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

Scapholunate Ligament Injuries

Injuries to the scapholunate interosseous ligament (SLIL) complex can result in a predictable cascade of incongruous motion in the carpus that leads to radiocarpal degeneration. Both acute traumatic impact and repetitive motion can render the SLIL insufficient. A thorough understanding of SLIL anatomy is required for appropriate diagnosis and treatment. Here, we review scapholunate ligament anatomy, prevention strategies, methods of diagnosis, nonoperative and operative treatments, and outcomes. A myriad of treatment options exist for each stage of the SLIL injury, and management should be an open discussion between the patient and physician.

Periarticular Proprioception: Analyzing the Three-Dimensional Structure of Corpuscular Mechanosensors in the Dorsal Part of the Scapholunate Ligament

INTRODUCTION

Sensory nerve endings transmit mechanical stimuli into afferent neural signals and form the basis of proprioception, giving rise to the self-perception of dynamic stability of joints. We aimed to analyze the three-dimensional structure of periarticular corpuscular sensory nerve endings in a carpal ligament to enhance our understanding of their microstructure.

METHODS

Two dorsal parts of the scapholunate ligament were excised from two human cadaveric wrist specimens. Consecutive cryosections were stained with immunofluorescence markers protein S100B, neurotrophin receptor p75, protein gene product 9.5 (PGP 9.5), and 4',6-diamidino-2-phenylindole. Three-dimensional images of sensory nerve endings were obtained using confocal laser scanning microscopy, and subsequent analysis was performed using Imaris software.

RESULTS

Ruffini endings were characterized by a PGP 9.5-positive central axon, with a median diameter of 4.63 μm and a median of 25 cells. The p75-positive capsule had a range in thickness of 0.94 μm and 15.5 μm, consisting of single to three layers of lamellar cells. Ruffini endings were significantly smaller in volume than Pacini corpuscles or Golgi-like endings. The latter contained a median of three intracorpuscular structures. Ruffini endings and Golgi-like endings presented a similar structural composition of their capsule and subscapular space. The central axon of Pacini corpuscles was surrounded by S100-positive cells forming the inner core which was significantly smaller than the outer core, which was immunoreactive for p75 and PGP 9.5.

CONCLUSION

This study reports new data regarding the intricate outer and intracorpuscular three-dimensional morphology of periarticular sensory nerve endings, including the volume, number of cells, and structural composition. These results may form a basis to differ between normal and pathological morphological changes in periarticular sensory nerve endings in future studies.

Scapholunate and lunotriquetral joint dynamic stabilizers and their role in wrist neuromuscular control and proprioception

BACKGROUND

Recent research interest has grown in exploring the role of muscles, isometric contraction, proprioception, and neuromuscular control in addressing dynamic scapholunate and lunotriquetral joint instability, marking a shift in the understanding of wrist stability.

PURPOSE

To present a comprehensive review of the carpal ligaments anatomy and wrist biomechanics, with a particular focus on the role of proprioception in dynamic carpal stability and their role in managing scapholunate (SL) and lunotriquetral (LTq) dynamic instabilities.

STUDY DESIGN

We conducted a systematic search of the literature and review of the most relevant papers published and indexed in pubmed, related to wrist biomechanics, proprioception and its contribution to carpal dynamic stability.

METHODS

The study involved a comprehensive review of neuromuscular mechanisms in dynamic stabilization of the carpus, based on cadaver studies. The 3D position of the scaphoid, triquetrum, and capitate was monitored before and after tendon loading.

RESULTS

The extensor carpi ulnaris (ECU) and the flexor carpi radialis (FCR) are identified as the primary pronators of the midcarpal joint. The ECU's pronation effect can potentially strain the scapholunate ligament, while the supinator muscles, the abductor pollicis longus (APL), the extensor carpi radialis longus (ECRL), and the flexor carpi ulnaris (FCU), have a protective role, particularly in cases of scapholunate ligament dysfunctions. The FCR, despite being a pronator of the distal row, has a beneficial effect as it provokes supination of the scaphoid.

CONCLUSIONS

Comprehending carpal dysfunctions and instabilities hinges on understanding carpal anatomy and normal biomechanics. Proprioception, encompassing joint position sensation and neuromuscular control, is pivotal for stability. Biomechanical research informs tailored muscle strengthening for specific carpal issues. Supinator muscles should be strengthened for SL injuries, and ECU-focused strengthening and proprioceptive training are key for dynamic LTq instabilities. Ongoing research should delve into the intricate relationship between carpal ligaments, muscles, and proprioception to enhance wrist stability.

The Effect of Proprioceptive Training on Hand Function and Activity Limitation After Open Carpal Tunnel Release Surgery: A Randomized Controlled Study

OBJECTIVE

To investigate the effect of proprioceptive training on hand function and activity limitation in patients undergoing open carpal tunnel release surgery.

DESIGN

Randomized controlled study.

SETTING

A university hospital.

PARTICIPANTS

Thirty patients were included in the study and randomized to proprioceptive training (PT) and conventional rehabilitation (CR) groups.

INTERVENTION

One week after surgery, both groups received CR for 6 weeks. All participants were asked to perform home-based exercises daily in 3 sets with 10 repetitions. For the PT group, a 6-step PT program was conducted starting from Week 6. Both groups received face-to-face interventions twice a week for 12 weeks.

MAIN OUTCOME MEASURES

The outcome measures included the Purdue Pegboard Test (PPT), the joint position sense test (JPST), the Boston Carpal Tunnel Questionnaire, and the Patient-Specific Functional Scale. In total, 3 assessments were performed (at 1, 6 and 12 weeks postoperatively).

RESULTS

In the PT group, the results for PPT were statistically significant (P<.05). Although there was a greater decrease in the absolute angular error value (JPST) of the PT group compared to the CR group, the difference was nonsignificant (P>.05). Similar reductions in activity limitation were seen in both groups (PT: 176%, CR: 175%). Symptom severity decreased by 40% in the PT group vs 32% in the CR group. The effect sizes were larger for the changes between the second and third assessments in the PT group compared to the CR group in all parameters tested.

CONCLUSION

When applied after carpal tunnel release surgery, PT may potentially to improve hand functions, reduce activity limitation, increase participation in activities of daily living, and thus improve quality of life.

Effectiveness of proprioceptive neuromuscular facilitation therapy and strength training among post-menopausal women with thumb carpometacarpal osteoarthritis. A randomized trial

BACKGROUND

Thumb carpometacarpal osteoarthritis (CMC OA) greatly affects post-menopausal women. It is characterized by pain and functional deficits that limit the performance of activities of daily life and affect quality of life.

PURPOSE

Analyze the effects of 4/weeks strength training, with and without proprioceptive neuromuscular facilitation (PNF) on the disability among post-menopausal women with thumb CMC OA. Secondly, analyze the effects on pain, mobility, and strength.

STUDY DESIGN

Superiority randomized clinical trial.

METHODS

42 women were randomly allocated to strength training program (SEG, n = 21) and to a strength training plus PNF therapy program (PNFG, n = 21). The Disability (disabilities of the arm, shoulder and hand questionnaire), pain (visual analogue scale), mobility (Kapandji Test), and hand strength were evaluated pre, post intervention (at 4 weeks) and follow-up (at 8 weeks).

RESULTS

Disability was significantly reduced in both groups after intervention, but reduction was statistically superior in PNFG (between-group mean difference [MD] = -16.69 points; CI = -21.56:-11.82; P<.001; d = 2.14). Similar results were observed for secondary outcomes: pain (MD = -2.03; CI = -2.83:-1.22; P<.001; d = 1.58), mobility (MD = 0.96; CI = 0.52:1.38; P<.001; d = 1.40) and strength (grip: MD = 3.47kg; CI = 1.25:5.69; P = .003; d = 0.97, palmar: MD = 0.97kg; CI = 0.14:1.80; P = .024; d = 0.72, tip: MD = 1.12kg; CI = 0.41:1.83; P = .003; d = 0.99 and key pinch: MD = 0.85kg; CI = 0.001:1.70; P = .049; d = 0.62). These improvements were maintained at follow-up.

CONCLUSIONS

The combination of PNF exercises and strength training is more effective for reducing disability pain and improve mobility and strength in post-menopausal women with CMC OA than a programme based solely on strength.

Wrist proprioception-An update on scientific insights and clinical implications in rehabilitation of the wrist

The field of wrist proprioception, as it relates to rehabilitation and surgery, has gone through a period of intense growth in the past decade. From being primarily focused on the function of the joint and ligaments in patients with wrist trauma or after wrist surgery, the understanding is now that of a greater complexity in treating not just the wrist but the hand and arm as a whole. Proprioception is derived from the Latin words "proprius" - belonging to (oneself) and "-ception" to sense. In other words, how to sense ourselves. To have a complete sense of self, multiple sensory afferents originating from joints, ligaments, muscles, tendons, nerves, skin, vision, and hearing work together to orchestrate a balanced integration of sensorimotor functions, with the true goal to perceive and adapt to the physical world around us. In this update on wrist proprioception, we review current developments in the understanding of proprioception, with an implication for our everyday work as hand therapists and hand surgeons. Each contributing sense-joint, ligaments, muscles, skin, and brain-will be reviewed, and the clinical relevance will be discussed. An updated wrist rehabilitation protocol is proposed where the therapist is guided to rehabilitate a patient after wrist trauma and/or surgery in 4 stages: (1) basic hand and wrist rehabilitation with a focus on reducing edema, pain, and scar formation; (2) proprioception awareness to improve the sense of joint motion and position; (3) conscious neuromuscular rehabilitation where isometric exercises of muscles that are beneficial for a particular injury are promoted, whereas others that are potentially harmful are avoided; and (4) unconscious neuromuscular rehabilitation with training of the reflex and joint protective senses.

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.

Can a structured home-based rehabilitation program reduce dorsal central wrist pain?

OBJECTIVES

Dorsal central wrist pain, often a consequence of peri-scapholunate ligament injury, can result in a decline in functional performance. There is a scarcity of clinical data evaluating the effectiveness of conservative management on peri-scapholunate ligament injury. Conservative management includes education, immobilization with orthotic devices, scapholunate-stabilizing muscle strengthening, and proprioception training. The identification of the ligamento-muscular reflex and scapholunate-stabilizing muscles formed the rationale for a rehabilitation training program. We have devised an innovative standardized 16-week treatment program for patients with dorsal central wrist pain associated with acute peri-SL ligament injury. We hypothesized that the program can effectively reduce dorsal wrist pain and improve functional performance.

MATERIALS AND METHODS

Recruited subjects underwent the 16-week home-based program, which included immobilization and rehabilitation exercises, to improve their wrist stability. Follow-up was arranged every 4 weeks for progress monitoring. The Short-Form 12 item questionnaire version 2, power grip, pinch grip, wrist range of motion, total performance score and total pain score when performing activities of daily living were used to evaluate the effectiveness of the program. An exercise adherence questionnaire was used to evaluate adherence to the home rehabilitation program.

RESULTS

Twenty-three subjects (26 wrists) completed the program. Pain on visual analog scale improved by 5.1 cm and total pain score improved from 14.4/20 to 19.5/20. Total performance score reached 39/40, which indicated near-normal wrist function. Power grip and pinch grip increased by 22.3% and 17.8%, respectively. The physical component scale of the Short-Form 12 item questionnaire showed significant improvement, while the mental component scale did not. Overall adherence was fair.

DISCUSSION

Conservative management, including immobilization and rehabilitation training, can provide significant clinical improvement in patients with dorsal central wrist pain associated with acute peri-scapholunate ligament injury.

CONCLUSION

Standardized wrist rehabilitation can be taken as a reference treatment modality. It is an evidence-based non-invasive treatment option for clinicians and therapists.

The effect of mirror therapy in the rehabilitation of flexor tendon injuries after primary surgical repair

OBJECTIVE

The aim of this study was to evaluate the effectiveness of mirror therapy and to provide a clinical basis for better functional recovery in the rehabilitation of patients with flexor tendon injury.

MATERIALS AND METHODS

Thirty patients were included and randomly divided between two groups: mirror therapy and conventional treatment. A physical therapy program consisting of whirlpool, ultrasound and transcutaneous electrical nerve stimulation was applied to both groups. In the mirror therapy group, flexor tendon gliding, blocking exercises, joint range of motion and resistance exercises were performed with the healthy hand via a mirror. In the conventional treatment group, the same exercises were performed with the affected hand without mirror. This treatment was continued for 12 sessions over 4 weeks. Joint range of motion, handgrip strength, pain, functionality, dexterity and kinesiophobia were evaluated before and after treatment.

RESULTS

More improvement was observed in the mirror therapy group in terms of pain on visual analog scale, Patient-Rated Wrist Evaluation, Hand Function Index and Disabilities of the Arm, Shoulder and Hand scores (p = 0.025, p = 0.004, p < 0.001 and p < 0.001, respectively). There was no significant difference between groups for the other parameters (Tampa Kinesiophobia Scale, Purdue Pegboard test, total active range movement, or handgrip strength: p > 0.05).

CONCLUSION

This study shows that mirror therapy in postoperative rehabilitation of flexor tendon injuries is more effective than conventional in terms of reducing the severity of pain and restoring hand function.

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 .

Comparison of the validity and reliability of three different methods used for wrist proprioception measurement

BACKGROUND

ː Early detection of loss of proprioception is essential to prevent injury and maintain professional work activities. However, although many different methods are present for wrist proprioception measurement, these methods' validity and reliability studies are quite limited.

OBJECTIVE

To compare the validity and reliability of the goniometer, inclinometer, and joint position sense goniometer methods used in measuring wrist active joint position sense (AJPS).

METHODS

ː Thirty-two volunteer healthy participants (64 wrists) between the ages of 19-31 (mean age:23,34 ± 3,84) were included in the study. Wrist AJPS was assessed with an isokinetic dynamometer as a reference standard in addition to an inclinometer, goniometer, and joint position sense goniometer (JPSG). Spearman's Correlation Coefficient was used for validity analysis, and Intraclass Correlation Coefficient (ICC3,1) was used to analyze test-retest reliability.

RESULTS

ː It was found that the goniometer (p < 0.001, r = 0.529) is a moderately valid method to assess active wrist joint position sense. The JPSG (p < 0.001, r = 0.432) and inclinometer (p = 0.005, r = 0.350) have weak validity. According to the results of ICC3,1 analysis, the goniometer (p < 0.001, ICC3,1 = 0.422) and JPSG (p < 0.001, ICC3,1 = 0.369) were found to have poor reliability in assessing wrist AJPS, and the inclinometer (p = 0,183, ICC3,1 = 0,114) was not found as a reliable method.

CONCLUSIONS

ː Our results suggest that the JPSG and inclinometer should not be used in the wrist active joint position sense evaluation because of weak validity and poor reliability. The goniometer can be used in clinics and academic research to evaluate wrist joint position sense if the rater lacks a reliable and valid measurement tool.

A structured non-operative treatment program for traumatic triangular fibrocartilage complex tear: A quasi-experimental study

OBJECTIVES

Triangular fibrocartilage complex (TFCC) injury is a common cause of ulnar-sided wrist pain. However, treatment protocols vary across clinical settings and a standardized treatment protocol is needed to improve quality of care. We devised a rehabilitation regime which comprised both orthoses and exercises. We hypothesized that the program can effectively reduce pain and improve functional performance.

MATERIALS AND METHODS

Thirty-two subjects participated in the 5-phase rehabilitation program. Progress was monitored every 3 weeks. Outcome measures comprised numeric pain rating scale (NPRS), activities of daily living (ADL) pain score, wrist range of motion (ROM), ADL performance score, patient-rated wrist evaluation (PRWE), power grip and distal radioulnar joint (DRUJ) instability grade.

RESULTS

NPRS decreased from 5.3/10 to 0.5/10 while the ADL pain score improved from 10/20 to 19.1/20. ROM in flexion/extension and supination/pronation improved by 35%. Functional performance on ADL performance score and PRWE improved from 21/40 to 38/40 and 49.5/100 to 14.6/100, respectively. Power grip increased by 59.5%, and DRUJ stability improved.

DISCUSSION

The combination of orthoses and progressive strengthening and proprioception training was effective in re-establishing DRUJ stability, and improving wrist strength and functional performance.

CONCLUSIONS

This study provided insight for the development of a rehabilitation protocol for patients with TFCC injury.

Scapholunate Instability: Diagnosis and Management - Classification and Treatment Considerations - Part 2

Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. Part 1 of this Current Concepts article reviewed the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical stabilizers. In this section, we provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. These updates clarify the importance of the critical stabilizers of the scapholunate interval, ligament-specific considerations in scapholunate ligament reconstruction, and the risks of ligament disinsertion when surgically exposing the dorsal wrist. We propose a ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes.

Immunohistochemical Investigation of Mechanoreceptors Within the Injured Scapholunate Ligament

PURPOSE

Scapholunate ligaments (SLLs) play a well-established role in maintaining carpal alignment and kinematics, and are innervated with sensory mechanoreceptors located within the ligaments. They are involved in the afferent arc of dynamic wrist stability. The aim of this study was to describe the changes in these mechanoreceptor populations in injured SLLs.

METHODS

Injured SLLs were collected from human wrists at the time of SLL reconstruction or limited wrist fusion, where the ligament remnants would otherwise be discarded. These specimens were formalin-fixed and paraffin-embedded for immunohistochemical analysis to identify mechanoreceptors, which were then classified by type and location within the ligament.

RESULTS

A total of 15 ligaments were collected, with the interval from injury ranging from 39 days-20 years. Eleven ligaments were collected less than one year after injury, and four ligaments were collected two years or more after injury. A total of 66 mechanoreceptors were identified, with 50 mechanoreceptors identified in nine of the 11 specimens collected less than one year after injury. In this group, 54% of the mechanoreceptors resided in the volar subunit, 20% in the dorsal subunit, and 26% in the proximal subunit. Two of the four specimens collected two years or later after injury contained mechanoreceptors, all of which were located in the dorsal subunit. Increasing time from injury demonstrated a decline in mechanoreceptor numbers within the volar subunit.

CONCLUSIONS

Mechanoreceptors were consistently located in the SLL, particularly in the volar subunit of specimens collected less than one year after injury.

CLINICAL RELEVANCE

Ligament reconstruction techniques aim to primarily reconstitute the biomechanical function of the disrupted SLL; however, re-establishing the afferent proprioceptive capacity of the SLL may be a secondary objective. This suggests the need to consider the reconstruction of its volar subunit particularly in those managed within one year of injury.

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 .

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.

Arthroscopic Capsulodesis for the Treatment of Dynamic Scapholunate Dissociations

Management of scapholunate dissociations remains a significant challenge. Open approaches suffer from a disadvantageous further impairment of the stabilizing local structures. The minimally invasive arthroscopic technique described provides reliable stability of the scapholunate interosseous ligament complex in dynamic lesions. The anatomic key structure is the dorsal capsuloligamentous scapholunate septum, which provides a mechanical connection between the scaphoid, lunate, and dorsal capsule of the wrist. Arthroscopic capsuloplasty aims to tighten and stabilize this complex structure in long term. This approach preserves the adjacent structures, namely the secondary wrist stabilizers and their neuromuscular feedback loops. With a certain degree of experience in wrist arthroscopy, the technique is reliably adaptable and reproducible.

Muscle responses during radial nerve-biased upper limb neurodynamic test in asymptomatic individuals: a cross-sectional study

This laboratory cross-sectional study aimed at explore the muscle response (MR) of the upper trapezius, infraspinatus, biceps brachii and extensor carpi radialis brevis (ECRB) during the radial nerve-biased upper limb neurodynamic test (RN-ULNT) in healthy participants. Myoelectric activity was stage-by-stage recorded during two sequencing variants of the RN-ULNT: S1, in which elbow extension was the last movement; and S2, in which wrist flexion was the last movement. Final elbow and wrist joint angle and sensory response (SR) in five zones (Z1-Z5) were also registered. MR was qualitatively categorized as 'absent' (No-MR), 'true' (TMR) or 'uneven' (UMR). In both sequences, significant increases in muscle activity occurred mostly during shoulder abduction and elbow extension (p ≤ 0.009). Also, elbow extension but not wrist flexion increased the activity of the ECRB muscle (p ≤ 0.009). S2 showed significantly higher upper trapezius (p = 0.04) and biceps brachii (p = 0.036) muscle activity during wrist flexion, and higher report of SR in Z1 and Z4 (p < 0.001) compared to S1. Only the ECRB muscle showed significant differences in the MR type between S1 and S2 (TMR, p = 0.016; UMR, = 0,012). Our results may be useful in the assessment of upper limb musculoskeletal disorders.

Effects of Presence Rate of the Palmaris Longus Tendon on Wrist Proprioception and Grip Strength

INTRODUCTION

The palmaris longus muscle displays a great variation in terms of incidence and shape. This study has documented the incidence ratio of this muscle among the students at Bolu Abant İzzet Baysal University, Faculty of Medicine, and has revealed the effects of its presence on wrist proprioception and grip strength.

METHODS

A total of 101 students between the ages of 18 and 25 were included in the study. Age, height, weight, body mass index (BMI), and dominant upper extremity of the individuals were recorded. After the presence of palmaris longus tendon (PLT) was determined by using the Schaeffer's test, wrist proprioception was evaluated by using a digital inclinometer, and grip strength was evaluated by using a hand dynamometer.

RESULTS

PLT absence rates were evaluated separately as right and left, and it was found as 16.8% and 17.8%. No correlation was found between the dominant upper extremity and BMI and the presence of PLT. The presence or absence of PLT has no effect on grip strength and wrist proprioception.  Conclusion: PLT is used in many clinical areas, such as reconstructive and cosmetic surgery, graft applications, tendon repairs, ptosis correction operations, and ligament stabilization. We think there will be no significant loss in the sense of proprioception and grip strength in the absence of PLT.

μ-band desynchronization in the contralateral central and central-parietal areas predicts proprioceptive acuity

Introduction

Position sense, which belongs to the sensory stream called proprioception, is pivotal for proper movement execution. Its comprehensive understanding is needed to fill existing knowledge gaps in human physiology, motor control, neurorehabilitation, and prosthetics. Although numerous studies have focused on different aspects of proprioception in humans, what has not been fully investigated so far are the neural correlates of proprioceptive acuity at the joints.

Methods

Here, we implemented a robot-based position sense test to elucidate the correlation between patterns of neural activity and the degree of accuracy and precision exhibited by the subjects. Eighteen healthy participants performed the test, and their electroencephalographic (EEG) activity was analyzed in its μ band (8–12 Hz), as the frequency band related to voluntary movement and somatosensory stimulation.

Results

We observed a significant positive correlation between the matching error, representing proprioceptive acuity, and the strength of the activation in contralateral hand motor and sensorimotor areas (left central and central-parietal areas). In absence of visual feedback, these same regions of interest (ROIs) presented a higher activation level compared to the association and visual areas. Remarkably, central and central-parietal activation was still observed when visual feedback was added, although a consistent activation in association and visual areas came up.

Conclusion

Summing up, this study supports the existence of a specific link between the magnitude of activation of motor and sensorimotor areas related to upper limb proprioceptive processing and the proprioceptive acuity at the joints.

Effects of an exercise program plus manual therapy in a patient with failed neck surgery syndrome: A case report

BACKGROUND

Patients who have undergone cervical surgery may present pain and dysfunction in the upper limb, which is often referred to as failed neck surgery syndrome. Little is known about the effects of an exercise program plus manual therapy in the treatment of prolonged neuropathic pain of the upper quadrant in a patient with failed neck surgery.

CASE DESCRIPTION

A 66-year-old woman consulted for neuropathic pain and dysfunction during grasping activities, as a result of failed neck surgery after 12 months. Clinical, functional, and electromyographic measurements were recorded at baseline and after treatment. The patient underwent a treatment for six weeks based on manual therapy for the upper limb and cervical spine and an exercise program for the scapular muscles, rotator cuff and wrist extensor muscles.

OUTCOMES

Positive clinically significant changes were observed in the Neuropathic Pain Questionnaire (DN4) (baseline = 7 points; post-treatment = 4 points), Neck Disability Index (NDI) (baseline = 36; post-treatment = 18 points), QuickDASH (baseline = 78; post- treatment = 32 points), Upper Limb Neurodynamic Test 1 (ULNT-1) (baseline = 75°; post- treatment = 42°) and grip strength (GS) (baseline = 23 kgf; post-treatment = to 32 kgf). Improvements in the surface electromyographic (sEMG) activity of the upper trapezius (UT), infraspinatus (IS) and radial wrist extensors (RWE) muscles also seemed to occur after treatment.

CONCLUSION

Treatment helped relieve neuropathic pain, decrease neck disability, and improve general upper limb function.

Development of a 3D-immunofluorescence analysis for sensory nerve endings in human ligaments

BACKGROUND

The analysis of ligamentous mechanoreceptors is difficult due to a high amount of unclassifiable mechanoreceptors, which result from incomplete visualization through limited microscopic techniques.

NEW METHOD

The method was developed using dorsal intercarpal ligaments and dorsal regions of the scapholunate interosseous ligament from human cadaver wrists. Consecutive 70 µm thick cryosections were stained with immunofluorescence markers for protein S100B, neurotrophin receptor p75 (p75), protein gene product 9.5 (PGP 9.5) and 4',6-diamidino-2-phenylindole (DAPI). 3D images of sensory nerve endings were obtained using a confocal laser scanning microscope. Experimental point spread functions (PSF) were used to deconvolve images. Sensory nerve endings were localised in each section plane and classified according to Freeman and Wyke. Finally, confocal data was visualized as 3D-images.

RESULTS

The method produced excellent image quality, revealing detailed three-dimensional structures. The created 3D-model of sensory nerve endings could be analyzed in all three dimensions, augmenting visualization of the form and immunoreactive pattern of sensory nerve endings. Deconvolution with experimentally measured PSFs aided in enhancing image quality.

COMPARISON WITH EXISTING METHODS

Using a triple immunofluorescent staining method allows to visualize the structure of sensory nerve endings more precisely than techniques with serial analysis of different monostaining of neural markers. Imaging in three dimensions enhances morphologic details, which are limited in 2D-microscopy.

CONCLUSION

3D-triple immunofluorescence produces high quality visualization of mechanoreceptors, thereby improving their analysis. As an elaborate technique, it is ideal for defined research questions concerning the microstructure of sensory nerve endings.

Tratamiento de lesiones escafolunares mediante reconstrucción con plastia del extensor radial largo del carpo

Objetivo Describir la técnica quirúrgica de reconstrucción del ligamento escafolunar asistida por artroscopia empleando como donante el extensor carpi radialis longus (ECRL), un músculo que, gracias a sus propiedades biomecánicas, puede ser muy ventajoso en este tipo de cirugía.

Técnica Quirúrgica Tras artroscopia diagnóstica inicial según la técnica habitual, se llevó a cabo la reconstrucción ligamentosa empleando un hemitendón del ECRL mediante técnica mínimamente invasiva. Los dispositivos de fijación empleados fueron el SwiveLock para el escafoides y el tornillo de biotenodesis de 3 × 8 mm (Arthrex, Naples, FL, EE.UU.) para el semilunar.

Complicaciones La complicación que puede surgir durante la realización de esta técnica es la extracción dificultosa de la plastia, por la intersección entre el primer y el segundo compartimentos extensores. Es fácilmente solventable realizando una incisión intermedia a nivel de la intersección para garantizar la adecuada liberación de la plastia a esta altura.

Conclusión Es posible reconstruir el intervalo escafolunar empleando un hemitendón del ECRL, que, por propiedades biomecánicas, puede ser más ventajoso a la hora de restaurar la biomecánica del carpo. Se precisan estudios posteriores para confirmar la idoneidad y la superioridad de este donante frente a otros empleados en las técnicas de reconstrucción.

EFECTO DEL EJERCICIO PROPIOCEPTIVO SOBRE EL EQUILIBRIO EN PATINADORES DE CARRERA JUVENILES

El objetivo del presente estudio fue determinar el efecto de un programa de ejercicio propioceptivo sobre el equilibrio en patinadores de carrera juveniles. Se realizó un estudio de alcance cuasiexperimental. Se aleatorizaron tres clubes de patinaje, dos al grupo control y otro al experimental. Participaron 49 jóvenes de ambos sexos entre 11 y 15 años. Al grupo experimental se le aplicó un programa de ejercicio propioceptivo, mientras el grupo control recibió un programa de entrenamiento convencional. Se realizó una evaluación estabilométrica, se midieron los límites de estabilidad, la amplitud y frecuencia de oscilaciones y el equilibrio estático. Ambos grupos mejoraron la frecuencia de balanceo en ambas direcciones, con ojos abiertos y ojos cerrados (p<0,050). Ninguno de los límites de estabilidad y amplitud de balanceo, así como el equilibrio estático evidenciaron cambios significativos (p>0,050). No se encontraron diferencias significativas en las medidas de cambio entre grupos en ninguna de las variables estudiadas (p>0,050).

Targeted sensorimotor retraining in the clinical setting: Improving patient outcomes following distal upper extremity injury

BACKGROUND

Existing theoretical evidence indicates sensorimotor retraining is beneficial following wrist injury. However, there are no large cohort studies applying the knowledge in a clinical setting.

PURPOSE OF THE STUDY

To Determine the clinical benefits of sensorimotor rehabilitation following distal upper extremity injury.

STUDY DESIGN

Prospective cohort study.

METHODS

A sensorimotor rehabilitation program was evaluated following distal upper extremity injury. A battery of clinical and patient-rated outcome measures (PROM) were taken before and after group completion.

RESULTS

Ninety-three patients, 49 males (53%) and 44 females (47%), completed the program. There were statistically significant improvements in 12 clinical measures. However, improvements in 11 of the clinical measures only had a small effect size (<0.5). Joint position sense had the greatest clinical change with a median improvement of 4° on the left and 3.9° on the right, and these had moderate effect sizes of 0.5 and 0.7, respectively. There were statistically significant improvements in all PROMs. PRWE had a median improvement of 21 (ES = 1.2). UEFI showed median improvements of 19.7 (ES = 1.4) and NRS (pain) median improved 2.5 (ES = 1.2). All PROM improvements had mean change greater than associated MCIDs.

DISCUSSION

These results indicate the benefits of sensorimotor group rehabilitation and supports existing literature regarding the importance of sensorimotor control for JPS accuracy and function. Group based sensorimotor programs present an efficient and low-cost opportunity to provide intervention to patients following upper extremity injury.

CONCLUSION

A sensorimotor group rehabilitation program may improve patient outcomes following distal upper extremity injury.

LEVEL OF EVIDENCE

Level 2b prospective cohort.

Hand functions and joint position sense in patients with psoriatic arthritis- a comparison with rheumatoid arthritis and healthy controls

BACKGROUND

Psoriatic arthritis is an inflammatory arthropathy accompanied by peripheral and axial joint involvement. Hand involvement has been demonstrated by various imaging methods in patients with psoriatic arthritis. However, few studies evaluated the hand in terms of functionality. The aim of the study is to compare hand functions and wrist joint position sense in psoriatic arthritis with rheumatoid arthritis and healthy controls.

METHODS

Patients with psoriatic arthritis (n = 21), rheumatoid arthritis (n = 21), and healthy controls (n = 21) were included in this cross-sectional study. The measurements were performed by a hand dynamometer for grip strength and endurance, and by a pinchmeter for pinch strength. Disability of Arm, Shoulder, and Hand Questionnaire was used to evaluate the functional disability. A goniometric test was used to assess wrist joint position sense.

FINDING

Patients with psoriatic arthritis had worse hand functional outcomes and higher position errors than healthy controls (p < 0.05). In addition, in terms of all variables, patients with psoriatic arthritis were found to be similar to the patients with rheumatoid arthritis (p > 0.05).

INTERPRETATION

Our study revealed that hand functions and wrist joint position sense were affected as much in patients with psoriatic arthritis as in patients with rheumatoid arthritis whose hand involvement is frequently reported in the literature. The grip endurance in psoriatic arthritis was assessed for the first time. Our results highlighted the necessity of treatment programs that include strength, endurance, and proprioception in patients with psoriatic arthritis who have hand involvement at least as much as those with rheumatoid arthritis.

Ulnar Wrist Pain in a Tennis Player: Case Review and Discussion: A Team-Based Approach

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Ulnar-sided wrist pain is a common cause of debilitating wrist pain in stick-handling athletes. Due to the complexity of surrounding anatomy, the evaluation and diagnosis can be challenging.

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Injury of the triangular fibrocartilage complex (TFCC) is the most common cause of ulnar-sided wrist pain. Repetitive, unrestricted pronosupination, wrist deviation, and axial-loading activity, such as in tennis, place substantial stress on the TFCC.

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The ulnotriquetral (UT) ligament is a palmar thickening of the ulnar capsule arising from the palmar radioulnar (PRU) ligament of the TFCC. When injured, the UT ligament can be a source of acute or chronic ulnar-sided wrist pain. The ligament can avulse off bone, can rupture completely, or can split longitudinally.

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Arthroscopic-assisted repair is a safe, reliable, and effective treatment for UT ligament split tears and peripheral TFCC tears.

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Although the benefit of a team-based approach may be realized by most patients, high-performing, stick-handling athletes are part of a unique population who execute repetitive, extraordinary wrist movements. The high demand and functional requirement expected of the wrists require a uniquely tailored approach to return them to the same level of competitive play.

Post-arthrolysis rehabilitation in a patient with wrist stiffness secondary to distal radio-ulnar fracture: A case report

BACKGROUND

Arthrolysis is usually performed when stiffness has a disabling effect on quality of life and in cases where physiotherapy has not been effective. This report describes one patient with a chronic stiff wrist who underwent open arthrolysis. The purpose of this case report is to describe the rehabilitation following arthrolysis, in order to illustrate the effects of intensive physiotherapy for this patient.

CASE DESCRIPTION

A 54-year-old woman with chronic wrist stiffness secondary to a radio-ulnar fracture was described. The patient presented severe pain and unsatisfactory wrist range of motion and muscle strength almost 2 years after the traumatic event.

INTERVENTION

Post-arthrolysis rehabilitation was based on edema control, manual therapy, transcutaneous electrical nerve stimulation (TENS), static splinting and strengthening exercises. In addition, graded motor imagery and proprioceptive rehabilitation were included to address impaired motor control. Outcome measures of passive range of motion (PROM), active range of motion (AROM), grip and pinch strength, numeric rating scale (NRS), disability of the arm, shoulder and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) were recorded.

CONCLUSIONS

The outcomes of this case report suggest that arthrolysis combined with immediate and intensive physiotherapy were a suitable option for the treatment of post-traumatic wrist stiffness in this patient. The passive motion measured intraoperatively was maintained, while pain, functional active motion and strength were improved allowing for social reintegration.

Wrist and forearm range of motion commencement time following primary triangular fibrocartilage complex foveal repair surgery: A scoping review

STUDY DESIGN

Scoping review.

BACKGROUND

Rehabilitation guidelines following triangular fibrocartilage complex (TFCC) foveal repair surgery have been inconsistently reported in the published literature, with no consensus regarding wrist or forearm range of motion (ROM) commencement time.

PURPOSE OF THE STUDY

To scope the available literature to identify the extent and strength of the evidence supporting the clinical guidelines for wrist and forearm ROM commencement time following primary TFCC foveal repair surgery.

METHODS

A systematic search produced 26 studies (3 retrospective cohort studies, 1 prospective cohort study, 1 retrospective comparative study, and 21 retrospective case series) that described specific rehabilitation protocols following TFCC foveal repair surgery.

RESULTS

No supporting evidence was identified regarding rehabilitation protocol recommendations across all the included studies. Postsurgery wrist ROM commencement ranged from 2 to 8 weeks; forearm ROM commencement ranged from 2 to 12 weeks. ROM commencement times did not appear to systematically influence the rate of adverse events, although adverse events were poorly reported.

CONCLUSIONS

TFCC rehabilitation protocols were poorly reported and varied widely between the included studies. Additional research is recommended to comprehensively evaluate the association between wrist and/or forearm ROM and the rate of adverse events for this complex and multifaceted condition.

A long-term effect of distal radius fracture on the sensorimotor control of the wrist joint in older adults

INTRODUCTION

Sensorimotor control can be disturbed because of pain and trauma. There is scarce comprehension about which component of the sensorimotor system would benefit the most from treatment in distal radius fracture (DRF).

PURPOSE OF THE STUDY

The purpose of this study was to determine whether the sensorimotor control of subjects with a history of DRF impaired compared with healthy subjects. If so, which component of the sensorimotor system is most affected.

METHODS

Nine healthy participants and 11 participants with a DRF history executed posture and reproduction tasks in interaction with a robotic wrist manipulator. A posture task with force perturbations assess sensorimotor control. Position and force reproduction tasks assessed sensory feedback. Electromyography recorded the muscle activity to study the motor part of the sensorimotor system.

STUDY DESIGN

Cross-sectional case-control.

RESULTS

The results showed that the motor responses to the perturbations during the posture task did not differ significantly, whereas the position reproduction did significantly differ between the 2 groups. Moreover, participants with a DRF history did not adapt to the changed dynamics of the environment during the posture task, whereas the controls did.

DISCUSSION

The results of this study imply that processing of sensory position feedback is impaired in people with a DRF history while sensorimotor control during a posture task is unaffected. A possible explanation for these results is that different neural networks are involved during reproduction and posture tasks.

CONCLUSIONS

A history of DRF is related to disturbed processing of sensory feedback of the sensorimotor system, especially the Joint Position Sense, which leads to an impairment in detecting a changed environment and adapting to it. Impaired Joint Position Sense and thereby the inability to adapt adequately to a changing environment should be taken into account during the rehabilitation of patients with DRF.

Clinical evaluation of a wrist sensorimotor rehabilitation program for triangular fibrocartilage complex injuries

Introduction

Triangular fibrocartilage complex (TFCC) injuries are associated with distal radioulnar joint (DRUJ) instability and impaired wrist proprioception. Sensorimotor training of extensor carpi ulnaris (ECU) and pronator quadratus (PQ) can enhance DRUJ stability. With limited evidence on effectiveness of TFCC sensorimotor rehabilitation, this study aimed to evaluate the effects and feasibility of a novel wrist sensorimotor rehabilitation program (WSRP) for TFCC injuries.

Methods

Patients diagnosed with TFCC injuries were recruited from May 2018 to January 2020 at an outpatient hand clinic in Singapore General Hospital. There are four stages in WSRP: (1) pain control, (2) muscle re-education and joint awareness, (3) neuromuscular rehabilitation, and (4) movement normalization and function. WSRP also incorporated dart throwing motion and proprioceptive neuromuscular facilitation. Outcome measures included grip strength measured with grip dynamometer, numerical pain rating scale, joint position sense (JPS) measurement, weight bearing measured with the 'push-off' test, and wrist function reported on the Patient Rated Wrist Hand Evaluation.

Results

Ten patients completed the WSRP. Mean changes were compared with minimal clinically important differences (MCID) for outcomes. All patients achieved MCID on pain, 70% of patients achieved MCID on grip strength, weight bearing and wrist function. Paired t-tests and Cohen's D for outcome measures were calculated. There were large effect sizes of 2.47, 1.35, and 2.81 for function, grip strength and pain respectively, and moderate effect sizes of 0.72 and 0.39 for axial loading and JPS respectively.

Discussion

WSRP presents a potential treatment approach in TFCC rehabilitation. There is a need for future prospective clinical trials with control groups.

Alterations in forearm muscle activation patterns after scapholunate interosseous ligament injury: A dynamic electromyography study

STUDY DESIGN

Case control.

PURPOSE OF THE STUDY

This study aimed to investigate the alterations seen in the activation patterns of the forearm muscles and to demonstrate the associated functional outcomes, in patients with scapholunate interosseous ligament (SLIL) injury.

METHODS

The study involved 15 patients with SLIL injury (instability group) and 11 healthy participants (control group). Both groups were evaluated with regard to their pain, grip strength, and upper extremity functional level (disabilities of the arm, shoulder and hand and patient-rated wrist evaluation questionnaires), and they also underwent a dynamic electromyography analysis of their forearm muscle activity. The activation patterns of the extensor carpi ulnaris (ECU), extensor carpi radialis (ECR), flexor carpi ulnaris, and flexor carpi radialis muscles during wrist extension and flexion were recorded by means of surface electromyography.

RESULTS

In the instability group, the pain severity was higher and the functional level was worse than in the control group (P < .05). Furthermore, during wrist extension, the ECR activity was lower and the ECU activity was higher in the instability group than in the control group (P < .05).

CONCLUSION

Dynamic stabilization of the wrist, flexor carpi ulnaris, and flexor carpi radialis muscles have been shown to play an active role with ECU and ECR. Increased ECU and decreased ECR activation may pose a potential risk in terms of enhancing the scapholunate gap. We, therefore, propose that appropriate preventive neuromuscular exercise strategies implemented as part of a physiotherapy program for patients with SLIL lesions might increase the contribution of the dynamic stability effect of the relevant muscles.

Intrarater reliability test of the ISOmetric power device-A new instrument for assessment of isometric force in six directions of wrist motion

STUDY DESIGN

Descriptive reliability study.

INTRODUCTION

A well-functioning wrist requires sufficient range of motion accompanied by adequate strength in every movement and direction-factors that are not regularly measured simultaneously in patients with wrist problems today. The ISOmetric Power device (ISOP) is a new instrument that measures isometric wrist force in all six directions of motion, but its intrarater reliability in a healthy population has not yet been evaluated.

PURPOSE OF THE STUDY

The purpose of this study was to perform an intrarater reliability test of the ISOP in healthy participants.

METHODS

Thirty-two healthy study participants (16 women/16 men; mean age 38.3 years; SD 6.5) were included. With a standardized testing protocol, the three planes of wrist motion- wrist flexion/extension, radial/ulnar deviation, pro/supination-were measured at one time interval (T1) and repeated after one week (T2). The results were analyzed using the intraclass correlation coefficient (ICC). A paired-samples t-test was also performed to determine if a statistically significant difference (P < .05) existed between the first and the second test values. Measurements with Jamar Dynamometer were performed at both time intervals, for internal control of measurement intrarater reliability.

RESULTS

Excellent correlations (ICC: 0.90-0.99) were found for all test-retests performed. The lowest value (ICC: 0.90) was seen for supination and the highest value (ICC: 0.99) for flexion of the left hand. No statistically significant differences were found in any of the pairs (P > .05) in terms of test-re-test, which additionally strengthen the correlation between the first and second test values.

DISCUSSION

Contrary to the Jamar Dynamometer, the ISOP is not designed for measuring grip strength, but for assessing the isometric muscle force in flexion, extension, pronation, supination, and radial and ulnar deviation. A systematic review has reported a moderate to strong correlation between isometric strength and dynamic performances. Thus, the ISOP is a more complete and applicable instrument for evaluating the functional strength in different directions in the upper extremity.

CONCLUSIONS

The ISOmetric Power device shows excellent intrarater reliability and is proposed to be a possible valuable wrist strength assessment tool to aid in both diagnostics and outcome measures of wrist and upper extremity disorders.

Joint position sense, motor imagery and tactile acuity in lateral elbow tendinopathy: A cross-sectional study

BACKGROUND

Impairments of sensorimotor function are evident in individuals with lateral elbow tendinopathy (LET), although understanding of the mechanisms for this is lacking.

OBJECTIVES

To determine if motor imagery, tactile acuity and wrist joint position sense (JPS) are impaired in participants with unilateral LET compared to controls, whether deficits are localised to the affected side, and whether deficits relate to severity of pain.

DESIGN

Cross-sectional study with control group.

METHODS

14 participants with unilateral LET of 6 weeks or longer and 14 matched control participants were assessed bilaterally for motor imagery (left/right hand judgement task), tactile acuity (two-point discrimination test) and wrist JPS (reposition test for flexion and extension). Pain levels were measured using a numeric rating scale.

RESULTS

Significant differences in JPS were observed for wrist extension only, such that participants with LET adopted less extended postures with their affected side when compared to their unaffected side (MD = 2.97°; p = 0.01) and to the matched-affected side of controls (MD = 4.89°; p < 0.01). No differences in tactile acuity or motor imagery were observed.

CONCLUSION

Altered wrist extension JPS, but not motor imagery or tactile acuity, was found in the affected side of patients with unilateral LET when compared to non-injured side and asymptomatic controls.

The effect of muscle fatigue on wrist joint position sense in healthy adults

STUDY DESIGN

Pretest and posttest experimental study.

INTRODUCTION

The effect of muscle fatigue on wrist joint position sense (JPS) has yet to be determined.

PURPOSE OF THE STUDY

The primary aim was to determine whether muscle fatigue affects wrist JPS in healthy adults. The secondary aims were to compare the effect of muscle fatigue on younger and older adults JPS and determine the association between JPS rate of change and total muscle fatigue (TMF) rates postexercise.

METHODS

Forty male and female healthy adults were assigned into younger (18-40 years) and older (41-65 years) groups. Preexercise and postexercise testing consisted of active wrist JPS, handgrip, and wrist extensor strength assessments. Muscle fatigue was induced via a calibrated gripper and wrist extension dumbbell exercises. Dependent variables were the JPS rate of change (ie, preexercise and postexercise), TMF rate (ie, grip and wrist extension average strength decline), and Borg Rating of Perceived Exertion scale scores.

RESULTS

Postexercise wrist JPS test scores were significantly higher than preexercise. Exercises induced statistically significant TMF rates and Borg Rating of Perceived Exertion scores among all participants. No statistically significant age-group differences on JPS rate of change, and TMF rate was found. A statistically significant mild correlation (r = 0.425) existed between JPS rate of change and TMF rates.

DISCUSSION

Postexercise fatigue significantly impairs wrist JPS in both younger and older adults. On average, an 18% muscle strength decline led to 215% wrist JPS deficit.

CONCLUSIONS

Significant wrist proprioception deficits persist for ≤5 min following exertional exercises, regardless of age level.

Joint position sense impairments in older adults with carpometacarpal osteoarthritis: A descriptive comparative study

STUDY DESIGN

This study has a descriptive-comparative, cross-sectional design.

INTRODUCTION

Sensorimotor (SM) impairments have been observed after common wrist and hand injuries such as distal radius fractures. However, there is a lack of research regarding SM impairments in patients with carpometacarpal (CMC) osteoarthritis (OA).

PURPOSE OF THE STUDY

This study sought to quantify proprioception deficits in older adults with CMC OA as compared with healthy adults using the joint position sense (JPS) test.

METHODS

The active JPS test was used to measure proprioception function in 29 thumbs with CMC OA and their 29 matched-control healthy counterparts. For comparison, participants with unilateral CMC OA were matched against themselves, whereas those with lateral CMC OA were age matched with a healthy participant. Data analysis was performed to compute the mean error of JPS; an unpaired t test was used to compare the mean error of the non-CMC OA group with the healthy control group.

RESULTS

The mean positional error measured from subjects with CMC OA was 9.53° compared with 1.32° for the age-matched healthy subjects. The effect size for the difference in means was D = 1.96.

CONCLUSIONS

Thumb SM impairments were found to be greater in subjects with CMC OA than in their healthy counterparts when using the JPS test to assess proprioception.

SMoC-Wrist: a sensorimotor control-based exercise program for patients with chronic wrist pain

STUDY DESIGN

This is a narrative review.

INTRODUCTION

Chronic wrist pain is a common disorder that can lead to considerable disability in performing activities in daily living and at work. Patients with nonspecific chronic wrist pain are regularly referred to a physiotherapist/hand therapist. Immobilization, avoiding excessive wrist load, steroid injections, and various physical therapy methods predominantly focus on the pain itself. However, these methods often do not result in a satisfactory long-term pain relief.

PURPOSE OF THE STUDY

In this article, we will describe the principles behind and content of a sensorimotor control-based exercise program as introduced by Videler et al., modified and substantiated by current insights into sensorimotor control training and wrist kinetics.

METHODS

Both structure and content of the modified exercise program (SMoC-wrist) are substantiated by recent scientific literature.

RESULTS

A clear 4-level exercise model based on sensorimotor principles is presented, that is, proprioceptive level, conscious static/isometric level, conscious dynamic level, and unconscious dynamic level. The content of each level and the transition toward the next level are described in detail.

DISCUSSION

Besides the substantiation of the exercise program, possible outcome measures for joint position sense and kinesthesia of the wrist are discussed.

CONCLUSION

We modified and substantiated a widely used exercise program for patients with nonspecific chronic wrist pain based on recent insights into sensorimotor control principles and wrist kinematics. The presented exercise program (SMoC-wrist) is not primarily focused on reducing pain but on functional reeducation and strengthening of the neuromusculoskeletal system on the basis of sensorimotor control principles.

A New "Denervation" Technique for Painful Arthritic Wrist

Wrist denervation is, by the way, one of the most performed and long-lasting surgical technique for wrist arthritis. Despite many progresses in upper extremity joint arthroplasty, wrist arthritis remains difficult to treat specially in young patients and heavy manual workers. The aim of this technical article is to describe a new outpatient's procedure in which applying pulsed radio frequency on nerve structure of the wrist could achieve similar clinical results of a wrist denervation without surgical incision.

Use of mobile applications in hand therapy

INTRODUCTION

Mobile devices can be incorporated into therapy as an engaging alternative to traditional therapy options. The use of mobile devices and smartphone applications can enhance the quality of care provided by health care professionals.

PURPOSE

To find mobile apps that can be incorporated into hand therapy practice.

METHODS

Hand therapy evaluation, interventions, proprioception, laterality, and home exercise program applications can be incorporated into practice. Patient education can also be provided via the use of mobile applications.

CONCLUSION

Smartphone applications can be a valuable intervention and impact performance in individuals with impaired hand function. Smartphone applications offer a client-centered, and potentially motivating, activity option that can be utilized to aid the hand therapist.

Clinical evaluation of thumb base osteoarthritis: A scoping review

Introduction

Thumb base osteoarthritis (OA) is a prevalent hand OA phenotype, associated with specific risk factors, treatment strategies, and requiring a distinct subset of evaluative approaches. This paper aimed at surveying our clinical evaluative methods and identifying gaps in our ability to capture the thumb's unique attributes and how they could impact our treatment recommendations.

Methods

A scoping review was conducted in accordance with the Joanna Briggs Institute methodology to gather relevant published and non-published articles regarding clinical tests currently available to assess the physical presentation of thumb base OA with special consideration of its specific multifactorial parameters namely architecture, ligaments, biomechanics, neuromuscular control, and proprioception. A full search strategy of MEDLINE, CINAHL, EMBASE, Scopus, Google Scholar, and Clinical Trials.gov from their inception through May 2020 was performed.

Results

Of 1936 citation identified, 54 met the inclusion criteria. Fifty-two clinical physical tests for the evaluation of thumb base OA were extracted, most of which well suited to address research questions regarding efficacy of clinical intervention, however providing limited information regarding the underlying impairments of ligaments, biomechanics, neuromuscular or proprioceptive components.

Conclusions

The tests and measures specific to the basal thumb OA phenotype, and capable of isolating its multifactorial contributors are scarce. Our limited physical assessment repertoire impedes our ability to describe and answer explicative research questions. Without these we cannot evaluate the effect of conservative management and provide specific treatment recommendations. Further research is needed to develop and validate distinct clinical tools for this debilitating pathology.

Long-Term Results of Arthroscopic Capsular Shrinkage for Palmar Midcarpal Instability of the Wrist

Background  Midcarpal instability is a term for a collection of poorly understood conditions where the proximal row of the carpus is unstable. The most common type of midcarpal instability is palmar midcarpal instability (PMCI). Treatment for PMCI includes nonoperative proprioceptive retraining of the wrist, splints, and strengthening. If this fails, various authors have suggested several different fusions, tenodesis procedures, or capsular shrinkage. There are no long-term case series in the literature. Objective  The aim of this study is to assess the long-term results of arthroscopic capsular shrinkage when used for PMCI of the wrist. Methods  A prospective cohort study of patients who underwent arthroscopic capsular shrinkage for PMCI was performed. Ethical board approval was given for this study. All patients were followed up and reviewed independently from the operating surgeon. Assessment included a structured questionnaire, disabilities of the arm, shoulder and hand (DASH) questionnaire, and clinical examination using a goniometer. PMCI was assessed objectively with the anterior drawer test and radiological imaging was only performed if clinically relevant to the residual symptoms. Results  Thirteen patients (15 wrists) underwent arthroscopic capsular shrinkage for PMCI. Twelve patients (14 wrists) were available for clinical review with a follow-up rate of 92.3%. The mean time from index procedure to final review was 12 years (range: 10-14years). The symptoms of instability had completely resolved in nine wrists (7 patients). Only 2 of the 14 wrists had symptoms that were reproduced with a positive anterior drawer test. All other wrists were stable on objective assessment. The mean DASH score had improved from pre op of 34 to post op of 12.1 and at 12-year follow-up this had deteriorated minimally to 15.3. Assessment of the range of motion showed an average increase in range of flexion/extension by 22 degrees. Patient satisfaction was excellent. The patients rated that nine wrists were much better than presurgery, three as better, one unchanged, and one worse. Discussion/Conclusion  There are no studies looking at the long-term natural history of treatments for PMCI. The lead author proposes a grading system for symptomatic PMCI that has been retrospectively applied to this cohort. It is a grading system from 1 to 4 and is based on a treatment algorithm. This is the first long-term study from any joint, where the results of capsular shrinkage have been maintained over time. In this series, we have not seen any deleterious effect from possible mechanoreceptor injury. We suspect that functioning mechanoreceptors are more relevant in the unstable joint, than the structurally stable joint. The authors propose that thermal capsular shrinkage is an effective and durable option for use in mild-to-moderate forms of PMCI.

A Systematic Review of EMG Applications for the Characterization of Forearm and Hand Muscle Activity during Activities of Daily Living: Results, Challenges, and Open Issues

The role of the hand is crucial for the performance of activities of daily living, thereby ensuring a full and autonomous life. Its motion is controlled by a complex musculoskeletal system of approximately 38 muscles. Therefore, measuring and interpreting the muscle activation signals that drive hand motion is of great importance in many scientific domains, such as neuroscience, rehabilitation, physiotherapy, robotics, prosthetics, and biomechanics. Electromyography (EMG) can be used to carry out the neuromuscular characterization, but it is cumbersome because of the complexity of the musculoskeletal system of the forearm and hand. This paper reviews the main studies in which EMG has been applied to characterize the muscle activity of the forearm and hand during activities of daily living, with special attention to muscle synergies, which are thought to be used by the nervous system to simplify the control of the numerous muscles by actuating them in task-relevant subgroups. The state of the art of the current results are presented, which may help to guide and foster progress in many scientific domains. Furthermore, the most important challenges and open issues are identified in order to achieve a better understanding of human hand behavior, improve rehabilitation protocols, more intuitive control of prostheses, and more realistic biomechanical models.

Demystifying Palmar Midcarpal Instability

Palmar midcarpal instability is an uncommon condition diagnosed clinically with a painful pathognomonic clunk on terminal ulnar deviation of the wrist. Various causes have been described, but congenital laxity of the carpal ligaments is thought to be a key contributor. Treatment commences with conservative measures. This includes proprioceptive training based on more recent concepts on the sensorimotor function of the wrist. When these measures plateau, surgery is considered. The lack of high-level evidence and consensus on its cause continue to hamper our understanding and knowledge of this condition. The purpose of this review is to examine the current evidence to conceptualize this mysterious, yet infrequent phenomenon, and to provide an algorithm on its management.

Modified Viegas dorsal capsuloplasty for chronic partial injury of the scapholunate ligament in young athletes: outcomes at 24 months

The treatment of chronic scapholunate ligament tears in patients with high demand, such as young athletes, is difficult as traditional techniques are associated with some loss of wrist motion and grip strength. This retrospective investigation studied young athletes (≤20 years old) with chronic scapholunate ligament lesions and a minimum follow-up of 24 months, treated with a modified Viegas dorsal capsuloplasty. Twenty-six young athletes (mean age 17 years) were included. A partial scapholunate ligament tear (Geissler III) was seen in 25 patients. At the last follow-up, a significantly different improvement was seen in all measured parameters and all patients could return to their original competitive activity, within 6 months (range 4-12) after surgery.Level of evidence: IV.

Intelligent Rehabilitation Assistance Tools for Distal Radius Fracture: A Systematic Review Based on Literatures and Mobile Application Stores

Objective

To systematically analyze the existing intelligent rehabilitation mobile applications (APPs) related to distal radius fracture (DRF) and evaluate their features and characteristics, so as to help doctors and patients to make evidence-based choice for appropriate intelligent-assisted rehabilitation.

Methods

Literatures which in regard to the intelligent rehabilitation tools of DRF were systematic retrieved from the PubMed, the Cochrane library, Wan Fang, and VIP Data. The effective APPs were systematically screened out through the APP markets of iOS and Android mobile platform, and the functional characteristics of different APPs were evaluated and analyzed.

Results

A total of 8 literatures and 31 APPs were included, which were divided into four categories: intelligent intervention, angle measurement, intelligent monitoring, and auxiliary rehabilitation games. These APPs provide support for the patients' home rehabilitation guidance and training and make up for the high cost and space limitations of traditional rehabilitation methods. The intelligent intervention category has the largest download ratio in the APP market. Angle measurement tools help DRF patients to measure the joint angle autonomously to judge the degree of rehabilitation, which is the most concentrated type of literature research. Some of the APPs and tools have obtained good clinical verification. However, due to the restrictions of cost, geographic authority, and applicable population, a large number of APPs still lack effective evidence to support popularization.

Conclusion

Patients with DRF could draw support from different kinds of APPs in order to fulfill personal need and promote self-management. Intelligent rehabilitation APPs play a positive role in the rehabilitation of patients, but the acceptance of the utilization for intelligent rehabilitation APPs is relatively low, which might need follow-up research to address the conundrum.

Robotic Assessments of Proprioception and the Impact of Age

We examined different methods of robotic proprioception assessment and provided comparison with the wrist position sense test gold standard assessment. The aim is to determine which of the assessments are the most reliable and would be acceptable for clinical evaluation. 31 children between six and sixteen participated in a pilot assessment trial and completed all four of the assessments. The assessments included the manual and robotic versions of the wrist position sense test, the joint position matching assessment and the psychometric threshold determination assessment. There was not a significant difference between the manual and robotic wrist position sense tests but there were significant differences with the other assessments. The study also examined the effect of age on the different assessments and found that three of the assessments, excluding the joint position matching assessment, can differentiate between children of different ages. This study concludes that the significant differences between the assessments indicates that proprioception in the wrist is complex and multifaceted. Further studies will likely need to include multiple assessments to gain a more complete understanding of proprioception.

Arthroscopic treatment for nonunion of the scaphoid

Scaphoid nonunion has traditionally been treated by open surgery where the pseudarthrosis has been cleaned while either a structural wedged bone graft, or chips of cancellous bone has been used to fill the defect. K-wires or a screw has been used to stabilize the bone. Using the arthroscopic technique for treatment of nonunion of the scaphoid gives us small exposure to the joint, however with an excellent view of the bones, the articular surfaces and the intraarticular ligaments. The results from arthroscopic treatment for scaphoid nonunion with bone grafting using chips of cancellous bone are as good as from the open technique. The arthroscopic treatment, though, helps us to diagnose and treat concomitant lesions. There is less damage of blood supply, nerves and capsule, which might lead to a faster recovery and rehabilitation. The technique will be described and discussed.

Sensory Processing, Functional Performance and Quality of Life in Unilateral Cerebral Palsy Children: A Cross-Sectional Study

Background: The study of children with unilateral cerebral palsy (UCP) has traditionally focused on motor aspects. The extent to which sensory processing disorders can affect their functional performance and quality of life (QoL) is uncertain. This study aimed to explore the differences in sensory processing between UCP and typical development (TD) children and to analyze the relationship of sensory processing with functional performance and QoL. Methods: Fifty-three children aged from 6 to 15 years (TD = 24; UCP = 29) were recruited. The Child Sensory Profile 2, Pediatric Evaluation of Disability Inventory—Computer Adaptive Test and Kidscreen were used to evaluate sensory processing, functional performance and QoL. Results: UCP children showed sensory processing difficulties (avoidance: p = 0.02; registration: p = 0.00; body position: p = 0.00; oral: p = 0.02; social-emotional: p = 0.01), and scored lower in functional performance (daily activities: p = 0.00; mobility: p = 0.00; social/cognitive: p = 0.04) and in physical well-being (p = 0.00). The highest correlations in UCP group were found between proprioceptive processing and daily activities and mobility (r = −0.39); auditory, visual and tactile information and school environment (r = −0.63; r = −0.51; r = −0.46); behavioral and social-emotional responses and psychological well-being (r = −0.64; r = −0.49). Conclusions: UCP children have greater difficulty in sensory processing than TD children. Difficulties in proprioceptive processing contribute to poorer functional performance. Auditory, visual and tactile processing is associated with participation in the school environment and behavioral and social-emotional responses related to sensory processing are associated with the psychological well-being.

The Effect of the Powerball Gyroscope as a Treatment Device for Nonspecific Wrist Pain

OBJECTIVE

The aim of this study was to determine the effect of using the Powerball gyroscope as a treatment device on pain and change in endurance in nonspecific wrist pain.

METHODS

This study was a within-participants pre- and postintervention study consisting of 40 participants between ages 18 and 35 with an equal male-to-female ratio. The participants used the Powerball gyroscope for 5 minutes per treatment session. Treatment comprised 12 sessions carried out 3 × per week over a 4-week period. Participants completed objective and subjective data before the first, seventh, and 12th sessions. Objective data were recorded using the Jamar dynamometer to measure grip strength. Subjective data were gathered using the Patient-Rated Wrist Evaluation Questionnaire. Participants then used the Powerball gyroscope in the hand with the affected wrist. The Wilcoxon signed rank test and 1-way repeated-measures analysis of variance were used to analyze the changes.

RESULTS

A significant decrease in pain was noted throughout the study, but the most significant changes occurred between the seventh and 12th treatment sessions (P < .01). A significant increase in grip strength was also noted throughout the study, with the greater increase in grip strength occurring during the first 7 treatments (P < .02).

CONCLUSION

The Powerball gyroscope showed a change in outcome regarding nonspecific wrist pain and grip strength.