Pain along the radial aspect of the wrist and forearm is a

Transcription

1 Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report Michael J. Walker, PT, DSc, OCS, CSCS, FAAOMPT 1 Study Design: Clinical case report. Objectives: To describe a manual physical therapy examination and intervention approach for a patient with radial-sided wrist pain. Background: A 55-year-old woman with a 2-year history of chronic right wrist and forearm pain was referred to physical therapy with a diagnosis of de Quervain s disease. Her current symptoms were present for 6 weeks despite primary care management with wrist splinting and medications. Previous episodes were partially resolved following occupational therapy treatments. Methods and Measures: Examination of the patient s wrist and hand revealed isolated radiocarpal, intercarpal, and carpometacarpal joint dysfunctions. Evaluation of the cervical spine, shoulder, and elbow were negative. Impairment-based treatment was provided during 8 visits over a 4-week period. These treatments consisted of manual physical therapy techniques and self-mobilizations applied to the radiocarpal, intercarpal, and carpometacarpal joints. Results: The initial treatment session decreased the patient s numeric pain rating scale (NPRS) from 7/10 to 4/10 and improved her functional rating on the Patient-Specific Functional Scale (PSFS) from an average of 4/10 to 8.2/10. At treatment completion, she achieved a pain-free state (NPRS, 0/10) and nearly full function (PSFS, 9.8/10). These results were maintained at a long-term follow-up performed 10 months after treatment. Conclusion: Several diagnoses have the potential for causing or referring pain into the radial wrist and forearm region, often times mimicking de Quervain s disease. An impairment-based manual physical therapy model may be an effective approach in identifying joint dysfunctions and managing patients with radial wrist pain. Key Words: de Quervain s disease, impairment-based, manipulation, mobilization Pain along the radial aspect of the wrist and forearm is a common symptom for several pathoanatomical diagnoses. These diagnoses include de Quervain s disease, intersection syndrome, intercarpal instabilities, scaphoid fracture, superficial radial neuritis, C6 cervical radiculitis/radiculopathy, and arthroses of the first carpometacarpal (CMC), intercarpal (IC), or radiocarpal (RC) joints. 3,9,10,18,21,24-26 Despite having several diagnoses from which to choose, physical therapists often find that a patient s signs and symptoms do not neatly fit into a diagnostic label. Because an exact 1 Assistant Chief, Physical Therapy Service, General Leonard Wood Army Community Hospital, Fort Leonard Wood, MO. This case report was completed during doctoral training in the US Army-Baylor University Postprofessional Doctoral Program in Orthopaedic and Manual Physical Therapy, Brooke Army Medical Center, Fort Sam Houston, TX. The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Address correspondence to Michael J. Walker, 64 Delafield, Fort Leonard Wood, MO michael.walker@amedd.army.mil diagnosis is often unknown, Maitland 13 purports that many musculoskeletal conditions may be identified by the presence of the abnormal joint signs of pain, stiffness, and spasm. These abnormal findings, capable of reproducing the patient s symptoms during the physical exam, form the basis for diagnosis and guide subsequent interventions. 13 A thorough examination is critical for understanding the nature and behavior of a patient s condition. The examination must include all regions that may contribute to the symptoms of radial wrist pain or numbness. In addition to an upper-quarter screening exam (to include the cervical spine), several structures in the radial dorsal zone must be examined. 28 These include the scaphoid, scaphotrapezial joint, trapezium, first CMC joint, tendons of the first 3 extensor compartments, and the dorsal radial sensory nerve. 26 Most of the limited medical research for radial wrist pain diagnoses is focused on the common overuse injury known as de Quervain s disease. It was first described as a tenovaginitis, or thickening of the fibrous sheath of the first extensor compartment. 6 Since then, this definition has been expanded to include the inflammation of the synovial sheaths of the extensor pollicis brevis and abduc- Journal of Orthopaedic & Sports Physical Therapy 761

2 tor pollicis longus tendons. 6 Recent histological studies, however, have found that this disorder is characterized by degeneration and thickening of the tendon sheath and is not an active inflammatory condition. 6,22 Typical physical therapy management of de Quervain s disease and other wrist disorders consists of: thumb and wrist splinting; physical agents such as ice, heat, transcutaneous electrical nerve stimulation (TENS), ultrasound, and iontophoresis; friction massage; joint mobilization; active exercise; and patient education. 16,28 Several studies have concluded that local steroid injections are an effective treatment option for de Quervain s disease, 7,20,23,31 especially in treating patients with moderate to severe symptoms that affect their daily activity levels. 11 In a study by Lane et al, 11 wrist splints and nonsteroidal antiinflammatory drugs were found to be effective only in patients with minimal symptoms and no restrictions in daily activities. No added benefit has been found in using a combined injection and splinting approach. 29 However, several complications (ie, skin and subcutaneous fat atrophy, skin depigmentation, infection, tendon rupture, and pituitary-adrenal suppression) have been cited following local steroid injections, specifically with multiple injections. 24 Two case reports have been published that describe manual physical therapy treatment for de Quervain s disease. Backstrom 2 reported the complete resolution of symptoms in a patient with a 2-month history of de Quervain s tenosynovitis by incorporating mobilization with movement (MWMS) techniques into an overall treatment plan. MWMS, as described by Mulligan, 15 uses passive mobilization to theoretically correct subtle joint malalignments, while the patient performs active movements in this corrected joint position. The 2-month treatment program described in this case report consisted of the use of MWMS with radial gliding of the proximal carpal row, MWMS with ulnar gliding of the trapezium, capitate manipulation, carpal and first CMC joint mobilizations, transverse friction massage over the first dorsal tunnel, and conventional physical therapy modalities such as superficial heat, ice, iontophoresis, and wrist splinting. The second case report, by Anderson and Tichenor, 1 used an Australian approach to manual physical therapy for the treatment of a patient with a 6-year history of multiple upper extremity conditions, including cervical spine dysfunction, wrist joint dysfunction, de Quervain s tenosynovitis, hand numbness and tingling, and superficial radial nerve involvement. The Australian approach, as described by Maitland, 13 uses a thorough examination process to identify impairments and develop hypotheses for the cause of symptoms. Treatment techniques are selected, used, and modified based on the patient s response to the examination and intervention. In this case report, the patient reported no wrist or hand pain following a 6-month treatment program consisting of central and unilateral cervical mobilizations, carpal bone mobilizations, cervical and upper extremity stretches, transverse friction massage to the abductor pollicis longus and extensor pollicis brevis tendons, and neural mobilizations. The purpose of this case report is to describe an impairment-based manual physical therapy examination and treatment approach for a patient with radial-sided wrist pain. In contrast to the case reports just cited, this paper presents a patient with localized radial wrist joint dysfunctions and uses a treatment plan based solely on manual physical therapy techniques. METHODS History/Systems Review A 55-year-old, right-hand-dominant woman with right radial wrist and forearm pain was referred to physical therapy by her primary care physician with a medical diagnosis of de Quervain s disease. The patient reported a 2-year history of chronic right wrist pain that was aggravated 6 weeks prior to her physical therapy appointment. She described her pain as a constant aching, burning, and pulling sensation that varied in intensity depending on her activities. These symptoms began near the base of her right thumb and radiated proximally into her radial forearm. She denied having neck, shoulder, or elbow pain, numbness or tingling, or upper extremity weakness symptoms at the time of her examination. The body chart (Figure 1) depicts the patient s pain distribution. The patient attributed her pain to repetitive lifting at work, but denied any recent changes to her work patterns or lifting activities. As a store receiving specialist, her duties involved lifting and sorting boxes of merchandise (4 to 5 hours daily), computer inventory tracking (2 to 3 hours daily), cashier duties (1 hour daily), and money-counting/cash control activities (5 to 6 hours, twice weekly). The patient enjoyed yard work and knitting as her recreational activities. Her current pain was aggravated with lifting, pushing or pulling, washing dishes, turning doorknobs, and gripping activities. Once aggravated, her symptoms would gradually ease to baseline following 1 hour of rest in a neutral wrist position. She was attempting to manage her current pain intensity with nonsteroidal anti-inflammatory medications and a short arm thumb spica splint that immobilized her RC joint in a neutral wrist position and her first CMC joint in thumb abduction. All activities without her splint resulted in an immediate increase in pain. The patient s 24-hour symptom behavior was unremarkable; she reported increased pain with activity and denied morning stiffness or night pain. 762 J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

3 Working Hypothesis The patient presented to physical therapy with chronic radial wrist and forearm pain that were of moderate severity and irritability. Her pain was easily aggravated and required at least 1 hour of rest to return to baseline status. De Quervain s disease was identified as a working hypothesis, based on the patient s prior medical history and diagnoses, her repetitive job activities, and the location and behavior of her pain symptoms. The plan for the initial physical examination was to evaluate her wrist and hand complex with specific emphasis on the RC, IC, and first CMC joints underlying her area of pain. Given the patient s prior history of neck arthritis, a cervical clearing exam and neurological screening were indicated to rule out radial neuritis or C6 radiculitis/radiculopathy. Tests and Measures FIGURE 1. Body chart indicating area of pain. Abbreviations: P1, primary pain; C, constant pain; V, variable intensity depending on activity;, cleared or no complaints by patient. Prior episodes of radial wrist and thumb pain were diagnosed as right de Quervain s tenosynovitis and first CMC joint arthritis by primary care and rheumatology services. The actual presence of CMC joint arthritis was uncertain. Radiographs were interpreted as positive for osteoarthritis by her rheumatologist and negative by the radiologist. Previous treatment consisted of nonsteroidal antiinflammatory medications and an occupational therapy regimen of short arm thumb spica splinting, first CMC joint arthritis splinting, stretching exercises, ultrasound, and ergonomic education. She reported gradual improvement during her 5-month treatment program. At discharge, 20 months prior to her initial visit in physical therapy, her pain had decreased to 2/10 on the numeric pain rating scale while she performed activities out of her splint. Medical screening for systemic disease revealed a history of hypertension, fibromyalgia, and osteoarthritis in her neck, back, and hands. All conditions were asymptomatic at this time, with exception for her right thumb and forearm. Prior surgical history included bilateral simple mastectomies for fibrocystic disease and an extensive family history of breast cancer. The patient s goals were to return to all work activities, knitting, and yard work without pain. Pain Assessment The patient rated her current resting pain symptoms at 7/10 on the 11-point numeric pain rating scale (NPRS), 8 where 0 equals no pain and 10 equals the worst pain imaginable. This tool has been demonstrated to be a valid, internally consistent, and responsive outcome measure. 14,17 Functional Assessment The Patient-Specific Functional Scale (PSFS) was used as an outcome assessment tool to measure functional activities important to the patient. 27 This tool measures the patient s ability to perform specific activities on a scale of 0 to 10, where 0 indicates that she is unable to perform the activity and 10 indicates the ability to perform the task at her preinjury level. This scale has been studied with several different patient populations and found to be a valid, reliable, and responsive outcome tool. 4,17,19,27,30 Using this scale, the patient rated her ability to lift at 3/10, wash dishes at 5/10, and push or pull at 4/10. For a functional task, the patient was asked to lift her purse with her right hand. This task immediately increased her resting pain when using a neutral or pronated grip. Observation/Posture The patient presented to the clinic wearing a short arm thumb spica splint. No swelling was visible along the radial forearm, wrist, or thumb upon removal of the splint. She exhibited a normal sitting posture with no forward head or shoulder positioning. Clearing Exams The cervical spine was cleared using active motion testing and manual overpressure into extension, bilateral rotation, and quadrant maneuvers. The right elbow joint was cleared using full active flexion and extension motions with manual overpressure applied at end ranges. Joints were cleared when active motion and overpressure testing failed to reproduce the patient s pain symptoms. J Orthop Sports Phys Ther Volume 34 Number 12 December

4 FIGURE 2. Radiocarpal joint mobilization technique demonstrating anterior-posterior glide. FIGURE 3. Radiocarpal joint mobilization technique demonstrating ulnar transverse glide Motion Testing Active and passive motion testing of the right wrist revealed full range of motion in all planes. Pain symptoms worsened near the RC joint when overpressure was applied to end-range flexion, radial deviation, and ulnar deviation. Wrist extension and forearm pronation and supination were full and painless with overpressure. Neurological Tests This examination revealed normal strength and sensation in her upper extremities bilaterally. Radial nerve tension testing was performed with the ULNT2b method described by Butler. 3 To specifically test the dorsal radial sensory nerve, the specific hand variation used in this test included a clenched fist around the patient s flexed thumb and wrist ulnar deviation. The patient reported an increase in her radial wrist pain and a strong pulling sensation radiating into her distal radial forearm with this hand positioning. This test was considered negative for radial nerve involvement because symptoms did not increase with further sensitization into shoulder abduction or contralateral cervical side bending. 3 The patient complained of mild stretching pain in the radial wrist when performing the same test on her left upper extremity. Tinel s or percussion testing over the median nerve at the carpal tunnel and superficial radial nerve at the dorsal radial aspect of the wrist were negative. The patient had normal strength (5/5) with manual muscle testing in all planes of the right wrist. Increased pain along the radial wrist and forearm was elicited while resisting right thumb extension. Special Tests The patient had a positive right Finkelstein test 12 with reproduction of her pain and pulling sensation into the radial wrist and forearm. Pain was expected with this test, as it closely resembles the passive wrist positioning involved in radial nerve tension testing (ULNT2b). Finkelstein testing of the left wrist elicited a mild stretch on exam. The first CMC joint grind test, 12 performed by passively rotating the first metacarpal while applying axial compression to the CMC joint, resulted in mild localized pain without reproduction of her radial wrist and forearm pain. Joint Play (Accessory Motion) Testing Passive accessory motion testing was performed at the RC joint. Anterior-posterior (AP) gliding of this joint (Figure 2), which moves the proximal carpal row posterior in relation to the radius, yielded hypomobility and increased pain within the RC joint. Symptoms remained unchanged with posterior-anterior (PA) gliding of the RC joint. Applying an ulnar (medial 13 ) transverse glide to the proximal carpal row (Figure 3) in relation to the stabilized radius revealed minor hypomobility and immediately decreased her radial wrist and forearm pain. Based on these symptom responses, further passive accessory motion testing of the IC, first CMC, and distal radioulnar joints was deferred to allow adequate time for an initial treatment session. Diagnosis Based on the physical exam findings, the primary hypothesis was revised to right RC joint dysfunction with referred pain into the radial forearm. Palpation and accessory motion testing of the RC joint revealed underlying hypomobility that either reproduced or relieved the patient s pain symptoms, depending on the direction of mobilization. The primary impairments found on examination were related to specific joint dysfunctions and not strictly limited to a soft tissue injury, such as de Quervain s disease. It is unlikely that passive accessory motion testing or joint mobilizations would have such an immediate effect on the proposed causes of de Quervain s disease, which are either a stenosis of the extensor tendon compartments 9 or degeneration of the tendon sheath. 6,22 Although further testing was warranted, 764 J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

5 the first CMC joint was considered a possible pain source due to mild tenderness on palpation and grind testing. A good prognosis was anticipated based on her immediate decrease in pain following RC joint ulnar glide mobilizations. Short-term treatment goals were to obtain pain-free active wrist and thumb motion, gripping, and 2- to 5-kg lifting activities within 2 weeks. Long-term goals were to return to pain-free activities and unrestricted lifting in 4 weeks. TABLE 1. Summary of treatment interventions and results. Session 1(day0) 2(day4) 3(day11) Subjective Report and Objective Evaluation Treatment Interventions Posttreatment Reassessment See written narrative for history and physical exam 4/10 pain vicinity of ICJ and CMCJ No radial forearm pain Using thumb spica for CMCJ pain No pain lifting 4.5 kg or dishwashing Pain with end range wrist flexion and radial deviation Hypomobility and pain at RCJ, ICJ, and first CMCJ TTP at EPL/AbPL tendons 85%-90% improvement Mild soreness at volar wrist for 2 days No splinting required for activities Pain with end range wrist flexion Tenderness at RCJ and ICJ 4 (day 13) 2/10 soreness at volar radial wrist Performing all activities with minimal complaints, lifting kg Pain with end range wrist radial deviation and flexion overpressure Tenderness at RCJ, ICJ, and EPB/ AbPL 5 (day 20) No resting pain Volar radial wrist pain with endrange motions Aggravated with lifting 13.6 kg Pain with end range wrist flexion and radial deviation, and forearm supination Tenderness at volar RCJ 6 (day 22) Woke with 7/10 pain, eased to 3/10 Pain with lifting purse this morning Pain with forearm supination overpressure Crepitus and pain with RCJ AP glides 7 (day 27) Resolved symptoms for 5 days Aggravated CMCJ pain while peeling cantaloupe day prior Full motion, no overpressure pain Pain with first CMCJ extension/ flexion Decreased thumb extension by 5 8 (day 32) Dull ache at CMCJ Aggravated with pulling activities at work Pain with thumb extension TTP at first CMCJ RCJ ulnar and AP glides Self-mobilizations: RCJ ulnar and AP glides Wean from short arm thumb spica splint RCJ ulnar and AP glides Scaphotrapezium ICJ AP glides First CMCJ extension mobilizations EPB/AbPL longitudinal stretch Self-mobilizations continued, add scaphotrapezium ICJ AP glides Wean from first CMC joint arthritis splint RCJ and scaphotrapezium ICJ AP glides RCJ longitudinal distraction Self-mobilizations, add wrist distraction Discontinue thumb spica splint RCJ ulnar glides Scaphotrapezium ICJ AP glides EPB/AbPL longitudinal stretch Self mobilizations continue as provided RCJ supination and ulnar glide mobilizations Wrist radial deviation mobilizations Self mobilizations continued, add RCJ supination RCJ supination mobilizations RCJ AP glides Self mobilizations, continue as provided CMCJ PA mobilizations CMCJ extension mobilizations Self-mobilizations: CMCJ PA and extension CMCJ PA mobilizations with distraction Self mobilizations: continue CMCJ PA mobilizations, add distraction Decreased forearm pain to 0/10 Full wrist motion, no pain with overpressure Mild pain with Finkelstein test Lifting purse without pain Full wrist motion, mild pain with wrist flexion overpressure No TTP EPB/AbPL Full wrist motion, mild pain with wrist flexion overpressure Full wrist motion, no pain with overpressure No tenderness with palpation or mobilization No resting pain Full wrist motion, mild pain with wrist radial deviation overpressure Full wrist motion, no pain with forearm supination overpressure Lifting purse without pain Full thumb extension and flexion without pain Minimal TTP on exam FAROM thumb extension and flexion without pain No TTP on exam Abbreviations: AbPL, abductor pollicis longus; AP, anterior-posterior; CMCJ, carpometacarpal joint; EPB, extensor pollicis brevis; FAROM, full active range of motion; ICJ, intercarpal joint; PA, posterior-anterior; RCJ, radiocarpal joint; TTP, tender to palpation. J Orthop Sports Phys Ther Volume 34 Number 12 December

6 Intervention The patient received 8 physical therapy sessions over a 4-week period. An impairment-based approach was used to guide the selection and application of treatment techniques. Table 1 provides a summary of each treatment session, including pretreatment subjective and objective findings, treatment interventions, and posttreatment results. Treatment techniques were initially targeted at identified dysfunctions within the radiocarpal joint. As treatment progressed, the scaphotrapezium IC and first CMC joints were also assessed and treated. Full descriptions of the treatment techniques are available in Maitland s 13 text on peripheral joint manipulation and will not be detailed in this case report. A subtlety that was added to the performance of several techniques was the use of slight longitudinal distraction to further gap or unload the joint as the mobilization force was applied. Small amplitude mobilizations into joint resistance (grades IV to IV+) were used with a typical treatment duration for each mobilization technique, ranging from 3 to 6 bouts of 30 seconds. FIGURE 4. Radiocarpal joint ulnar transverse glide selfmobilization. FIGURE 5. Radiocarpal joint anterior-posterior glide selfmobilization. The initial treatment session consisted of AP and ulnar transverse-glide mobilizations of the RC joint to treat the patient s pain and hypomobility symptoms (Figures 2 and 3). The patient reported an immediate decrease in her right forearm pain from 7/10 to 0/10 following the ulnar transverse-glide mobilizations. AP mobilizations initially increased her RC joint pain; however, her pain and hypomobility decreased as treatment continued. Following the initial treatment session, the patient reported pain-free wrist motion with overpressure and the ability to lift her purse in a pronated or neutral wrist position without pain. A home exercise program consisting of ulnar and AP glide self-mobilizations was provided to replicate and reinforce the clinic treatment program. Ulnar transverse-glide self-mobilizations (Figure 4) were performed with the patient resting the ulnar border of her right forearm on a firm surface with the ulnar styloid just off the edge. The patient applied an ulnarly directed mobilization force to the proximal carpal row using the web space of her opposite hand. AP self-mobilizations (Figure 5) were similarly applied with her forearm in a supinated position. The patient was encouraged to maintain full active motion, perform work and recreational activities as tolerated without increasing pain, and wean herself from the short arm thumb spica splint. Prior to beginning the second treatment session, the patient reported complete resolution of her radial forearm pain. Her pain symptoms were rated at 4/10 and were now localized to the RC, scaphotrapezium IC, and first CMC joints. She had stopped using the short arm thumb spica splint and began wearing her first CMC joint arthritis splint. This splint immobilized the CMC joint in abduction, while allowing full wrist motion. She reported no pain or limitations with light lifting activities at work ( 4.5 kg) and washing dishes. Symptoms remained aggravated with quick movements into radial deviation, gripping, and turning doorknobs. Other aggravating activities added to the Patient-Specific Functional Scale included mixing batter (PSFS, 7) while cooking and repetitive money counting (PSFS, 6) at work. Active motion testing revealed increased pain during wrist flexion and radial deviation. This pain response was reproduced with AP accessory motion testing at the RC, scaphotrapezium IC, and first CMC joints. Her second treatment session consisted of AP and ulnar transverse-glide mobilizations of the RC joint, AP mobilizations of the scaphotrapezium IC joint, first CMC joint passive extension mobilizations, and longitudinal stretching of the extensor pollicis brevis and abductor pollicis longus tendons. These interventions resulted in decreased resting pain to 0/10, minimal pain with wrist flexion overpressure, and no pain with accessory motion testing or palpation. The patient s home exercise program was progressed to include AP self- 766 J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

7 home exercise program continued to focus on selfmobilizations that reinforced clinic treatments. RESULTS FIGURE 6. Scaphotrapezium intercarpal joint anterior-posterior self-mobilization. Pain and Function NPRS PSFS Initial 4 d 5 wk 9 wk 10 mo FIGURE 7. Pain (numeric pain rating scale) and functional (Patient- Specific Functional Scale) improvements. mobilizations of the scaphotrapezium IC joint (Figure 6). This mobilization technique consisted of the patient s supinated forearm resting on a firm surface with the distal carpal row off the surface edge. The patient was instructed to grasp the scaphoid bone (identified by the patient as the bone in the snuff box) with her thumb and index finger, and then to apply a mobilization force towards the floor. As before, pain-free motion and activities were encouraged with a gradual weaning of her first CMC joint arthritis splint. Prior to the patient s third treatment session (10 days after her initial visit), she reported an 85% to 90% improvement in her pain and functional abilities. She had discontinued all of her splint use for activities at home and work. Residual intermittent pain and joint dysfunction symptoms were treated over the next 3 weeks with 6 treatment sessions. The RC and IC joints required 4 additional treatments for complete resolution of localized joint pain. The final 2 treatment sessions focused on the first CMC joint to relieve joint pain that was recently aggravated by peeling a cantaloupe. The patient had improved joint mobility and reported complete relief of current symptoms following each treatment session. The The patient reported a decrease in pain from 7/10 to 4/10 on the NPRS and functional improvement from 4/10 to 8.2/10 on the PSFS after her first treatment session. The patient returned to physical therapy 4 days after her final treatment and reported excellent overall improvement. She had occasional twinges of pain while performing pulling activities at work (PSFS rating of 9 for this activity). Otherwise, she was asymptomatic and returned to all of her normal activities. The overall PSFS for all 5 activities demonstrated excellent improvement with an average rating of 9.8/10. At subsequent follow-ups, performed at 9 weeks and 10 months after treatment completion, the patient remained asymptomatic with no pain symptoms (NPRS, 0/10) and an improvement to full function for all PSFS activities (PSFS, 10/10). Improvements using the NPRS and PSFS are shown in Table 2 and graphically depicted in Figure 7. On physical examination, the patient achieved and maintained pain-free wrist and thumb range of motion, resisted manual muscle testing, and passive accessory motion testing in all planes. She had negative Finkelstein and CMC grind tests. Although not tested during treatment, her maximum grip strength at the 9-week follow-up was pain-free and measured 35.8 kg on her right and 31.3 kg on her left. DISCUSSION As previously mentioned, several diagnoses have the potential for causing or referring pain into the radial wrist and forearm region. 3,9,10,18,21,24-26 These conditions must be considered in the differential diagnosis process. During the patient interview, carpal instability and scaphoid fracture were excluded due to the lack of previous trauma to the region. Cervical (C6) radiculitis or radiculopathy were considered unlikely diagnoses due to no recent complaints of neck pain, no aggravating activities related to cervical postures or motions, and no upper extremity paresthesia. These diagnoses, along with superficial radial neuritis, were subsequently ruled out based on normal cervical clearing and neurological exams. De Quervain s disease and first CMC joint arthrosis were possible diagnoses based on the patient s work environment, prior medical history, and symptom presentation. The rapid improvement of pain symptoms following the application of joint mobilization techniques made the diagnosis of de Quervain s disease doubtful. It is unlikely that these techniques would affect a stenosis of the extensor tendon com- J Orthop Sports Phys Ther Volume 34 Number 12 December

8 TABLE 2. Numeric pain rating scale* and Patient-Specific Functional Scale scores. Initial 4 d 5 wk 9 wk 10 mo NPRS (0-10) PSFS (0-10) Lifting Washing dishes Pushing or pulling Mixing batter Money counting Average Score * Numeric pain rating scale (0, no pain; 10, worst pain imaginable). Patient-Specific Functional Scale (0, unable to perform activity; 10, ability to perform activity at preinjury levels [normal function]). Not obtained during initial evaluation. Added at 4-day follow-up due to improvements in previous measures. Activity was not performed since initial visit. partments 9 or tendon sheath degeneration. 6,22 Although arthroses of the CMC, IC, or RC joints were potential diagnoses, repeat imaging was not deemed necessary, given the patient s normal radiographs from 2 years prior and her positive treatment response. Ultimately, an exact pathoanatomical diagnosis for this patient was not known and, in fact, not required for effective outcomes. A cluster of physical impairments were identified during the physical examination that appeared to contribute to the patient s symptoms. These joint impairments formed the basis for the diagnosis of RC, IC, and CMC joint dysfunctions. An impairment-based treatment approach was used to select, apply, and assess the effectiveness of appropriate manual physical therapy intervention strategies. These treatment techniques were specifically targeted at the physical impairments of joint pain and hypomobility. The patient reported a 3-point reduction in pain intensity (NPRS) and a 4-point increase in functional ability (PSFS) after 1 treatment session, and a self-reported 85% to 90% improvement and discontinued splint wear after her second treatment session. Six additional sessions were used to treat the residual symptoms and impairments in the RC, IC, and first CMC joints. This impairment-based treatment approach seemed to provide an excellent outcome for this patient in terms of pain relief and functional improvement. This case report differs from the 2 previous de Quervain s disease case reports 1,2 on several points. This report uses 2 valid, reliable, and responsive outcome tools for pain (NPRS) and function (PSFS) to measure patient improvement. Pretreatment grip strength and prehension testing were not used, but would have been valuable tools in measuring functional outcomes. In contrast to the patient with multiple upper quarter impairments presented by Anderson and Tichenor, 1 this report highlights a patient with pain and dysfunction localized to the RC, IC, and first CMC joints. The disparity in patient complexity is clearly evident in the different treatment durations (6 months versus 4 weeks) required for symptom resolution. Backstrom 2 presented a patient with a 2-month history of de Quervain s disease that was treated with conventional therapies (iontophoresis, ice, and wrist bracing), conventional joint mobilizations, and adjunctive mobilization with movement techniques. In contrast to Backstrom s study, this case report used an impairment-based treatment program that consisted of only manual physical therapy techniques. Selfmobilization techniques were used in a home exercise program that reproduced and reinforced the clinic treatment. Wrist splinting was discontinued after the second treatment session to encourage normal joint motion and limit the effects of immobilization. CONCLUSIONS This case report highlights the use of an impairment-based manual physical therapy approach for the examination and treatment of a patient with radial wrist pain. Joint impairments formed the basis for the patient s diagnosis, whereas common pathoanatomical diagnoses appeared inappropriate and not specific enough to guide treatment intervention. The impairment-based manual physical therapy approach used in this case report appears to have contributed to the patient s expeditious resolution of pain and full return to activity. Given the inherent limitations of a case report, 5 randomized clinical trials are ultimately necessary to establish a direct cause-and-effect relationship for this approach. REFERENCES 1. Anderson M, Tichenor CJ. A patient with de Quervain s tenosynovitis: a case report using an Australian approach to manual therapy. Phys Ther. 1994;74: 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;32:86-94; discussion J Orthop Sports Phys Ther Volume 34 Number 12 December 2004

9 3. Butler DS. Mobilisation of the Nervous System. Mebourne, Australia: Churchill Livingstone; Chatman AB, Hyams SP, Neel JM, et al. The Patient- Specific Functional Scale: measurement properties in patients with knee dysfunction. Phys Ther. 1997;77: Childs JD. Case reports: can we improve? J Orthop Sports Phys Ther. 2004;34: Clarke MT, Lyall HA, Grant JW, Matthewson MH. The histopathology of de Quervain s disease. J Hand Surg [Br]. 1998;23: Harvey FJ, Harvey PM, Horsley MW. De Quervain s disease: surgical or nonsurgical treatment. J Hand Surg [Am]. 1990;15: Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain. 1994;58: Kay NR. De Quervain s disease. Changing pathology or changing perception? J Hand Surg [Br]. 2000;25: Kozin SH. The surgical treatment of scaphotrapeziotrapezoid osteoarthritis. Hand Clin. 2001;17: Lane LB, Boretz RS, Stuchin SA. Treatment of de Quervain s disease:role of conservative management. J Hand Surg [Br]. 2001;26: Magee DJ. Orhopaedic Physical Assessment. 2nd ed. Philadelphia, PA: W. B. Saunders Company; Maitland GD. Peripheral Manipulation. 3rd ed. Oxford, UK: Butterworth-Henemann; McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med. 1988;18: Mulligan BR. Manual Therapy: NAGS, SNAGS, MWMS, etc. 4th ed. Wellington, New Zealand: Plane View Services; Palmieri TJ, Grand FM, Hay EL, Burke C. Treatment of osteoarthritis in the hand and wrist. Nonoperative treatment. Hand Clin. 1987;3: Pengel LH, Refshauge KM, Maher CG. Responsiveness of pain, disability, and physical impairment outcomes in patients with low back pain. Spine. 2004;29: Pick RY. De Quervain s disease: a clinical triad. Clin Orthop. 1979; Pietrobon R, Coeytaux RR, Carey TS, Richardson WJ, DeVellis RF. Standard scales for measurement of functional outcome for cervical pain or dysfunction: a systematic review. Spine. 2002;27: Rankin ME, Rankin EA. Injection therapy for management of stenosing tenosynovitis (de Quervain s disease) of the wrist. J Natl Med Assoc. 1998;90: Rask MR. Superficial radial neuritis and De Quervain s disease. Report of three cases. Clin Orthop. 1978; Read HS, Hooper G, Davie R. Histological appearances in post-partum de Quervain s disease. J Hand Surg [Br]. 2000;25: Sakai N. Selective corticosteroid injection into the extensor pollicis brevis tenosynovium for de Quervain s disease. Orthopedics. 2002;25: Sampson SP, Wisch D, Badalamente MA. Complications of conservative and surgical treatment of de Quervain s disease and trigger fingers. Hand Clin. 1994;10: Servi JT. Wrist pain from overuse: detecting and relieving intersection syndrome. Phys Sports Med. 1997;25: Skirven T. Clinical examination of the wrist. J Hand Ther. 1996;9: Stratford PW, Gill C, Westaway MD, Binkley JM. Assessing disability and change on individual patients: a report of a patient specific measure. Physiother Can. 1995;47: Waite J. Physical therapy management for patients with wrist and hand disorders. Orthop Phys Ther Clin N Am. 1999;8: Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain s disease. J Hand Surg [Am]. 1994;19: Westaway MD, Stratford PW, Binkley JM. The patientspecific functional scale: validation of its use in persons with neck dysfunction. J Orthop Sports Phys Ther. 1998;27: Zingas C, Failla JM, Van Holsbeeck M. Injection accuracy and clinical relief of de Quervain s tendinitis. J Hand Surg [Am]. 1998;23: J Orthop Sports Phys Ther Volume 34 Number 12 December