Disability and Rehabilitation: Assistive Technology
ISSN: 1748-3107 (Print) 1748-3115 (Online) Journal homepage: http://www.tandfonline.com/loi/iidt20
The effect of new dynamic splint in pinch strength in De Quervain syndrome: a comparative study Zahra Nemati, Mohammad Ali Javanshir, Hassan Saeedi, Farzad Farmani & Siamak Aghajani Fesharaki To cite this article: Zahra Nemati, Mohammad Ali Javanshir, Hassan Saeedi, Farzad Farmani & Siamak Aghajani Fesharaki (2016): The effect of new dynamic splint in pinch strength in De Quervain syndrome: a comparative study, Disability and Rehabilitation: Assistive Technology, DOI: 10.3109/17483107.2016.1139635 To link to this article: http://dx.doi.org/10.3109/17483107.2016.1139635
Published online: 17 Feb 2016.
Submit your article to this journal
Article views: 6
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iidt20 Download by: [Washington University in St Louis]
Date: 07 March 2016, At: 05:19
DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY, 2016 http://dx.doi.org/10.3109/17483107.2016.1139635
RESEARCH PAPER
The effect of new dynamic splint in pinch strength in De Quervain syndrome: a comparative study Zahra Nematia, Mohammad Ali Javanshira, Hassan Saeedia, Farzad Farmanib and Siamak Aghajani Fesharakia
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
a Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran; bDepartment of Orthotics and Prosthetics, School of Rehabilitation Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
ABSTRACT
ARTICLE HISTORY
Objective For patients with De Quervain syndrome using thumb spica orthosis is restricting, so many patient are dissatisfied with using static model. The aim of this study is to compare the effect of modified dynamic and conventional static orthoses on pinch power and functional abilities of hand in De Quervain syndrome. Method In this quasi-experimental study, palmar and lateral pinch strength of the thumb, pain and functional abilities of hand, patient’s satisfaction of orthoses, were evaluated after using modified dynamic and conventional static orthosis in two groups. Results Both orthoses improved palmar and lateral pinch strength of the thumb, pain level and functional abilities. In comparison of mentioned variables, there was no significant difference between two groups regarding to pain recovery and abilities improvement (p40.05). However, the satisfaction level of the patients who had used dynamic orthosis was higher (p50.05). Conclusion It seems, adding a joint to the static thumb spica leads to patient’s relief and consequently to their satisfaction.
Received 22 May 2015 Revised 4 January 2016 Accepted 5 January 2016 Published online 10 February 2016 KEYWORDS
Conservative treatment; DASH questionnaire; De Quervain syndrome; long thumb spica; thumb orthosis
ä IMPLICATIONS FOR REHABILITATION
The dynamic thumb spica, is easier to use and patients satisfaction is higher than static thumb spica. Therefore, it can be used for conservative treatment of De Quervain syndrome.
Introduction De Quervain syndrome is an inflammation which tightens tendon canals of abductor pollicis longus and extensor pollicis brevis muscles that pass through the first posterior compartment of the carpometacarpal joint of the wrist.[1] These extensric muscles are responsible for thumb abduction and extension.[2] In the primary stage of syndrome, the tendons look normal, but in the chronic stage, tendons become degenerative.[3] The cause of De Quervain tenosynovitis is unknown.[3] Overuse or repeated stresses over the wrist and thumb in activities like washing clothes, manual closing or opening the screws, typing, playing piano, weaving, sewing and cutting could lead to De Quervain.[1,4,5] These repeated stresses result in inflaming of the tendons or swelling of extensor retinaculum.[1] Frequent tensions and constant contractions of the tendons may cause friction and inflammation, which finally result in tightening of the tendon canal.[4] Statistics have shown that the prevalence rate of De CONTACT Mohammad Ali Javanshir of Medical Sciences, Tehran, Iran ß 2016 Taylor & Francis
[email protected]
Quervain in normal population is 3.7%.[6] This prevalence rate in women is 3–4 times more than men.[7,8] Generally, various treatments are prescribed based on the stage of the syndrome. When the disease is in its acute stage, in which the syndrome is not much developed, non-surgical treatment is performed, that could be classified in two pharmacological and nonpharmacological treatment groups.[9] Non-pharmacological treatment group includes making change in activities, posture improvement, ergonomic changes, use of orthosis for hand immobilization, heat, cold and electrical nerves stimulation.[4] In the researches it has been mentioned that the best and safest conservative treatment for De Quervain syndrome is resting and immobilizing of the thumb.[10,11] Hand orthoses including hard and soft ones are usually prescribed as a common non-surgical method.[1] Static orthoses, prohibit the movement of hand and thumb, and alternatively result in reducing the inflammation of the tendon sheath.[9] Rigid design known as
Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
2
Z. NEMATI ET AL.
thumb spica splint restricts all movements of wrist, so patients are not satisfied with them during their daily activities. On the other hand, soft designs provide no limitation on wrist movements while ulnar and radial deviations of wrist intensify symptoms.[1,2] It is proved that, using orthoses are very effective in the acute stage and can potentially reduce the pain and inflammation.[12] The primary goal of using orthosis in this stage is resting of the involved limb and reducing inflammation which is followed by reduction in slipping of abductor pollicis longus and extensor pollicis brevis tendons in the first posterior compartment. Rest leads to reducing the forces exerted by these muscles which help to syndrome cure.[1,7] Long thumb spica is a custom made hard orthosis which is usually used for treating De Quervain syndrome.[5] Backstrom et al. [13] and Huang et al. [5] indicated that thumb spica is the best option for preventing ulnar deviation of the wrist and flexion of the thumb. Since in radial and ulnar deviation of the wrist tightening of the muscles occurs, which can lead to inflammation of the tendon sheet, many studies have suggested that limitation of these movements, in addition to the thumb immobilization, is necessary.[1,14,15] On the other hand, biomechanical studies have indicated that, as flexor and extensor muscles are not active in radial and ulnar deviation, they do not need to be immobilized.[2] As in hard thumb spica all motions of the wrist is limited, performance of the hand is significantly decreased. Therefore, many people are not willing to use the hard orthoses full time.[1] Some believe that, one solution for this problem is using soft hand orthoses during daily activities and utilizing hard static hand orthoses during nights.[1] Opponents of this idea state that, since ulnar deviation and radial deviation along with pinching motions exert a great stress on the involved muscles, their activities should be limited as much as possible, while Soft orthoses do not limit wrist motions.[6] On the other hand, prescribing two different orthoses simultaneously, imposes double expenses to the patient. Thus, in this study, we used a modified dynamic hand orthosis so that ulnar and radial deviation motions could be effectively limited, while flexion and extension of the wrist is achieved. In this orthosis, thumb comfortably is fixed in radial abduction form. In order to determine the effectiveness of the freedom of flexion and extension of the wrist on improving the symptoms of the disease, this research was conducted to compare the effect of conventional static and modified dynamic orthoses on functional abilities of the hand and pinch strength in women with De Quervain syndrome.
Methods Patients This quasi-experimental study was conducted on 24 women with acute De Quervain syndrome, in Orthotics and Prosthetics department of Iran University of Medical Sciences. This research was approved by the local committee of ethics of Tehran University of Medical Sciences (No. 91/ D/130/3636) and informed written consent was read and signed by all the participants. Inclusion criteria included, being a woman between 18 and 60 years, having De Quervain syndrome diagnosed by a hand surgeon through examination and positive Finkelsteine test and finally ability to speak Persian.[7,16] Exclusion criteria included, presence of other orthopaedic diseases in hand and wrist such as rheumatoid arthritis or osteoarthritis or other kinds of arthritis, having steroid injection for De Quervain syndrome in last 3 months, history of hand surgery and hand skin problems.[7,16] Patients were randomly divided into two groups. The first group used conventional static orthoses and the second one utilized modified dynamic orthoses.[9] During the treatment period, patients were encouraged to do their daily activities just like before.[9]
Measures In order to measure the amount of pain and functional abilities of the hand, DASH1 questionnaires,[17] were used. Validity and reliability of these questionnaires have been demonstrated in other study.[18] Cultural adaptation and validation of this questionnaire to Persian was performed by Mousavi et al.[19] This questionnaire contained 30 main questions which evaluated functional abilities of the upper limb in daily living activities. Patients were asked to score each question from 1 to 5. The higher score indicated more disability and pain. Measurement of palmar and lateral pinch strength was performed by Jamar pinch gauge, model 749805, in kilograms.[20] Each motion was measured 3 times with 1-min intervals.[21] The patients were asked to push the handle between thumb and index with maximum power while sitting and the elbow was in mid position on the table. The mean values were considered as the data.[21] Patients were asked to use the orthoses at least 6 h/day for 2 weeks.[9] Satisfaction rated by visual analogue scale (VAS), ranging from 0 (no satisfaction) to 100 (high level of satisfaction).[22]
Intervention The treatment in the first group was performed by onepiece-custom-fabricated long thumb spica (Figure 1)
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
EFFECT OF NEW DYNAMIC SPLINT IN DE QUERVAIN SYNDROME
which in addition to fixing the thumb in radial abduction, limited all wrist movements. The treatment in the second group included using dynamic long thumb spica (Figure 2). The modified dynamic orthosis contained two separated parts including hand portion and forearm portion which were jointed with two tongues at radiocarpal joint of the wrist. In addition, tongues determined the place of the hinged joint of the orthosis. Both orthoses were made from a 2-mm-thick orfit sheet according to the patient’s hand size and from a correct pattern which were placed in boiling water to be shaped on the patient’s limb.[23] During the shaping process, the elbow of the patient, while sitting, was fixed on a flat surface, So that the thumb could be in comfortable radial abduction position, and the wrist in 10–20 degree of extension.[1] After cooling and fine tuning, straps were added to the orthosis. The participants of both groups were asked to wear the orthoses at least 6 h/day for a 2-week period.[9]
Data analysis The data were analyzed by SPSS statistical software version 19.0 (SPSS Inc., Chicago, IL). Statistical tests were performed using Kolmogorov–Smirnov test, paired t-test and independent t-test. The significant level of 0.05 was considered.
3
pain, independent t-test was used, the results of each showed that there were not significant differences between two groups (Table 1). Pain, disability, palmar and lateral pinch strength in the first session of measurements in two groups were similar (Table 2). After 2-week intervention, the results showed decreasing in pain and increasing in functional abilities and strength at both groups. However, there was no statistically significant difference between the two groups (Table 3). Regarding satisfaction, which was examined by VAS on the second session after intervention, showed that the patients who utilized dynamic orthoses were more satisfied (64.27 ± 4.22) in their daily activities due to the presence of a joint in the wrist of the dynamic orthoses in compare of the patients who used static orthoses (49.72 ± 4.34) (p ¼ 0.005) (Table 4).
Table 1. Comparison of the mean of age, BMI and DASH score between two groups by paired t-test. Variable
Mean in dynamic orthosis (SD)
Mean in static orthosis (SD)
p Values
AGE BMI DASH score
49.25 ± 6.99 27.46 ± 2.45 62.47 ± 8.41
50.92 ± 7.32 26.48 ± 2.54 60.06 ± 8.42
0.575 0.347 0.490
Findings
Table 2. Comparison of PPS and LPS mean in first session between two groups by independent sample t-test.
Normality of the data was assessed by using the Kolmogorov–Smirnov technique (p40.05). To investigate the equality of both groups in age, BMI, intensity of
Variable
Mean in dynamic orthosis (SD)
Mean in static orthosis (SD)
p Values
PPS1 LPS1 DASH1
4.24 ± 0.78 1.61 ± 0.33 62.47 ± 8.41
3.96 ± 0.91 1.36 ± 0.36 60.06 ± 8.42
0.432 0.096 0.490
PPS: palmar pinch strength; LPS: lateral pinch strength.
Table 3. Comparison of PPS, LPS and DASH mean between two sessions in two groups by paired t-test.
Figure 1. Static orthoses, conventional design.
Variable
Session
Mean in dynamic orthosis (SD)
Mean in static orthosis (SD)
PPS
1 2 p values 1 2 p values 1 2 p values
4.24 ± 0.78 4.94 ± 1.22 0.001 1.61 ± 0.33 1.99 ± 0.38 0.003 62.47 ± 8.41 40.88 ± 7.81 0.001
3.96 ± 0.91 4.58 ± 0.95 0.002 1.36 ± 0.36 1.87 ± 0.4 0.001 60.06 ± 8.42 39.26 ± 6.54 0.001
LPS DASH
Table 4. Comparison of VAS mean between two groups in second session by independent sample t-test.
Figure 2. Dynamic orthoses, new design.
Variable
Mean in dynamic orthosis (SD)
Mean in static orthosis (SD)
p Values
VAS
64.27 ± 4.22
49.72 ± 4.34
0.001
4
Z. NEMATI ET AL.
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
Discussion This study aimed to compare the effect of modified dynamic and conventional static thumb spica orthoses on the pain and functional abilities of hand in women suffering from De Quervain syndrome. It was indicated that using orthoses in both groups lowered pain and increased functional abilities and also lateral and palmar pinch strength, which in turn shows the positive effect of using orthoses in treatment of patients with De Quervain syndrome. In addition, regarding pain and functional mobilities, no significant differences were diagnosed between two groups after 2 weeks orthotic intervention. It seems that, fixing the thumb in a comfortable position in both types of orthoses which resulted in reducing the friction among tendons and between tendons and the tunnel that they pass through, and consequently, decreasing oedema in tendons sheath, is the main reason of reduced pain and increased functional mobility of the hand. On the other side, the satisfaction rate evaluations showed that patients who had used the dynamic orthoses were more satisfied than the patients who had used the static ones. It seems that being more satisfied with dynamic orthosis is because of having the ability of moving the wrist and doing the daily activities more comfortably. Results obtained from this study show the important role of the thumb in performing daily activities as it demonstrated in previous studies.[24,25] That is, pain in thumb results in decreased gripping ability and in turn, inadequacy in doing daily tasks.[21] This problem is due to involvement of the thumb in 45–60% of the daily activities.[25] The primary treatment to reduce the inflammation in posterior compartment is immobilization of the wrist and hand in a thumb spica orthosis.[14] Ulnar and radial deviations in wrist are harmful motions which could potentially result in tension or contraction of the tendons.[1,15] Since the abductor pollicis longus and extensor pollicis brevis tendons are the most lateral muscles in the lateral side of wrist, they are not active during flexion and extension of the wrist, although abductor pollicis longus has a small level arm for flexion of the wrist, and during resistive flexion movements, are slightly active.[2] As patients with De Quervain syndrome are usually prohibited from heavy hand movements,[1] it seems that these muscles are inactive during flexion and extension of the wrist. Lane et al. [12] showed that using hand orthoses is effective in reducing the pain and improving symptoms on acute phase. In addition, Lin et al. [26] indicated that using hand orthosis along with other conservative methods were effective in the treatment of De Quervain syndrome. In a study conducted by Stical et al. [9] decreased pain was
seen in patients that used hand orthoses for De Quervain. Findings of the present study were similar to the results of all three afore-mentioned ones. In these studies and our study, patients were provided with orthotic intervention during the acute period and experienced improved symptoms.[9,12,26] Although Sitkul mentioned the least limitation the most satisfaction, at this research, patients were significantly more satisfied with modified dynamic orthosis compared with the static one. It seems that, this high rate of satisfaction was due to having more freedom of movements and as a result more capability to perform daily tasks and activities for the patients while using dynamic orthosis. Thus, it can be concluded that if the thumb is fixed in an appropriate position, wrist is not required to be immobilized. On the other hand, since it has not conducted any study which compares the effect of full free and full limited motions of the wrist in treating De Quervain syndrome, and according to biomechanical findings,[2,7] limiting ulnar and radial deviations seems necessary. Therefore, it could be said that as for applying necessary immobilizations in ulnar and radial deviations and unnecessary immobilizations in wrist flexion and extension, modified dynamic thumb spica could be the most appropriate orthoses for the patients with De Quervain syndrome. Although it is proved that orthotic intervention is an effective approach to treat De Quervain syndrome,[1] in a study conducted by Weiss et al.,[27] it was concluded that using orthosis alone has small effect in improving symptoms of the syndrome and pain reduction. This controversy could occur because Weiss did not classified patients according to the stage of syndrome. Generally, in the present study, no significant differences were seen between two orthoses regarding reducing pain, increasing functional ability and enhancing palmar and lateral performances pinch power. These findings emphasize the similar effect of these two orthoses on pain and functional abilities of the hand in treating De Quervain syndrome. On the other hand, participants were significantly more satisfied with new modified orthosis in compare of conventional thumb spica, which indicate that dynamic orthosis is more comfortable.
Limitation The study duration was approximately short, so longterm directives cannot be given. We did not have any control on patients about using the orthoses.
Conclusion This study shows that static and modified dynamic thumb spica orthoses were similar regarding to the
EFFECT OF NEW DYNAMIC SPLINT IN DE QUERVAIN SYNDROME
effect on pain and functional abilities of the patients with De Quervain syndrome. However, according to the higher rate of satisfaction of the patients utilizing dynamic orthosis, the use of new dynamic orthosis is recommended instead of the conventional static model.
Acknowledgements We want to thank all the people who participated in this research.
Disclosure statement
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
References [1] Hsu JD, Michael J, Fisk J. AAOS atlas of orthoses and assistive devices. 4th ed. Philadelphia: Mosby, Elsevier; 2008. [2] Neumann DA, Rowan EE. Kinesiology of the musculoskeletal system: foundations for physical rehabilitation. 2nd ed. St. Louis (MO): Mosby; 2002. [3] Ross A. Adams’s outline of orthopaedics. J Bone Joint Surg Br. 2010;92:904. [4] Rush J. De Quervain’s disease. Curr Orthop. 2000;14:380–383. [5] Huang T-H, Feng C-K, Gung Y-W, et al. Optimization design of thumbspica splint using finite element method. Med Biol Eng Comput. 2006;44:1105–1111. [6] Adachi S, Yamamoto A, Kobayashi T, et al. Prevalence of de Quervain’s disease in the general population and risk factors. Kitakanto Med J. 2011;61:479–482. [7] Mackin E, Hunter JM, Callahan AD, et al. Rehabilitation of the hand and upper extremity. St. Louis (MO): Mosby; 1990. [8] LAPIDUS PW, Fenton R. Stenosing tenovaginitis at the wrist and fingers; report of 423 cases in 369 patients with 354 operations. AMA Arch Surg. 1952;64:475–487. [9] Jongprasitkul H, Suputtitada A. Elastic bandage vs. neoprene thumb stabilizer splint in acute De Quervain’s tenosynovitis. Asian Biomed. 2011;5:263–267. [10] Rettig AC. Athletic injuries of the wrist and hand: part II: overuse injuries of the wrist and traumatic injuries to the hand. Am J Sports Med. 2004;32: 262–273. [11] Papa JA. Conservative management of De Quervain’s stenosing tenosynovitis: a case report. J Can Chiropr Assoc. 2012;56:112–120.
5
[12] Lane L, Boretz R, Stuchin S. Treatment of de Quervain’s disease: role of conservative management. J Hand Surg Br. 2001;26:258–260. [13] Backstrom KM. Mobilization with movement as an adjunct intervention in a patient with complicated de Quervain’s tenosynovitis: a case report. J Orthop Sports Phys Ther. 2002;32:86. [14] Hunter JM, Schneider L, Mackin E, et al. Rehabilitation of the hand. St. Louis (MO): Mosby; 1990. [15] Koman LA, Li Z, Smith BP, et al. Rehabilitation of the hand and upper extremity. 6th ed. Philadelphia: Mosby, Elsevier; 2011. p. 580–585. [16] Batteson R, Hammond A, Burke F, et al. The de Quervain’s screening tool: validity and reliability of a measure to support clinical diagnosis and management. Musculoskeletal Care. 2008;6:168–180. [17] Hudak PL, Amadio PC, Bombardier C, et al. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Head). Am J Ind Med. 1996;29:602–608. [18] Luc D. The DASH questionnaire and score in the evaluation of hand and wrist disorders. Acta Orthop Belg. 2008;74:575–581. [19] Mousavi SJ, Parnianpour M, Abedi M, et al. Cultural adaptation and validation of the Persian version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure. Clin Rehabil. 2008;22:749–757. [20] Fournier K, Bourbonnais D, Bravo G, et al. Reliability and validity of pinch and thumb strength measurements in de Quervain’s disease. J Hand Ther. 2006;19:2–11. [21] Forget N, Piotte F, Arsenault J, et al. Bilateral thumb’s active range of motion and strength in de Quervain’s disease: comparison with a normal sample. J Hand Ther. 2008;21:276–285. [22] Paul-Dauphin A, Guillemin F, Virion J-M, Brianuˆ¨Ion S. Bias and precision in visual analogue scales: a randomized controlled trial. Am J Epidemiol. 1999;150:1117–1127. [23] Dival TA. Hand splinting: principles of design and fabrication. W.B. Saunders, the University of Michigan; 1997. p. 154–156. [24] Kapandji I. The physiology of the joints, vol. 1. New York: Churchill Livingstone; 1982. [25] Dominick KL, Jordan JM, Renner JB, et al. Relationship of radiographic and clinical variables to pinch and grip strength among individuals with osteoarthritis. Arthritis Rheum. 2005;52:1424–1430. [26] Lin JT, Stubblefield MD. De Quervain’s tenosynovitis in patients with lymphedema: a report of 2 cases with management approach. Arch Phys Med Rehabil. 2003;84:1554–1557. [27] Weiss A-PC, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg. 1994;19:595–598.
ISSN: 1748-3107 (Print) 1748-3115 (Online) Journal homepage: http://www.tandfonline.com/loi/iidt20
The effect of new dynamic splint in pinch strength in De Quervain syndrome: a comparative study Zahra Nemati, Mohammad Ali Javanshir, Hassan Saeedi, Farzad Farmani & Siamak Aghajani Fesharaki To cite this article: Zahra Nemati, Mohammad Ali Javanshir, Hassan Saeedi, Farzad Farmani & Siamak Aghajani Fesharaki (2016): The effect of new dynamic splint in pinch strength in De Quervain syndrome: a comparative study, Disability and Rehabilitation: Assistive Technology, DOI: 10.3109/17483107.2016.1139635 To link to this article: http://dx.doi.org/10.3109/17483107.2016.1139635
Published online: 17 Feb 2016.
Submit your article to this journal
Article views: 6
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iidt20 Download by: [Washington University in St Louis]
Date: 07 March 2016, At: 05:19
DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY, 2016 http://dx.doi.org/10.3109/17483107.2016.1139635
RESEARCH PAPER
The effect of new dynamic splint in pinch strength in De Quervain syndrome: a comparative study Zahra Nematia, Mohammad Ali Javanshira, Hassan Saeedia, Farzad Farmanib and Siamak Aghajani Fesharakia
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
a Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran; bDepartment of Orthotics and Prosthetics, School of Rehabilitation Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
ABSTRACT
ARTICLE HISTORY
Objective For patients with De Quervain syndrome using thumb spica orthosis is restricting, so many patient are dissatisfied with using static model. The aim of this study is to compare the effect of modified dynamic and conventional static orthoses on pinch power and functional abilities of hand in De Quervain syndrome. Method In this quasi-experimental study, palmar and lateral pinch strength of the thumb, pain and functional abilities of hand, patient’s satisfaction of orthoses, were evaluated after using modified dynamic and conventional static orthosis in two groups. Results Both orthoses improved palmar and lateral pinch strength of the thumb, pain level and functional abilities. In comparison of mentioned variables, there was no significant difference between two groups regarding to pain recovery and abilities improvement (p40.05). However, the satisfaction level of the patients who had used dynamic orthosis was higher (p50.05). Conclusion It seems, adding a joint to the static thumb spica leads to patient’s relief and consequently to their satisfaction.
Received 22 May 2015 Revised 4 January 2016 Accepted 5 January 2016 Published online 10 February 2016 KEYWORDS
Conservative treatment; DASH questionnaire; De Quervain syndrome; long thumb spica; thumb orthosis
ä IMPLICATIONS FOR REHABILITATION
The dynamic thumb spica, is easier to use and patients satisfaction is higher than static thumb spica. Therefore, it can be used for conservative treatment of De Quervain syndrome.
Introduction De Quervain syndrome is an inflammation which tightens tendon canals of abductor pollicis longus and extensor pollicis brevis muscles that pass through the first posterior compartment of the carpometacarpal joint of the wrist.[1] These extensric muscles are responsible for thumb abduction and extension.[2] In the primary stage of syndrome, the tendons look normal, but in the chronic stage, tendons become degenerative.[3] The cause of De Quervain tenosynovitis is unknown.[3] Overuse or repeated stresses over the wrist and thumb in activities like washing clothes, manual closing or opening the screws, typing, playing piano, weaving, sewing and cutting could lead to De Quervain.[1,4,5] These repeated stresses result in inflaming of the tendons or swelling of extensor retinaculum.[1] Frequent tensions and constant contractions of the tendons may cause friction and inflammation, which finally result in tightening of the tendon canal.[4] Statistics have shown that the prevalence rate of De CONTACT Mohammad Ali Javanshir of Medical Sciences, Tehran, Iran ß 2016 Taylor & Francis
[email protected]
Quervain in normal population is 3.7%.[6] This prevalence rate in women is 3–4 times more than men.[7,8] Generally, various treatments are prescribed based on the stage of the syndrome. When the disease is in its acute stage, in which the syndrome is not much developed, non-surgical treatment is performed, that could be classified in two pharmacological and nonpharmacological treatment groups.[9] Non-pharmacological treatment group includes making change in activities, posture improvement, ergonomic changes, use of orthosis for hand immobilization, heat, cold and electrical nerves stimulation.[4] In the researches it has been mentioned that the best and safest conservative treatment for De Quervain syndrome is resting and immobilizing of the thumb.[10,11] Hand orthoses including hard and soft ones are usually prescribed as a common non-surgical method.[1] Static orthoses, prohibit the movement of hand and thumb, and alternatively result in reducing the inflammation of the tendon sheath.[9] Rigid design known as
Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
2
Z. NEMATI ET AL.
thumb spica splint restricts all movements of wrist, so patients are not satisfied with them during their daily activities. On the other hand, soft designs provide no limitation on wrist movements while ulnar and radial deviations of wrist intensify symptoms.[1,2] It is proved that, using orthoses are very effective in the acute stage and can potentially reduce the pain and inflammation.[12] The primary goal of using orthosis in this stage is resting of the involved limb and reducing inflammation which is followed by reduction in slipping of abductor pollicis longus and extensor pollicis brevis tendons in the first posterior compartment. Rest leads to reducing the forces exerted by these muscles which help to syndrome cure.[1,7] Long thumb spica is a custom made hard orthosis which is usually used for treating De Quervain syndrome.[5] Backstrom et al. [13] and Huang et al. [5] indicated that thumb spica is the best option for preventing ulnar deviation of the wrist and flexion of the thumb. Since in radial and ulnar deviation of the wrist tightening of the muscles occurs, which can lead to inflammation of the tendon sheet, many studies have suggested that limitation of these movements, in addition to the thumb immobilization, is necessary.[1,14,15] On the other hand, biomechanical studies have indicated that, as flexor and extensor muscles are not active in radial and ulnar deviation, they do not need to be immobilized.[2] As in hard thumb spica all motions of the wrist is limited, performance of the hand is significantly decreased. Therefore, many people are not willing to use the hard orthoses full time.[1] Some believe that, one solution for this problem is using soft hand orthoses during daily activities and utilizing hard static hand orthoses during nights.[1] Opponents of this idea state that, since ulnar deviation and radial deviation along with pinching motions exert a great stress on the involved muscles, their activities should be limited as much as possible, while Soft orthoses do not limit wrist motions.[6] On the other hand, prescribing two different orthoses simultaneously, imposes double expenses to the patient. Thus, in this study, we used a modified dynamic hand orthosis so that ulnar and radial deviation motions could be effectively limited, while flexion and extension of the wrist is achieved. In this orthosis, thumb comfortably is fixed in radial abduction form. In order to determine the effectiveness of the freedom of flexion and extension of the wrist on improving the symptoms of the disease, this research was conducted to compare the effect of conventional static and modified dynamic orthoses on functional abilities of the hand and pinch strength in women with De Quervain syndrome.
Methods Patients This quasi-experimental study was conducted on 24 women with acute De Quervain syndrome, in Orthotics and Prosthetics department of Iran University of Medical Sciences. This research was approved by the local committee of ethics of Tehran University of Medical Sciences (No. 91/ D/130/3636) and informed written consent was read and signed by all the participants. Inclusion criteria included, being a woman between 18 and 60 years, having De Quervain syndrome diagnosed by a hand surgeon through examination and positive Finkelsteine test and finally ability to speak Persian.[7,16] Exclusion criteria included, presence of other orthopaedic diseases in hand and wrist such as rheumatoid arthritis or osteoarthritis or other kinds of arthritis, having steroid injection for De Quervain syndrome in last 3 months, history of hand surgery and hand skin problems.[7,16] Patients were randomly divided into two groups. The first group used conventional static orthoses and the second one utilized modified dynamic orthoses.[9] During the treatment period, patients were encouraged to do their daily activities just like before.[9]
Measures In order to measure the amount of pain and functional abilities of the hand, DASH1 questionnaires,[17] were used. Validity and reliability of these questionnaires have been demonstrated in other study.[18] Cultural adaptation and validation of this questionnaire to Persian was performed by Mousavi et al.[19] This questionnaire contained 30 main questions which evaluated functional abilities of the upper limb in daily living activities. Patients were asked to score each question from 1 to 5. The higher score indicated more disability and pain. Measurement of palmar and lateral pinch strength was performed by Jamar pinch gauge, model 749805, in kilograms.[20] Each motion was measured 3 times with 1-min intervals.[21] The patients were asked to push the handle between thumb and index with maximum power while sitting and the elbow was in mid position on the table. The mean values were considered as the data.[21] Patients were asked to use the orthoses at least 6 h/day for 2 weeks.[9] Satisfaction rated by visual analogue scale (VAS), ranging from 0 (no satisfaction) to 100 (high level of satisfaction).[22]
Intervention The treatment in the first group was performed by onepiece-custom-fabricated long thumb spica (Figure 1)
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
EFFECT OF NEW DYNAMIC SPLINT IN DE QUERVAIN SYNDROME
which in addition to fixing the thumb in radial abduction, limited all wrist movements. The treatment in the second group included using dynamic long thumb spica (Figure 2). The modified dynamic orthosis contained two separated parts including hand portion and forearm portion which were jointed with two tongues at radiocarpal joint of the wrist. In addition, tongues determined the place of the hinged joint of the orthosis. Both orthoses were made from a 2-mm-thick orfit sheet according to the patient’s hand size and from a correct pattern which were placed in boiling water to be shaped on the patient’s limb.[23] During the shaping process, the elbow of the patient, while sitting, was fixed on a flat surface, So that the thumb could be in comfortable radial abduction position, and the wrist in 10–20 degree of extension.[1] After cooling and fine tuning, straps were added to the orthosis. The participants of both groups were asked to wear the orthoses at least 6 h/day for a 2-week period.[9]
Data analysis The data were analyzed by SPSS statistical software version 19.0 (SPSS Inc., Chicago, IL). Statistical tests were performed using Kolmogorov–Smirnov test, paired t-test and independent t-test. The significant level of 0.05 was considered.
3
pain, independent t-test was used, the results of each showed that there were not significant differences between two groups (Table 1). Pain, disability, palmar and lateral pinch strength in the first session of measurements in two groups were similar (Table 2). After 2-week intervention, the results showed decreasing in pain and increasing in functional abilities and strength at both groups. However, there was no statistically significant difference between the two groups (Table 3). Regarding satisfaction, which was examined by VAS on the second session after intervention, showed that the patients who utilized dynamic orthoses were more satisfied (64.27 ± 4.22) in their daily activities due to the presence of a joint in the wrist of the dynamic orthoses in compare of the patients who used static orthoses (49.72 ± 4.34) (p ¼ 0.005) (Table 4).
Table 1. Comparison of the mean of age, BMI and DASH score between two groups by paired t-test. Variable
Mean in dynamic orthosis (SD)
Mean in static orthosis (SD)
p Values
AGE BMI DASH score
49.25 ± 6.99 27.46 ± 2.45 62.47 ± 8.41
50.92 ± 7.32 26.48 ± 2.54 60.06 ± 8.42
0.575 0.347 0.490
Findings
Table 2. Comparison of PPS and LPS mean in first session between two groups by independent sample t-test.
Normality of the data was assessed by using the Kolmogorov–Smirnov technique (p40.05). To investigate the equality of both groups in age, BMI, intensity of
Variable
Mean in dynamic orthosis (SD)
Mean in static orthosis (SD)
p Values
PPS1 LPS1 DASH1
4.24 ± 0.78 1.61 ± 0.33 62.47 ± 8.41
3.96 ± 0.91 1.36 ± 0.36 60.06 ± 8.42
0.432 0.096 0.490
PPS: palmar pinch strength; LPS: lateral pinch strength.
Table 3. Comparison of PPS, LPS and DASH mean between two sessions in two groups by paired t-test.
Figure 1. Static orthoses, conventional design.
Variable
Session
Mean in dynamic orthosis (SD)
Mean in static orthosis (SD)
PPS
1 2 p values 1 2 p values 1 2 p values
4.24 ± 0.78 4.94 ± 1.22 0.001 1.61 ± 0.33 1.99 ± 0.38 0.003 62.47 ± 8.41 40.88 ± 7.81 0.001
3.96 ± 0.91 4.58 ± 0.95 0.002 1.36 ± 0.36 1.87 ± 0.4 0.001 60.06 ± 8.42 39.26 ± 6.54 0.001
LPS DASH
Table 4. Comparison of VAS mean between two groups in second session by independent sample t-test.
Figure 2. Dynamic orthoses, new design.
Variable
Mean in dynamic orthosis (SD)
Mean in static orthosis (SD)
p Values
VAS
64.27 ± 4.22
49.72 ± 4.34
0.001
4
Z. NEMATI ET AL.
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
Discussion This study aimed to compare the effect of modified dynamic and conventional static thumb spica orthoses on the pain and functional abilities of hand in women suffering from De Quervain syndrome. It was indicated that using orthoses in both groups lowered pain and increased functional abilities and also lateral and palmar pinch strength, which in turn shows the positive effect of using orthoses in treatment of patients with De Quervain syndrome. In addition, regarding pain and functional mobilities, no significant differences were diagnosed between two groups after 2 weeks orthotic intervention. It seems that, fixing the thumb in a comfortable position in both types of orthoses which resulted in reducing the friction among tendons and between tendons and the tunnel that they pass through, and consequently, decreasing oedema in tendons sheath, is the main reason of reduced pain and increased functional mobility of the hand. On the other side, the satisfaction rate evaluations showed that patients who had used the dynamic orthoses were more satisfied than the patients who had used the static ones. It seems that being more satisfied with dynamic orthosis is because of having the ability of moving the wrist and doing the daily activities more comfortably. Results obtained from this study show the important role of the thumb in performing daily activities as it demonstrated in previous studies.[24,25] That is, pain in thumb results in decreased gripping ability and in turn, inadequacy in doing daily tasks.[21] This problem is due to involvement of the thumb in 45–60% of the daily activities.[25] The primary treatment to reduce the inflammation in posterior compartment is immobilization of the wrist and hand in a thumb spica orthosis.[14] Ulnar and radial deviations in wrist are harmful motions which could potentially result in tension or contraction of the tendons.[1,15] Since the abductor pollicis longus and extensor pollicis brevis tendons are the most lateral muscles in the lateral side of wrist, they are not active during flexion and extension of the wrist, although abductor pollicis longus has a small level arm for flexion of the wrist, and during resistive flexion movements, are slightly active.[2] As patients with De Quervain syndrome are usually prohibited from heavy hand movements,[1] it seems that these muscles are inactive during flexion and extension of the wrist. Lane et al. [12] showed that using hand orthoses is effective in reducing the pain and improving symptoms on acute phase. In addition, Lin et al. [26] indicated that using hand orthosis along with other conservative methods were effective in the treatment of De Quervain syndrome. In a study conducted by Stical et al. [9] decreased pain was
seen in patients that used hand orthoses for De Quervain. Findings of the present study were similar to the results of all three afore-mentioned ones. In these studies and our study, patients were provided with orthotic intervention during the acute period and experienced improved symptoms.[9,12,26] Although Sitkul mentioned the least limitation the most satisfaction, at this research, patients were significantly more satisfied with modified dynamic orthosis compared with the static one. It seems that, this high rate of satisfaction was due to having more freedom of movements and as a result more capability to perform daily tasks and activities for the patients while using dynamic orthosis. Thus, it can be concluded that if the thumb is fixed in an appropriate position, wrist is not required to be immobilized. On the other hand, since it has not conducted any study which compares the effect of full free and full limited motions of the wrist in treating De Quervain syndrome, and according to biomechanical findings,[2,7] limiting ulnar and radial deviations seems necessary. Therefore, it could be said that as for applying necessary immobilizations in ulnar and radial deviations and unnecessary immobilizations in wrist flexion and extension, modified dynamic thumb spica could be the most appropriate orthoses for the patients with De Quervain syndrome. Although it is proved that orthotic intervention is an effective approach to treat De Quervain syndrome,[1] in a study conducted by Weiss et al.,[27] it was concluded that using orthosis alone has small effect in improving symptoms of the syndrome and pain reduction. This controversy could occur because Weiss did not classified patients according to the stage of syndrome. Generally, in the present study, no significant differences were seen between two orthoses regarding reducing pain, increasing functional ability and enhancing palmar and lateral performances pinch power. These findings emphasize the similar effect of these two orthoses on pain and functional abilities of the hand in treating De Quervain syndrome. On the other hand, participants were significantly more satisfied with new modified orthosis in compare of conventional thumb spica, which indicate that dynamic orthosis is more comfortable.
Limitation The study duration was approximately short, so longterm directives cannot be given. We did not have any control on patients about using the orthoses.
Conclusion This study shows that static and modified dynamic thumb spica orthoses were similar regarding to the
EFFECT OF NEW DYNAMIC SPLINT IN DE QUERVAIN SYNDROME
effect on pain and functional abilities of the patients with De Quervain syndrome. However, according to the higher rate of satisfaction of the patients utilizing dynamic orthosis, the use of new dynamic orthosis is recommended instead of the conventional static model.
Acknowledgements We want to thank all the people who participated in this research.
Disclosure statement
Downloaded by [Washington University in St Louis] at 05:19 07 March 2016
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
References [1] Hsu JD, Michael J, Fisk J. AAOS atlas of orthoses and assistive devices. 4th ed. Philadelphia: Mosby, Elsevier; 2008. [2] Neumann DA, Rowan EE. Kinesiology of the musculoskeletal system: foundations for physical rehabilitation. 2nd ed. St. Louis (MO): Mosby; 2002. [3] Ross A. Adams’s outline of orthopaedics. J Bone Joint Surg Br. 2010;92:904. [4] Rush J. De Quervain’s disease. Curr Orthop. 2000;14:380–383. [5] Huang T-H, Feng C-K, Gung Y-W, et al. Optimization design of thumbspica splint using finite element method. Med Biol Eng Comput. 2006;44:1105–1111. [6] Adachi S, Yamamoto A, Kobayashi T, et al. Prevalence of de Quervain’s disease in the general population and risk factors. Kitakanto Med J. 2011;61:479–482. [7] Mackin E, Hunter JM, Callahan AD, et al. Rehabilitation of the hand and upper extremity. St. Louis (MO): Mosby; 1990. [8] LAPIDUS PW, Fenton R. Stenosing tenovaginitis at the wrist and fingers; report of 423 cases in 369 patients with 354 operations. AMA Arch Surg. 1952;64:475–487. [9] Jongprasitkul H, Suputtitada A. Elastic bandage vs. neoprene thumb stabilizer splint in acute De Quervain’s tenosynovitis. Asian Biomed. 2011;5:263–267. [10] Rettig AC. Athletic injuries of the wrist and hand: part II: overuse injuries of the wrist and traumatic injuries to the hand. Am J Sports Med. 2004;32: 262–273. [11] Papa JA. Conservative management of De Quervain’s stenosing tenosynovitis: a case report. J Can Chiropr Assoc. 2012;56:112–120.
5
[12] Lane L, Boretz R, Stuchin S. Treatment of de Quervain’s disease: role of conservative management. J Hand Surg Br. 2001;26:258–260. [13] Backstrom KM. Mobilization with movement as an adjunct intervention in a patient with complicated de Quervain’s tenosynovitis: a case report. J Orthop Sports Phys Ther. 2002;32:86. [14] Hunter JM, Schneider L, Mackin E, et al. Rehabilitation of the hand. St. Louis (MO): Mosby; 1990. [15] Koman LA, Li Z, Smith BP, et al. Rehabilitation of the hand and upper extremity. 6th ed. Philadelphia: Mosby, Elsevier; 2011. p. 580–585. [16] Batteson R, Hammond A, Burke F, et al. The de Quervain’s screening tool: validity and reliability of a measure to support clinical diagnosis and management. Musculoskeletal Care. 2008;6:168–180. [17] Hudak PL, Amadio PC, Bombardier C, et al. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Head). Am J Ind Med. 1996;29:602–608. [18] Luc D. The DASH questionnaire and score in the evaluation of hand and wrist disorders. Acta Orthop Belg. 2008;74:575–581. [19] Mousavi SJ, Parnianpour M, Abedi M, et al. Cultural adaptation and validation of the Persian version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure. Clin Rehabil. 2008;22:749–757. [20] Fournier K, Bourbonnais D, Bravo G, et al. Reliability and validity of pinch and thumb strength measurements in de Quervain’s disease. J Hand Ther. 2006;19:2–11. [21] Forget N, Piotte F, Arsenault J, et al. Bilateral thumb’s active range of motion and strength in de Quervain’s disease: comparison with a normal sample. J Hand Ther. 2008;21:276–285. [22] Paul-Dauphin A, Guillemin F, Virion J-M, Brianuˆ¨Ion S. Bias and precision in visual analogue scales: a randomized controlled trial. Am J Epidemiol. 1999;150:1117–1127. [23] Dival TA. Hand splinting: principles of design and fabrication. W.B. Saunders, the University of Michigan; 1997. p. 154–156. [24] Kapandji I. The physiology of the joints, vol. 1. New York: Churchill Livingstone; 1982. [25] Dominick KL, Jordan JM, Renner JB, et al. Relationship of radiographic and clinical variables to pinch and grip strength among individuals with osteoarthritis. Arthritis Rheum. 2005;52:1424–1430. [26] Lin JT, Stubblefield MD. De Quervain’s tenosynovitis in patients with lymphedema: a report of 2 cases with management approach. Arch Phys Med Rehabil. 2003;84:1554–1557. [27] Weiss A-PC, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg. 1994;19:595–598.
