A case report submitted for the degree of. Doctor of Physical Therapy. Carroll University. Waukesha, WI. Kyle Vande Hei, SPT.

Transcription

1 The effect of H-wave therapy on pain control and return to function following carpal tunnel surgery in a 49 year old African American female: A Case Report A case report submitted for the degree of Doctor of Physical Therapy at Carroll University Waukesha, WI Kyle Vande Hei, SPT Spring 2014 Vande Hei 1

2 The effect of H-wave therapy on pain control and return to function following carpal tunnel surgery in a 49 year old African American female: A Case Report Kyle Vande Hei, SPT* Jane F. Hopp, PhD** Jennifer Supko, DPT*** *Doctor of Physical Therapy Student, Doctor of Physical Therapy Program, Carroll University, Waukesha, WI **Dean, College of Natural, Health Sciences and Business, Carroll University, Waukesha, WI ***Doctor of Physical Therapy, Clinic Director, Physiotherapy Associates Bloomingdale, Brandon, FL Vande Hei 2

3 ABSTRACT Background & purpose: H-wave therapy (HWT) has been shown to have hypoalgesic effects for chronic pain and to improve function following rotator cuff surgeries but effect on pain following acute surgeries is not known. This case report was conducted to address the effectiveness of HWT for pain control and return to prior function following carpal tunnel surgery. Case description: The subject is a 49 year old African-American female who presented to therapy following her left carpal tunnel surgery with primary impairments of left wrist pain and decreased left wrist range of motion (ROM) and strength. The subject had previously undergone right carpal tunnel surgery and had received physical therapy with interventions focused on stretching, ROM activities and strengthening with cryotherapy used for pain relief. Following Physical Therapy the patient demonstrated improved ROM and strength in the right upper extremity but with ongoing pain in the right wrist. Following the left carpal tunnel surgery interventions were similar with HWT as the primary pain control modality. Outcomes: The patient returned to work within 2 weeks of initiating therapy and demonstrated improved ROM, strength, decreased pain intensity, and improved functional outcome scores following treatment. HWT produced immediate but temporary pain relief with application. Discussion: There are a multitude of hypotheses regarding the mechanism of action of HWT. Since HWT produced a local hypoalgesic effect in this case report following application, this may be due to a direct effect on the underlying nerves. Further research needs to be conducted to determine the physiological action of HWT to broaden its clinical use. Key words: Carpal tunnel surgery, carpal tunnel syndrome, CTS, H-wave therapy, HWT Manuscript word count: 3,217 words Vande Hei 3

4 BACKGROUND AND PURPOSE Carpal tunnel syndrome (CTS) is the most prevalent entrapment neuropathy of the wrist. CTS may be associated with various pre-existing diseases but overuse-type injuries that are a result of repetitive motions are often a major contributing factor 1,2. With a prevalence ranging from 2.7 to 5.8 percent 2 and work-related tasks frequently being the underlying cause of CTS, the symptoms typically limit the an individual s functional abilities. Conservative treatment is the first choice of management but in more severe cases surgery may be required. Outcomes following surgical management are dependent upon the degree of nerve damage and the duration of compression but one of the most important factors of a poor post-surgical prognosis is severe post-operative pillar pain 1. Pillar pain is described as a deep ache over the thenar or hypothenar eminence that is often brought on by gripping and carrying with the affected hand 3. The presence of pillar pain greater than 18 months post-operatively is also associated with dissatisfaction with the surgical outcomes 3. Despite the prevalence of CTS and the importance of limiting post-operative inflammation and pain levels, little research has addressed pain control modalities outside of cryotherapy and NSAIDs. With the depth of penetration of cryotherapy being approximately one cm 4, the physiological effects of cryotherapy may not penetrate completely through the thenar eminence and into the carpal tunnel which is the origin of pillar pain. HWT is an electro-therapeutic treatment developed by Electronic Waveform Lab that delivers a biphasic wave of long pulse duration with either a low (2 pps) or high (60 pps) frequency 5. A study by McDowell et al. found that after 15 minutes of high frequency HWT subjects showed a significant elevation in mechanical pain threshold compared to the placebo groups. Although the actual physiological mechanism of HWT is unknown, it is proposed that the stimulation-inducted hypoalgesia may be due to the effects on conduction of underlying nerves 6. In a study by Blum et al. 7, HWT was found to result in improved range of motion (ROM) following a rotator cuff surgery and resulted in better functional outcome compared to a placebo treatment. Although this study did not directly address the hypoalgesic effects of HWT, the improvements in ROM suggested that HWT had significant pain relieving effects in these patients. Although HWT has been shown to have hypoalgesic effects and result in improved ROM and function following rotator cuff surgery, HWT has not been used as the primary pain control modality following carpal tunnel surgery. The purpose of this intervention case report is to explore the effectiveness of HWT in pain control following carpal tunnel surgery as identified by 1) patient reports of pain severity on a daily basis and 2) functional outcomes related to ADLs and work tasks. HISTORY AND SYSTEM S REVIEW The patient was a 49 year old African American female who presented to outpatient physical therapy one month post left carpal tunnel surgery (December 2013) as the primary diagnosis. The patient s past medical and surgical history was positive for Hepatitis B in 1980, current smoker since 1996, anxiety since 2013, carpal tunnel syndrome of both wrists and initial carpal tunnel surgery of the right wrist in August The patient also had a history of numbness and tingling of both hands in the median nerve distribution which directly led to the diagnosis of bilateral carpal tunnel syndrome in May Other than the previously listed conditions, a systems review was unremarkable and the patient Vande Hei 4

5 reported her overall health at present as very good. The patient was employed as a mortgage specialist, working hours/week on a computer which likely contributed to the diagnosis of carpal tunnel syndrome which is why the patient s medical management was being paid by Worker s Compensation insurance. Prior to the surgery the patient reported severe pain with typing, writing, carrying and lifting light objects, and any tasks requiring gripping or grasping of either hand. The patient chose to have the right wrist operated on in August 2013 due to being right handed and no longer being able to use the right hand for work related tasks. Following the initial surgery the patient had high level of post-operative pillar pain for three months which is why she waited four months to have the left wrist operated on. Therapy following the initial surgery focused on wrist ROM activities, strengthening, and cryotherapy for pain control. The patient s goal for this episode of care was to decrease her post-operative pain level and return to work as quickly as possible once the pain was under control. CLINICAL IMPRESSION #1 The primary problem of the patient in this case report was high post-operative pain levels following a carpal tunnel surgery. The clinical decision-making process used to select the following tests and measures at the initial therapy visit was based on the patient s pertinent medical and surgical history, particularly the recent carpal tunnel surgery of the right wrist, as well as clinical experience and knowledge of typical impairments following carpal tunnel surgery. Initial primary objective tests and measures included the patient s pain behavior using the visual analog scale (VAS) and functional outcomes including the Disabilities of the Arm, Shoulder, and Hand (DASH), the Carpal Tunnel Syndrome (CTS) Symptom Severity Scale (SSS), and the CTS Functional Status Scale (FSS). Secondary measures included grip strength, wrist and hand strength, palpation, wrist and elbow active range of motion (AROM), and joint integrity/mobility of the wrist complex. The participant was a particularly good candidate for this case report as she did not respond well to the use of cryotherapy following her last carpal tunnel surgery and she was highly motivated to return to her prior functional status EXAMINATION The patient s primary complaints were severe pain with typing, writing, carrying and lifting light objects, and any tasks requiring gripping or grasping of either hand. The patient was currently not working but reported that she would likely need to return to work sooner than later for financial reasons. ROM measurements were assessed using techniques defined by Norkin & White s Measurement of Joint Motion 9 and muscle testing was performed based on the description provided by Reese s Muscle and Sensory Testing 9.The DASH has been shown to be a reliable (ICC = 0.96) and valid outcome tool (Pearson r > 0.70) 10 and both the SSS and FSS have been shown to have high test-retest reliability (Pearson r = 0.91 and 0.93, respectively) 11. However, although all three outcomes have been shown to have high responsiveness, a minimal clinically important difference has not been established for any of the outcomes. Over a 24 hour period the patient reported 10/10 pain at worst and 7/10 pain at best with no apparent consistency in pain pattern other than an increase in pain with activity and a slight decrease with rest. The pain was located on the anterior aspect of the left forearm and volar surface into the left thumb and was described as sharp and stabbing. The patient stated that she considered 3/10 pain as tolerable. Joint play assessment revealed bilateral hypomobility of the anterior glide of the proximal radio-ulnar joint, posterior glide of the distal and proximal radio-ulnar joint, and long axis traction with reports of Vande Hei 5

6 pain with all glides on the left. The patient demonstrated hypersensitivity with palpation to the left anterior wrist and into the volar surface of the hand, impaired sensation in the medial distribution of the left wrist/hand, and increased tone of the left wrist flexor and extensor musculature. Scar tissue mobility was impaired but typical based on the healing time frame. No impairments were noted in the right hand or wrist region with palpation. Wrist and elbow AROM and strength findings are presented in Table 1. Scores of the initial functional outcome assessments were 29.2% on the DASH and 75% on the work module portion of the DASH, 4.0 on the SSS, and on the FSS. Based on the subjective and objective findings, the patient s primary impairments included: significant reports of pain at rest and increasing with activity, impaired joint mobility of bilateral wrist complexes, impaired left wrist and forearm AROM and strength, and decreased left grip strength. The results of the functional outcome assessments supported these findings and the signs and symptoms were consistent with the typical impairments following a carpal tunnel surgery. Based on the patient s daily job requirements and repetitive tasks, expected time to return to work was three months from the date of the surgery. The plan of care focused on improving the deficits through ROM and strengthening activities, joint mobilizations of the wrist complex and H-wave therapy for pain control. Functional and impairment goals were as follows: 1. Short term goal: Biomechanical improvements in joint mobility of the wrist complex to slight restrictions by January 27 th, Short term goal: Decrease patient s report of worst pain with ADLs and work related tasks to 8/10 by February 3 rd, Long term goal: Decrease patient s report of worst pain with ADLs and work related tasks to 5/10 by February 17 th, Long term goal: AROM improvements of the left wrist complex to 70 degrees of flexion, 70 degrees of forearm supination, 25 degrees of radial deviation, and 40 degrees of ulnar deviation for improved performance of work tasks and holding objects by February 17 th, Long term goal: Musculoskeletal improvements in average left grip strength to 35.0 pounds for grasping and holding objects by February 10 th, CLINICAL IMPRESSION #2 Based on the patient s history of high pain levels following her initial surgery as well as her current presentation of high pain intensity, the patient was appropriate for the use of HWT for pain control based on the potential hypoalgesic effects of HWT. To determine the overall effectiveness of HWT, pain intensity was assessed pre- and post-treatment and functional outcome measures were used to determine whether HWT effectively decreased the patient s pain to a tolerable level to function in daily life and work. Anticipated functional outcomes for this patient included full return to prior level of function including all work and recreational tasks without pain. The proposed frequency and duration of treatment was three visits/week for two weeks and then decreasing to 2 visits/week for an additional two weeks for a total of 4 weeks of treatment. INTERVENTIONS Since it had been a month since the date of surgery and the patient had not been moving the left hand or wrist much since the surgery due to pain, initial interventions focused on decreasing pain and Vande Hei 6

7 improving ROM before improving strength. Passive stretches of the wrist musculature, AROM activities, therapist applied PROM, scar and joint mobilizations, and soft tissue mobilizations were initially prescribed. As patient progressed, AROM of the left wrist with weight was added. Interventions performed at each session, goal of the interventions and the patient s response to the interventions are presented in Table 2. Progression was based on the patient s pain tolerance and increases in the patient s pain intensity were avoided as much as possible with all interventions. The patient was instructed to stretch to the point just before pain and to perform all interventions that were performed for a set period of time only as long as she could tolerate without increasing her pain level > 8/10. The interventions in Table 2 were the same interventions that were initiated and prescribed following the patient s initial carpal tunnel surgery of the right wrist. They were chosen because the patient had previously demonstrated improved AROM and strength of the right wrist and hand with the chosen interventions. The difference between the left wrist plan of care and the right wrist was the use of H-wave therapy for pain control at the end of therapy. Since the patient responded poorly to the use of cryotherapy for pain control of the right wrist and HWT has shown to have an analgesic effect, HWT was chosen over cryotherapy. Four electrodes were placed on the patient s left wrist/forearm. Figure 1 presents the electrode placement on the wrist. Two electrodes were placed proximally on the wrist flexor and extensor muscle bellies (labeled as electrode A) with low frequency (2 pps) applied to elicit a contraction and two electrodes were placed distally, one on the volar surface and one on the dorsal surface of the wrist (labeled as electrode A) with high frequency (60 pps) applied for the analgesic effect. Electrodes labeled B in Figure 1 were not used due to the location and nature of the patient s symptoms. HWT was applied for 15 minutes and intensity was dependent on the patient s tolerance with goals of >5 ma. The patient s pain level was assessed using the VAS both pre and post-treatment. The patient suffered a fall at the beginning of the second week of treatment which caused her pain to significantly increase and to miss one day of therapy. The patient ultimately received 7 treatments over a 3 week period which is 3 sessions less than initially planned. OUTCOMES The primary measure of pain intensity was recorded at each session pre- and post-treatment. Secondary measures were only assessed at initial and discharge dates. Following the evaluation insurance approved three weeks of therapy. The patient returned to work during the second week of therapy per company policy to continue to receive health care coverage. At discharge, the patient had pain with typing, writing, carrying and lifting light objects, and any tasks requiring gripping or grasping of either hand but reported the pain was 7/10 at worst with activity and decreased to 3/10 at rest, both lower than initially reported. The pain was localized to the left thenar eminence and was described as a dull ache. Joint play assessment showed improved mobility of the anterior glide of the proximal radio-ulnar joint, posterior glide of the distal and proximal radio-ulnar joints, and long axis traction and pain only reported with the posterior glide of the distal radio-ulnar joint. Palpation no longer revealed hypersensitivity but there were still reports of impaired sensation in the medial nerve distribution of the left hand but to a lesser extent than previous. Left wrist flexor and extensor musculature tone were within normal limits and scar mobility was still impaired. Final wrist and elbow AROM and strength results are presented in Table 3. Figure 2 presents the patient s pain pre- and post-application of HWT. Vande Hei 7

8 All planes of left wrist and elbow AROM improved from initial measures and the only reports of pain were with left radial deviation strength testing. Final results of the functional outcomes were 18.1% on the DASH and 50% on the work module portion of the DASH, 2.5 on the SSS, and 2.0 on the FSS, all showing improvements from baseline. Although the patient demonstrated improvements of all impairments, she did not meet her long-term pain or grip strength goal. However, at discharge the patient was functional in her current status and was content with the pain intensity and frequency that she was experiencing. DISCUSSION The purpose of this intervention case report was to explore the effectiveness of HWT in pain control and return to prior function following carpal tunnel surgery. On average the patient reported a 50% reduction in pain intensity following HWT which suggests that HWT had a direct and immediate effect on local pain intensity. Although the hypoalgesic mechanism of HWT is not known, the significant reduction in pillar pain from pre- to post-application of HWT in this case report advocates for further exploration into the hypoalgesic effects of HWT. McDowell et al. 6 proposed that HWT s hypoalgesic effect is due to the effect on the conduction of underlying nerves. Since pain due to carpal tunnel syndrome is due to median nerve compression, if McDowell s proposition is correct, it would make sense that it would have such a profound effect on pain intensity when used post carpal tunnel surgery since it is applied directly over the median nerve. The significant reduction in pain intensity following HWT would also allow the patient to participate in her regular activities and return to work sooner which is likely the reason for the significant improvement in her DASH, FSS, and SSS scores. Although no MCID has been established for these outcomes, research has shown that they are effective at evaluating change in function over time and it can be assumed that the improvements from baseline are clinically important as all three outcome scores increased. Blum et al. 7 looked the effect of HWT on pain relief for chronic soft tissue pain and found moderate to strong effect of HWT on pain relief which then led to a decrease in the intake of pain medication and an increase in functionality. These results are consistent with the findings of this case report. However, there is the potential that the patient responded to the soft tissue mobilization and joint mobilizations for pain control, but this would not account for the difference in pain report immediately before and after the application of HWT. Other studies have shown hypoalgesia benefits of HWT for neuropathic pain associated with diabetes as well as experimentally induced ischemic pain but these results have not been supported by follow-up studies 5. Early in the patient s rehabilitation process the patient s pain was relatively well controlled and responding well to HWT. Following a fall she experienced after three treatment sessions the patient missed one day of therapy and began reporting 10/10 pain on arrival. The patient s high pain level limited how aggressive the treatment sessions could be and slowed her overall progress. However, the patient continued to respond well to HWT even after the fall and continued to demonstrate an average of 50% reduction in pain intensity following application which suggests that the fall may have caused a setback in returning to the patient s prior level of function but did not affect the effectiveness of HWT. Therefore, the lack of goal achievement at discharge is likely due to the fall and not related to the interventions implemented. Vande Hei 8

9 Limitations to this study include a lack of specific parameters for the application of HWT to the wrist and forearm. Although an intensity goal of 5 ma in suggested, there is currently no known rationale or evidence of 5 ma producing better results than any other intensity. Previous research has shown that HWT produces the greatest increase in hypoalgesia in the first 10 minutes of application but that the mechanical pain threshold continues to steadily rise for up to 30 minutes 6. Since HWT was applied for 15 minutes in this case report, the full hypoalgesic effects of HWT may not have been achieved. The findings of this case report suggest that HWT may have potential as a primary pain control modality following carpal tunnel surgery. The subject reported approximately a 50% relief in pain intensity directly following application of HWT and was able to return to work within two weeks of initiating Physical Therapy. Although the pain relief was not long term, it may allow for faster recovery and return to function by limiting the detrimental effects of pillar pain following carpal tunnel surgery. If HWT has a direct effect on the nerve conduction velocity of underlying nerves, the potential benefits may be broadened to encompass a wide array of diagnoses. Further research needs to be done to determine whether the effectiveness of HWT can be expanded to other neurological-related diagnoses and to identify the specific mechanism of action of HWT. Vande Hei 9

10 REFERENCES 1. The Brigham and Women's Hospital. (2007). Standard of Care: Carpal Tunnel Syndrome. Department of Rehabilitation Services. 2. LeBlanc, K., & Cestia, W. (2011). Carpal Tunnel Syndrome. American Family Physician, 53(8), Yung, P., Hung, L., Tong, C., & Ho, P. (2005). Carpal tunnel release with a limited palmar incision: Clinical results and pillar pain at 18 months follow-up. Hand Surgery, 10(1), Michelle H. Cameron (2009). Physical Agents in Rehabilitation: From Research to Practice (3 nd Edition). Saunders 5. Johnson, M. (2001). Transcutaneous electrical nerve stimulation (TENS) and TENS-like devices: Do they provide pain relief? Pain Reviews, 8, McDowell, B., McCormack, K., Walsh, D., Baxter, D., & Allen, J. (1999). Comparative Analgesic Effects of H-Wave Therapy and Transcutaneous Electrical Nerve Stimulation on Pain Threshold in Humans. Archives of Physical Medicine Rehabilitation, 80, Blum, K., Chen, A., Chen, T., Prihoda, T., Schoolfield, J., DiNubile, N.,... Tung, H. (2008). The H-Wave device is an effective and safe non-pharmacological analgesic for chronic pain: a Metaanalysis. Advances in Therapy, 25(7), Norkin, Cynthia C. and White, D. Joyce (2009). Measurement of Joint Motion: A Guide to Goniometry (4th edition). F.A. Davis Company, Philadelphia. 9. Reese, N. (2012). Muscle and Sensory Testing (3 rd edition). Saunders. 10. Stiller, J., & Uhl, T. (2005). Outcomes measurement of upper extremity function. Human Kinetics, 10(3), Changulani, M., Okonkwo, U., Keswani, T., & Kalairajah, Y. (2008). Outcome evaluation measures for wrist and hand: Which one to choose? International Orthopaedics, 32, Vande Hei 10

11 Table 1: Initial wrist and elbow AROM and strength; * = with pain Left Right Motion AROM (degrees) Strength AROM (degrees) Strength Wrist extension (full fist) 63* 4/5* 76 4+/5* Wrist flexion (full fist) 60* 4/5* 60 4/5 Forearm Pronation 90* 4+/5* 90 4+/5 Forearm Supination 55* 4+/5* 65 4+/5 Radial Deviation 20* 4-/5* 24 4/5* Ulnar Deviation 37* 4/5* 35 4/5 Grip Strength (average) 30.0 pounds 40.0 pounds Vande Hei 11

12 Table 2: Intervention description, goals, and outcomes Session Interventions Description/Parameters Goal of Intervention 1 Thorough subjective and objective examination and baseline measurements were taken at the initial session and treatment was withheld except for H-wave therapy 1. H-wave therapy 2 1. Passive wrist stretches into flexion, extension, radial deviation and ulnar deviation 2. ABC s 3. Wrist PROM all planes 4. Isometric gripping 5. Joint mobilizations 6. Scar mobilization 7. Soft-tissue massage 8. H-wave therapy 1. Patient seated with forearm relaxed and supported for comfort. Four electrodes were placed as depicted in Figure 1 with the two proximal electrodes set to low frequency (2 pps) and the two distal electrodes set to high frequency (60 pps). Applied for 15 minutes at 4.0 ma. 1. Patient seated with hands held in prayer position until stretch is felt but before pain. Repeated into reverse prayer position. Patient with elbow extended and passively pulling left wrist into radial deviation and then ulnar deviation. Hold each 30 sec x Patient seated with elbow extended and forearm supported. Actively drawing ABCs without weight focusing on all movement coming from wrist. Performed 1x throughout. 3. Therapist passively moves patient s wrist through all planes of motion with 5 second holds at end range but not pushing into pain. Total of 5 minutes. 4. With red theraputty, patient actively grips putty and holds for approximately 5 seconds, relaxes and repeats. Goal of 2 minutes, initially Response 1. Decrease pain. 1. Preintervention pain: 8/10; Postintervention pain: 4/10 1. Increase ROM and decrease tone. 2. Increase ROM, light strengthening 3. Decrease pain and increase ROM 4. Grip strengthening 5. Decrease pain and guarding, increase ROM 6. Decrease scar tissue formation, improve scar mobility 7. Decrease pain and guarding, decrease tone 8. As previous. 1. No increase in pain, improved ROM 2. Slight fatigue and mild increase in pain level 3. No change in pain 4. Increase in pain to 8/10 after 1 minute. 5. Initial increase in pain with Grade II, decrease back to baseline with grade I of distal radio-ulnar joint. 6. No immediate effect. 7. Decrease in pain and tone of musculature 8. Preintervention pain: 8/10, Post- Vande Hei 12

13 3 1. Interventions 1-8 as previous. No new interventions initiated. 4 Withheld exercises 2 & 4 per patient discomfort performed 1 minute. 5. A-P and P-A joint mobilizations of the left proximal and distal radio-ulnar joints. Grade I/II x 2 minutes each joint. 6. Multidirectional scar mobilizations to left anterior wrist x 2 minutes. 7. With patient s forearm supported and relaxed, manual soft tissue mobilization to the left wrist flexor and extensor musculature using deep tissue massage cream and moderate pressure x 5 minutes. 8. As previously described but at 4.5 ma. As previous, advanced: 1. Performed ABCs x Isometric grip with red putty x 90 seconds 3. HWT at 5.1 ma. Exercises 1, 3, 5-8 as previous. 1. HWT at 5.0 ma As previous As previous. intervention pain: 5/10 1. Increased ROM. 2. Improved tolerance from previous. 3. No change. 4. Slight increase in pain. 5. Slight increase in pain. 6. No change. 7. Decreased pain. 8. Preintervention pain: 8/10; Postintervention pain: 4/10 1. Increased pain with all activities this session. 2. HWT: Preintervention Vande Hei 13

14 5 Performed all exercises as previous. Initiated: 1. Left wrist AROM: flexion, extension, radial deviation, ulnar deviation 6 All exercises as previous. 7 All exercises as previous; discontinued wrist PROM and scar mobilization. All exercises as previous. 1. AROM exercises performed with forearm supported on pillow with 3 pound weight. 10 repetitions x1. 2. HWT at 5.5 ma As previous, advanced: 1. Isometric grip x 2 minutes. 2. Only Grade II joint mobilizations 3. AROM exercises performed 10 repetitions x HWT at 5.5 ma. As previous, advanced: 1. HWT at 5.5 ma As previous 1. Wrist strengthening pain: 10/10; Postintervention pain: 7/ Increased ROM. 2. No change. 3. No change. 4. No change. 5. No change. 6. No change 7. Decreased pain 8. HWT: Preintervention pain: 10/10; Postintervention pain: 5/ Slight increase in pain As previous Exercises 1-7, 9 as previous. 1. HWT: Preintervention pain: 6/10; Postintervention pain 3/10 As previous. As previous. 1. HWT: Preintervention pain: 5/10; Postintervention pain: 3/10. Vande Hei 14

15 Table 3: Final wrist and elbow AROM and strength; * = with pain. Left Right Motion AROM (degrees) Strength AROM (degrees) Strength Wrist extension (full fist) 78 5-/ /5 Wrist flexion (full fist) 72 4+/5 60 4/5 Forearm Pronation 90 4+/ /5 Forearm Supination 69 4+/ /5 Radial Deviation 28 4+/5* 24 4/5 Ulnar Deviation 38 4+/5 35 4/5 Grip Strength (average) 33.0 pounds 40.0 pounds Vande Hei 15

16 Figure 1: H-wave therapy hand and forearm placement Vande Hei 16

17 Figure 2: Pain intensity pre- and post-hwt 12 Pain Intensity Pre- and Post-HWT 10 8 VAS score (0-10) 6 4 Pre-treatment Post-treatment Jan 23-Jan 26-Jan 29-Jan 1-Feb 4-Feb Vande Hei 17