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

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 .

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.

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 .

Proprioceptive rehabilitation strategies in posttraumatic wrist injuries. Scoping review

Background

The proprioceptive approach can effectively improve strength, mobility, edema reduction, and pain reduction, which in turn has a positive impact on functionality.

Objective

To identify proprioceptive rehabilitation strategies reported in the literature in adults with traumatic wrist injuries.

Methods

A scoping review was performed following the parameters of the Prisma ScR strategy. We included research with adult patients diagnosed with posttraumatic wrist injuries who used proprioceptive rehabilitation. Pain, functionality, strength, joint mobility ranges, and edema were evaluated.

Results

After removing duplicates and applying the exclusion criteria, a total of 123 articles were found, which left six articles, including 125 patients. Rehabilitation protocols based on proprioceptive neuromuscular facilitation and using sensorimotor tools that promote wrist recovery have been generated. In addition, other approaches have been established, such as motor imagery, which generates a work of identification and organization of movement, improving pain and manual function. However, longer follow-ups, standardization of the instruments used during proprioceptive intervention, and increasing the observed population are needed to generate a recommendation for early intervention and cost-benefit estimates.

Conclusion

Proprioceptive rehabilitation has demonstrated benefits in the recovery of the lower limb and hip or back. However, for the rehabilitation of traumatic wrist injuries, it is research pending. Well-described data and good quality designs are needed to routinely propose this strategy in the clinic.

Design and Performance Analysis of a Dynamic Magnetic Resonance Imaging-Compatible Device for Triangular Fibrocartilage Complex Injury Diagnosis

Pain and injury of the triangular fibrocartilage complex (TFCC) due to overuse or trauma are commonly diagnosed through static MRI scanning, while TFCC is always involved in radial and ulnar deviation of the wrist. To the best of our knowledge, a dynamic MRI diagnostic method and auxiliary tool have not been applied or fully developed in the literature. As such, this study presents the design and evaluation of a dynamic magnetic resonance imaging (MRI) auxiliary tool for TFCC injury diagnosis. First, 3D scanning and Python are used to measure and fit the radial and ulnar deviation trajectories of healthy participants and patients. 3D printing is then used to manufacture the auxiliary tool for dynamic MRI, and dynamic MRI diagnosis is then conducted to explore the clinical effect. The radial and ulnar deviation trajectory is presented as an asymmetric curve without an obvious circular centre, and the results indicate that the designed auxiliary device meets the requirements of the ulnar and radial movements of the human wrist. According to the MRI contrast test results, the image quality score of patients wearing the auxiliary device is higher than for those without. Such devices could assist clinicians in the diagnosis of TFCC damage, and our method could not only serve as the reference standard for clinical noninvasive diagnosis but also help in understanding the disease and improving the accuracy of TFCC diagnosis.

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.

Responsiveness and Validity of Weight-Bearing Test for Measuring Loading Capacity in Patients With Triangular Fibrocartilage Complex Injury

CONTEXT

Weight-bearing test (WBT) is a noninvasive quantitative test which has been used recently to determine loading capability of the individuals. The aim of this study was to strengthen the evidence for using the WBT test for measuring weight-bearing capacity of the upper-extremity with the specific objective of examining the internal and external responsiveness and concurrent validity of the test in patients with triangular fibrocartilage complex injury.

DESIGN

Single-group repeated measures.

METHODS

Internal responsiveness was assessed using effect size statistics. The correlation coefficient was used to examine external responsiveness by testing 5 hypotheses regarding predefined correlations between the changes in the measurements. Concurrent validity was evaluated by analyzing correlations between the WBT and other measurements. Thirty-one patients with triangular fibrocartilage complex injury were included for the analysis of the concurrent validity. Eighteen patients who completed all measurements at baseline and at 3-month follow-up enrolled for the responsiveness analysis. Measurements included the WBT, pain intensity, grip strength, and upper extremity functional level.

RESULTS

The WBT test was able to detect statistically significant changes in weight-bearing capacity between baseline and follow-up (P = .0001). The effect size of the WBT was large. Three out of 5 hypotheses (60%) were confirmed, a good correlation was found between changes scores of the WBT and grip strength (r = .478; P < .05). There were significant correlations between the WBT and other measurements (r value range from -.401 to .742; P < .05). A higher correlation was found between the WBT and grip strength (r = .742; P = .0001).

CONCLUSIONS

The responsiveness and concurrent validity of the WBT test confirmed that it is able to measure change in weight-bearing capacity in patients with triangular fibrocartilage complex injury.

Home exercise in the dart-throwing motion plane after distal radius fractures: A pilot randomized controlled trial

INTRODUCTION

During daily functions, our wrist moves through an oblique plane, named the dart-throwing motion (DTM) plane. This plane is considered a more stable plane because the proximal carpal row remains relatively immobile. However, rehabilitation programs that incorporate exercising in the DTM plane have yet to be explored.

PURPOSE OF THE STUDY

The purpose of this study was to evaluate the rehabilitation outcomes after treatment in the DTM plane compared with outcomes after treatment in the sagittal plane after distal radius fracture.

STUDY DESIGN

This is a pilot randomized controlled trial.

METHODS

Subjects after open reduction internal fixation were assigned into a research group (N = 12; ages 48.7 ± 7.3) and a control group (N = 12; ages 50.8 ± 15). The control group activated the wrist in the sagittal plane, whereas the research group activated the wrist in the DTM plane. Range of motion, pain levels, functional hand motor skills tests, and satisfaction from self-training exercise were measured before and after a 12-session intervention.

RESULTS

The outcome measures were similar between the treatment groups. The research group reported significantly higher satisfaction rates than the control group on topics such as general satisfaction (research group: 3.4 ± 0.7, control group: 2. 5 ± 1.2, P = .030), motivation to exert oneself (research group: 2.8 ± 1.0, control group: 2.3 ± 1.2, P = .009), progressed function (research group: 3.4 ± 0.7, control group: 2.4 ± 1.1, P = .012), and self-training contribution to the daily function (research group: 3.4 ± 0.7, control group: 2.5 ± 1.2, P = .030).

DISCUSSION AND CONCLUSION

Pilot results do not favor one treatment method over the other. However, exercising in the DTM plane may contribute to the satisfaction of the client and increase self-training motivation.

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.

Mid- and Long-Term Outcome After Arthroscopically Assisted Transosseous Triangular Fibrocartilage Complex Refixation-Good to Excellent Results in Spite of Some Loss of Stability of the Distal Radioulnar Joint

PURPOSE

To evaluate mid- and long-term outcomes after arthroscopically-assisted transosseous reattachment of the triangular fibrocartilage complex (TFCC) and to analyze the association of distal radioulnar joint (DRUJ) stability with the clinical outcome.

METHODS

Patients treated with an arthroscopically-assisted transosseous reattachment of the deep layer of the TFCC between 2000 and 2009 and a minimum follow-up of 12 months at mid-term and 4 years at long-term follow-up were retrospectively reviewed. Mayo Modified Wrist Score (MMWS); Disabilities of the Arm, Shoulder and Hand (DASH) score; pain visual analogue scale (VAS); grip strength and stability of the DRUJ were assessed at 2 follow-up clinical examinations. At the last follow-up, the Patient-Rated Wrist Evaluation score was additionally recorded.

RESULTS

Thirty patients with a mean age of 29 (±13) years were included. Most of the patients were female (70%, n = 21). The mid-term evaluation took place at a median of 30 months (range, 12-83 months). The assessed scores showed statistically significant clinical improvement (MMWS, P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 23 (76.7%) patients. At a median of 106 months (range 52-215 months), the long-term clinical assessment was performed. The evaluated scores demonstrated persisting significant improvement (MMWS P < .001; DASH score P < .001; VAS P < .001). Stability assessment showed a stable DRUJ in 19 patients (63.3%). DRUJ instability did not correlate with clinical outcome. No permanent surgery-related complications occurred.

CONCLUSION

Arthroscopically-assisted transosseous reattachment of the deep fibers of radioulnar ligaments leads to excellent and good clinical results in mid- and long-term follow-up. In 95.5% of the analyzed patients, the measured improvement in the DASH score exceeded the in literature reported minimal clinically important difference of 13.5. Loss of DRUJ stability during follow-up was not associated with deterioration of clinical parameters and patient satisfaction.

LEVEL OF EVIDENCE

Level IV, retrospective case series.