadratus muscles were prescribed. For the treatment of ulnar instability (n = 24), extensor carpi ulnaris and pronator quadratus were trained. All patients underwent proprioceptive training in open kinetic chain and closed kinetic chain, as well as strengthening of the unaffected hand. Changes before and after treatment were compared using the nonparametric Wilcoxon signed rank test.

RESULTS

A significant improvement with a large effect size in disabilities of the arm, shoulder, and hand (P < .001; d = 2.9) and visual analog scale (P < .001; d = 3.2) scores were obtained after treatment. Moreover, the changes were greater than the minimal clinically important difference of 10.8 and 1.4, respectively. Similar results were found when patients with radial instability and ulnar instability were analyzed separately.

CONCLUSIONS

Personalized training with specific proprioception and strengthening exercises produces improvements in functionality and pain perception in our cohort of people with carpal instability. These results highlight the importance of multicomponent exercise in the treatment of wrist instability. Future randomized clinical trials should further investigate the effectiveness of this protocol.

Outcomes of an exercise program in patients with dorsal or volar midcarpal laxity: a cohort study of 213 patients

PURPOSE

Describing the outcomes of an exercise program on wrist and hand function for patients with midcarpal instability (MCI).

MATERIALS AND METHODS

This study has a prospective cohort design. Two hundred and thirteen patients with MCI were included. The intervention was a 3-month exercise program consisting of hand therapy and home exercises. The primary outcome was perceived wrist and hand function evaluated with the Patient-Rated Wrist/Hand Evaluation (PRWHE) three months after treatment onset. Secondary outcomes were conversion to surgery, pain, and satisfaction with treatment results.

RESULTS

PRWHE total scores improved from 51 ± 19 (mean ± SD) to 33 ± 24 at 3 months (95% CI: 36-30, p < 0.001). All visual analog scales for pain demonstrated clinically relevant improvements at 6 weeks and 3 months (p < 0.001). At 3 months, 81% of the participants would undergo the treatment again. After a median follow-up of 2.8 years, 46 patients (22%) converted to surgery.

CONCLUSIONS

We found clinically relevant improvements in hand and wrist function and pain. Most participants would undergo treatment again and 78% of the participants did not convert to surgery. Hence, non-invasive treatment should be the primary treatment choice for patients with MCI.

A scoping review to map evidence regarding key domains and questions in the management of non-traumatic wrist disorders

Introduction

Non-traumatic wrist disorders (NTWD) are commonly encountered yet sparse resources exist to aid management. This study aimed to produce a literature map regarding diagnosis, management, pathways of care and outcome measures for NTWDs in the United Kingdom.

Methods

An interdisciplinary team of clinicians and academic researchers used Joanna Briggs Institute guidelines and the PRISMA ScR checklist in this scoping review. A mixed stakeholder group of patients and healthcare professionals identified 16 questions of importance to which the literature was mapped. An a-priori search strategy of both published and non-published material from five electronic databases and grey literature resources identified records. Two reviewers independently screened records for inclusion using explicit eligibility criteria with oversight from a third. Data extraction through narrative synthesis, charting and summary was performed independently by two reviewers.

Results

Of 185 studies meeting eligibility criteria, diagnoses of wrist pain, De Quervain's syndrome and ulna-sided pain were encountered most frequently, with uncontrolled non-randomised trial or cohort study being the most frequently used methodology. Diagnostic methods used included subjective questioning, self-reported pain, palpation and special tests. Best practice guidelines were found from three sources for two NTWD conditions. Seventeen types of conservative management, and 20 different patient-reported outcome measures were suggested for NTWD.

Conclusion

Substantial gaps in evidence exist in all parts of the patient journey for NTWD when mapped against an analytic framework (AF). Opportunities exist for future rigorous primary studies to address these gaps and the preliminary concerns about the quality of the literature regarding NTWD.

Effects of a neuromuscular joint-protective exercise therapy program for treatment of wrist osteoarthritis: a randomized controlled trial

BACKGROUND

Individuals with wrist osteoarthritis (OA) can suffer from pain, muscular weakness, and impaired motion of the wrist, which can reduce the quality of life. While there is strong evidence that all patients with OA should receive first-line treatment with education and exercises, this approach has not yet been proposed for individuals with wrist OA. Therefore, this trial aimed to evaluate the effectiveness of a first line neuromuscular joint-protective exercise therapy program compared to a training program with range of motion (ROM) exercises in patients with wrist OA.

METHODS

In this randomized controlled trial (RCT), 48 patients with symptomatic and radiographically confirmed wrist OA were randomly allocated to a 12-week self-management program with either a neuromuscular joint-protective exercise therapy program (intervention group) or a training program with ROM exercises only (control group). Our primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) with secondary outcome measures of grip strength, range of wrist motion, the Numerical Pain Rating, Scale (NPRS), the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Generalized Self-Efficacy Scale (GSES). The outcome measures were evaluated by a blinded assessor at baseline and 12 weeks. Between-groups differences were analyzed using the Mann-Whitney U test and within-group differences were analyzed with the Wilcoxon signed-rank test.

RESULTS

A total of 41 participants were analyzed at 12 weeks. There were no significant differences in PRWE between the groups at 12 weeks (p = 0.27). However, DASH improved significantly in the intervention group compared to the control group (p = 0.02) and NPRS on load within the intervention group (p = 0.006). The difference in DASH should be interpreted with caution since it could be due to a non-significant increase (worsening) from baseline in the control group in combination with a non-significant decrease (improvement) in the intervention group.

CONCLUSIONS

This RCT showed that the novel neuromuscular joint-protective exercise therapy program was not superior in reducing pain and improving function compared to a training program with ROM exercises at 12 weeks. Future research is warranted to evaluate the effectiveness of forthcoming exercise therapy treatment programs for patients with wrist OA.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05367817. Retrospectively registered on 10/05/2022. https://clinicaltrials.gov .

Palmar midcarpal instability a narrative review of the literature: Have we reached a consensus on a treatment?

Palmar midcarpal instability (PMCI) is a wrist condition that requires treatment through non-surgical rehabilitation programs or surgical stabilization. This condition's natural history is poorly understood, and the optimal treatment approach remains unknown. Non-surgical treatments are initially implemented, followed by surgical stabilization if necessary. Arthrodesis and soft tissue stabilization are the two main surgical options for PMCI, with no established gold standard for treatment. A systematic review of 12 articles comparing arthrodesis and soft tissue stabilization was conducted to identify the optimal treatment approach for PMCI. Arthrodesis techniques, such as lunotriquetral arthrodesis, showed high functional outcomes but also high reintervention rates due to nonunion. Soft tissue stabilization techniques showed superior functional outcomes with less mobility loss and lower reintervention rates compared to arthrodesis. However, more studies are required to determine the optimal soft tissue technique. Based on this review we created a treatment algorithm for PMCI starting with non-surgical treatment first, followed by surgical stabilization if needed. Soft tissue stabilization techniques are preferred over arthrodesis due to better functional outcomes and lower reintervention rates. However, each patient's treatment approach should be individualized and evaluated independently to determine the best course of action. PMCI is a rare wrist condition, and further research is needed to better understand its natural history and establish a gold standard for treatment. The lack of literature comparing the two surgical options underscores the need for further research to determine the optimal treatment approach. Nonetheless, the current evidence suggests that soft tissue stabilization is a promising alternative to arthrodesis, providing superior functional outcomes and lower reintervention rates.

A self-managed exercise therapy program for wrist osteoarthritis: study protocol for a randomized controlled trial

BACKGROUND

Post-traumatic wrist osteoarthritis (OA) can eventually lead to pain, muscular weakness, and stiffness of the wrist, which can affect the function of the entire upper limb and reduce the quality of life. Although there is strong evidence that all patients with OA should be offered adequate education and exercises as a first-line treatment, an effective self-management program, including structured education and therapeutic exercises, has not yet been introduced for individuals with wrist OA. This trial aims to evaluate the effectiveness of an exercise therapy program with joint protective strategies to improve neuromuscular control (intervention group) compared to a training program with range of motion exercises (control group).

METHODS

This is a single-blinded randomized controlled trial (RCT) with two treatment arms in patients with symptomatic and radiographically confirmed wrist OA. The trial will be conducted at a hand surgery department. The participants will be randomly assigned either to a neuromuscular exercise therapy program or to a training program with range of motion exercises only. Participants in both groups will receive a wrist orthosis and structured education on wrist anatomy, pathophysiology, and joint protective self-management strategies. The programs consist of home exercises that will be performed twice a day for 12 weeks. The Patient-Rated Wrist Evaluation (PRWE) is the primary outcome measure of pain and function. Wrist range of motion (ROM), grip strength, the Numeric Pain Rating scale (NPRS), Disabilities of the Arm, Shoulder, and Hand (DASH), the General Self-Efficacy Scale (GSES), Global Rating of Change (GROC), and conversion to surgery are the secondary measures of outcome. Assessments will be performed at baseline and at 3, 6, and 12 months after baseline by a blinded assessor.

DISCUSSION

The upcoming results from this trial may add new knowledge about the effectiveness of a self-managed exercise therapy program on pain and function for individuals with wrist OA. If the present self-management program proves to be effective, it can redefine current treatment strategies and may be implemented in wrist OA treatment protocols.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05367817. Retrospectively registered on 27 April 2022. https://clinicaltrials.gov .

Midcarpal Instability

Midcarpal instability (MCI) of the wrist represents multiple distinct clinical entities that all have in common abnormal force transmission across the midcarpal joint. This can be asymptomatic but can also result in painful wrist motion, a characteristic catch-up clunk, and symptoms of instability. The carpus is stabilized by numerous extrinsic and intrinsic ligaments. Dynamic joint reactive forces between the proximal and distal carpal rows help create reciprocal motion, which results in smooth, physiologic wrist mechanics. Diagnosis of MCI requires a thorough history, physical examination, and adequate imaging. MCI can be managed nonsurgically with activity modification, physical therapy, specialized orthotics, medications, and corticosteroid injections. A variety of surgical treatment options exists to treat symptomatic MCI. These include arthroscopic thermal capsulorrhaphy, ligament repair or reconstruction, radial osteotomies, and limited radiocarpal or intercarpal fusions. Capsulorrhaphy or ligament repair is favored for mild to moderate cases; osteotomies can be used for the correction of bony deformities contributing to instability, whereas partial wrist arthrodesis is indicated for severe or recurrent instability and fixed deformities.

Dynamic MRI of the wrist in less than 20 seconds: normal midcarpal motion and reader reliability

OBJECTIVE

To describe the normal motion pattern at the midcarpal compartment during active radial-ulnar deviation of the wrist using dynamic MRI, and to determine the observer performance for measurements obtained in asymptomatic volunteers.

METHODS

Dynamic MRI of 35 wrists in 19 asymptomatic volunteers (age mean 30.4 years, SD 8.6) was performed during active radial-ulnar deviation using a fast gradient-echo pulse sequence with 315 ms temporal resolution (acquisition time, 19 s). Two independent readers measured the transverse translation of the trapezium at the scaphotrapezium joint (STJ) and the capitate-to-triquetrum distance (CTD). Relationships between these measurements and laterality, sex, lunate type, and wrist kinematic pattern were evaluated.

RESULTS

At the STJ, the trapezium moved most in radial deviation, with an overall translation of 2.3 mm between ulnar and radial deviation. Mean CTD measurements were the greatest in ulnar deviation and varied 2.4 mm between ulnar and radial deviation. Mean CTD was greater in men than women in the neutral position (p = 0.019), and in wrists with type II lunate morphology during radial and ulnar deviation (p = 0.001, p = 0.014). There were no significant differences in trapezium translation or CTD with wrist laterality and kinematic pattern. Intraobserver and interobserver correlation coefficients were 0.97 and 0.87 for trapezium translation and 0.84 and 0.67 for CTD.

CONCLUSION

This study is the first to demonstrate the performance of dynamic MRI to quantify STJ motion and CTD. Dynamic MRI with a short acquisition time may be used as a tool to supplement static MRI in evaluation of the midcarpal compartment.

Palmar Capsuloligamentous Plication in Dorsal Capitolunate Instability: Technique and Preliminary Results

Midcarpal instability (MCI) is a form of the carpal instability nondissociative pattern and can be differentiated into dorsal, palmar, or extrinsic MCI. Dorsal MCI can frequently be observed in adolescent or adult patients due to trauma or hyperlaxity of the palmar intrinsic carpal ligaments. Clinical stress tests and cinematography are capable to depict the ligamentous instability centered around the capitolunate area. We describe a novel technique which aims to address palmar ligamentous hyperlaxity by plication of the radioscaphocapitate, radiolunotriquetral, and arcuate ligaments, thus closing the so-called space of Poirier. This palmar technique has been used in several cases in isolated form or in conjunction with other concomitant procedures. After the floor of the carpal tunnel and thus the palmar ligaments are exposed and the weak spot meticulously verified, 2 or rarely 3 deep FibreWire pulley sutures are used for capsuloligamentous plication. Among 11 patients, 4 cases (5 operated wrists) with isolated capitolunate capsuloligamentous plication were followed at an average of 2.6 years after surgery. The results were excellent with a mean postoperative Disabilities of the Arm, Shoulder and Hand Score of 9.7 (range, 6.9 to 15.0), mean numerical rating scale of 0 at rest and 1 (range, 0 to 2) during stress. All cases stated that they were very satisfied with the result and all would definitely elect to choose the surgery again. Palmar capsuloligamentous plication has been shown to be a quick, relatively easy and reliable procedure to reduce dorsal MCI in our patient cohort.