De Quervain’s tenosynovitis is an overuse disease that involves a thickening of the extensor retinaculum, which covers the first dorsal compartment. Parents or caretakers of infants are at increased risk of developing de Quervain’s tenosynovitis due to repetitive lifting and carrying actions forcing the wrist into ulnar deviation 1, 2, 3, 4.  Furthermore, soft tissue edema, fluid retention, and ligamentous laxity are common effects of pregnancy, which can impact the inflammatory response and pressure upon the first dorsal compartment 1. Other susceptible are those who do repetitive pinch or gripping or twisting activity on the job or at home. Adaptation of these jobs may be necessary to prevent this inflammatory response and development of de Quervain’s syndrome.

OT Treatment of de Quervain’s tenosynovitis
The treatment plan used for patients that present to OT with a certified hand therapist (CHT) for de Quervain’s tenosynovitis is to splint the joint for immediate support and positioning, initiate range of motion therapeutic exercise, and neuromuscular retraining of proper mechanics of the thumb. When pain and edema have decreased, strengthening and functional activity are incorporated into the treatment plan in preparation for return to normal daily activities. Each patient’s response to pain and treatment are different; therefore, deviation may be necessary.

Soft tissue management with manual therapy is performed along the first dorsal compartment tendons to relax tight musculature that can increase pain, as well as to enhance fluid drainage from muscle tissue5. It can be done with the hands or a tool for instrument assisted soft tissue mobilization (ASTM). In a study by Papa, it was found that use of a tool decreased tenderness and promoted healthy healing of the soft tissue 4. Unfortunately, limited evidence-based studies are available at this time describing this technique.

The goal of therapeutic exercises is to enhance gliding of the APL and EPB tendons in the first dorsal compartment 6. Pain-free active range of motion (AROM) exercise is initiated to the patient’s tolerance, focusing on the wrist and thumb joints. Strengthening exercises are then initiated to assist in return to functional activity6.

Post-op Occupational Therapy
Patients diagnosed with de Quervain’s syndrome, and who have had surgery, may have pain and swelling with decreased use of the affected extremity.
 Modalities such as ultrasound, fluidotherapy, superficial heat, or cryotherapy have been used in the postoperative treatment of de Quervain’s release.

Goals of Rehabilitation following de Quervain’s release:
1. At the initial post-op visit, the patient will be fit to a long opponens orthotic for rest and protection of the surgical site.
2. Goals will include control of post-op swelling, sensitivity, and scar management and the patient will be independent in self-care.
3. The patient will be provided a written home exercise program when appropriate and the patient will demonstrate the exercises correctly.
4. Improve functional use of the involved wrist to pre-morbid level in six weeks.
5. Provide a strengthening program as tolerated by the patient.

Post-operative Management: The hand is maintained in a soft bulky dressing for the first 2 to 3 days. A forearm-based thumb spica splint is then applied during the first 2 weeks to control postoperative pain and swelling. Gentle active ROM and tendon gliding should be initiated in the first few days postoperatively. The goal is full, pain-free excursion of the APB and EPB approximating Finkelstein’s test position. Grip and pinch strengthening exercises may begin at approximately 3 weeks and can be progressed gradually. By six weeks the patient usually is able to resume full activities.7
Strengthening exercises can be initiated when painful symptoms have subsided. Graded symptom-free exercises have been shown to increase metabolism, speed repair and prepare the patient to meet the physical demands of daily activities. Resistive exercises may be done in the isometric, isotonic, or isokinetic modes depending on patient’s tolerance.

The patient will be seen one to two times per week depending on the level of pain and dysfunction. The average duration is for six to eight weeks or as indicated by the patient’s status and progression.

Patient/Family Education: 1. Provide a home program with verbal and written instructions. 2. Review ergonomics, body mechanics, adaptive equipment and adaptations as needed during activities of daily living. 3. Provide splint don/doff instructions, wearing schedule and hygiene. 4. Review the basic anatomy and offer educational material on the diagnosis.

Re-evaluation/assessment: Standard time frame for treatment is 4 to 8 weeks with re-evaluation in 4 weeks. Goals will be reassessed monthly and a progress report sent to the referring surgeon every thirty days.

Discharge Planning: Commonly expected outcomes at discharge: Full resumption of pre-morbid activities and work with awareness of ergonomics, joint protection and proper positioning techniques. Patient’s discharge instructions: Continued awareness of correct positioning techniques, ergonomics and continuation of the home exercise program.

Transfer of Care (if applicable): Should painful symptoms persist and /or increase, the patient will be referred back to the PCP or specialist who referred patient to therapy.

References:
1. Borg-Stein J, Dugan SA. Musculoskeletal disorders of pregnancy, delivery and postpartum. Phys Med Rehabil Clin N Am. 2007;18:459–476. doi: 10.1016/j.pmr.2007.05.005. 
2. Harvey FJ, Harvey PM, Horsley MW. De Quervain’s disease: surgical or nonsurgical treatment. J Hand Surg. 1990;15A:83–87. doi: 10.1016/S0363-5023(09)91110-8. 
3. Ilyas AM, Ast M, Schaffer AA, Thoder J. De Quervain tenosynovitis of the wrist. J Am Acad Orthop Surg. 2007;15(12):757–764. 
4. Papa JA. Conservative management of de Quervain’s stenosing tenosynovitis: a case report. J Can Chiropr Assoc. 2012;56(2):112–120. 
5. Baker KG, Robertson VJ, Duck FA. A review of therapeutic ultrasound: biophysical effects. Phys Ther. 2001;81(7):1351–1358. 
6. Jaworski CA, Krause M, Brown J. Rehabilitation of the wrist and hand following sports injury. Clin Sports Med. 2010;29(1):61–80. doi: 10.1016/j.csm.2009.09.007. 
7. Lee Marilyn Peterson, Nasser-Sharif, Zelouf David: Surgeon’s and Therapists Management of Tendonopathies in the Hand and Wrist, Hunter J, Mackin E, Callahan A, Rehabilitation of the Hand, 5th ed. Vol. l, pp. 931-933.

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