Effective Conservative Treatments for De Quervain's Tenosynovitis: A Retrospective Study

Study Design: Retrospective chart review. Introduction: De Quervain’s tenosynovitis is a repetitive stress disorder occurring at the first dorsal compartment of the wrist at the radial styloid and is commonly treated by hand therapists. 1-3 Conservative treatments include activity modification, modalities, orthotics, and manual therapy. 4-7 The literature is unclear regarding best practice for treating de Quervain’s tenosynovitis with conservative methods. 5,8,9 Purpose of the study: The purpose of this study was to identify which treatment or treatment combinations was most effective to reduce pain and improve functional outcomes for patients with de Quervain’s tenosynovitis. Methods: A retrospective chart review was conducted with 42 patients seen in outpatient therapy. Patient pain was measured using the Numeric Pain Rating Scale (NPRS) and the QuickDASH was utilized to assess functional outcomes. 10,11 Results: Both iontophoresis with dexamethasone and therapeutic pulsed (20% or 50%) ultrasound (1.0-1.5 w/cm 2 ) were found to have clinical significance as well as statistical significance on the QuickDASH (p= 0.028) and NPRS (p= 0.046) respectively. Other treatment methods were found to be clinically significant but not statistically significant. Demographics of this sample were reflective of the literature as there were 32 women and 10 men. 6 The mean age of the sample was 39.13 years (range 19-63 years). Conclusion: This study demonstrated that iontophoresis with dexamethasone may improve functional outcomes while therapeutic pulsed (20% or 50%) ultrasound (1.0-1.5 w/cm 2 ) may be effective in decreasing pain in patients with de Quervain’s tenosynovitis. Level of Evidence: 4. 12 TREATMENTS FOR DE QUERVAIN’S TENOSYNOVITIS 3 Introduction De Quervain’s tenosynovitis is a condition characterized by inflammation at the first dorsal compartment of the wrist at the radial styloid. 2 Inflammation affects the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons and each of their tendon sheaths and may result in thickening of the first dorsal extensor sheath. Individuals who perform repetitive activities of the wrist and hand and who repeatedly use their thumbs in grasping and pinching motions are most susceptible to de Quervain’s tenosynovitis. 3 Population groups at an increased risk for the development of de Quervain’s tenosynovitis include: women, parents of young children, and individuals with job tasks that involve repetitive movements of the hand and wrist. 6 The main symptom of de Quervain’s tenosynovitis is pain with motions of the wrist or thumb. 13 Decreased abduction of the carpometacarpal joint of the thumb, palpable thickening of the extensor sheath and of the tendons distal to the extensor tunnel, and crepitus of the tendons moving through the extensor sheath may also occur. 2 Studies have agreed upon diagnostic criteria for de Quervain’s tenosynovitis including pain or tenderness over the radial side of the wrist and pain reproduced by resisted thumb extension or abduction. In addition, the Finkelstein’s test is a physical assessment used to diagnose de Quervain’s tenosynovitis, which is administered by folding the thumb across the palm and flexing the fingers over the thumb as the wrist is actively or passively deviated toward the ulnar side. 5 A positive test results in localized pain over the radial styloid and may indicate tenosynovitis of the APL and EPB tendons. Validity and reliability of this test has been questioned by several authors. 6,13-15 De Quervain’s tenosynovitis is one of the most common diagnoses treated by occupational therapists specializing in hand therapy; therefore, it is imperative that hand/ occupational therapists have knowledge of evidence-based tools and techniques specific to de TREATMENTS FOR DE QUERVAIN’S TENOSYNOVITIS 4 Quervain’s tenosynovitis. 1 Conservative occupational therapy treatments for de Quervain’s tenosynovitis include, but are not limited to, physical agent modalities (i.e. iontophoresis, ultrasound, and fluidotherapy), activity modification, manual therapy, anti-inflammatory medications, and a thumb spica or long opponens orthosis. 4-7 Although the existing literature provides information regarding tools and treatment methods, there is no consensus on the appropriate course of treatment for a patient with de Quervain’s tenosynovitis. 5,8 Similarly, there are no useful evidence-based recommendations for the treatment of de Quervain’s tenosynovitis as there are no randomized clinical trials available that assess the effectiveness of conservative treatment with this condition. 9 Effective treatment of de Quervain’s tenosynovitis using fluidotherapy, iontophoresis, and ultrasound therapy is not well supported in the literature, but these modalities are commonly used in clinical settings. Activity modification is usually addressed following the diagnosis of de Quervain’s tenosynovitis. Activity or worksite modifications may include rest, upper extremity orthoses, job and activity modifications, or physiotherapy. 16 Massage, joint manipulation, and joint stabilization techniques are the most common forms of manual therapy for treating de Quervain’s tenosynovitis. 17,18 This retrospective study was a collaboration between a university and a healthcare organization that explored the effectiveness of conservative hand/occupational therapy treatments and combination of treatments for individuals diagnosed with de Quervain’s tenosynovitis. Prior to data collection, this study was approved by two review boards: the university review board and the healthcare organization review board. TREATMENTS FOR DE QUERVAIN’S TENOSYNOVITIS 5 Purpose of the Study The purpose of the study was to identify which treatment or treatment combinations was most effective for patients diagnosed with de Quervain’s tenosynovitis. Effectiveness was determined by improvement on the QuickDASH and the Numeric Pain Rating Scale (NPRS). 10,11