- Email: [email protected]
de Quervain Tendinopathy: “Success” and Other Subtleties
1232
LETTERS TO THE EDITOR
study sample reported a score of 90 or better. Six months after surgery, the results were similar; the median MHQ score was 86, and 45% of participants scored 90 or above. There was no reason for us to believe that participants were attempting to portray delayed recovery. Like the authors of the original letter, we are concerned that psychosocial factors are commonly overlooked in hand surgery. The use of one’s hands is central to the human experience, and impairment of that can have devastating physical, psychological, social, and economic effects. Some patients may benefit from a multidisciplinary approach that considers both physical and psychosocial elements. As surgeon investigators, we can help advance patientcentered medicine by including assessments in our studies beyond the traditional objective measures.
University of Michigan Medical School Ann Arbor, MI http://dx.doi.org/10.1016/j.jhsa.2014.03.020
REFERENCES 1. Squitieri L, Reichert H, Kim HM, Chung KC. Application of the brief international classification of functioning, disability, and health core set as a conceptual model in distal radius fractures. J Hand Surg Am. 2010;35(11):1795e1e1805e1. 2. Lovgren A, Hellstrom K. Reliability and validity of measurement and associations between disability and behavioural factors in patients with Colles’ fracture. Physiother Theory Pract. 2012;28(3):188e197. 3. Bot AG, Mulders MA, Fostvedt S, Ring D. Determinants of grip strength in healthy subjects compared to that in patients recovering from a distal radius fracture. J Hand Surg Am. 2012;37(9):1874e1880. 4. MacDermid JC, Donner A, Richards RS, Roth JH. Patient versus injury factors as predictors of pain and disability six months after a distal radius fracture. J Clin Epidemiol. 2002;55(9):849e854. 5. Chung KC, Hamill JB, Kim HM, Walters MR, Wilkins EG. Predictors of patient satisfaction in an outpatient plastic surgery clinic. Ann Plast Surg. 1999;42(1):56e60. 6. Ghori AK, Chung KC. A decision-analysis model to diagnose feigned hand weakness. J Hand Surg Am. 2007;32(10):1638e1643.
Melissa J. Shauver, MPH Kate Wan-Chu Chang, MA Kevin C. Chung, MD, MS Section of Plastic Surgery Department of Surgery
de Quervain Tendinopathy: “Success” and Other Subtleties To the Editor: We appreciate the prospective randomized trial by Mardani-Kivi and colleagues,1 assessing the effectiveness of corticosteroid injection alone and combined with thumb spica casting for de Quervain tendinopathy. It is surprising how few clinical trials have addressed such a common problem. The authors use a primary outcome of “treatment success,” defined as no pain on the radial side of the wrist, no tenderness of the first dorsal compartment, and a negative Finkelstein test. We wonder whether “success” is a reliable and valid measure. It seems to us that the criteria for success are all subjective and prone to bias from both the patient and surgeon perspective. It is well-established that more treatment (ie, adding the splint) would be expected to result in less pain and disability (stronger placebo effect) than injection alone.2 Both the surgeon and the patient would likely expect more treatment to have greater success, creating biases that were not accounted for with blinding or sham treatments. In the absence of placebo controls and adequate blinding of the patients and the surgeons, we would argue that the results of this trial are predictable and indicate nothing about
J Hand Surg Am.
the effectiveness of splints or corticosteroids for de Quervain tendinopathy. We would also like to point out important subtleties in this and other articles that can affect our conception of hand illness. Such conceptions are known to affect symptoms, disability, and treatment choices. Patients were advised to reduce physical activities and rest as much as possible. As the authors correctly pointed out, de Quervain tendinopathy consists of myxoid degeneration rather than acute inflammation. There is no scientific evidence that strict rest is disease modifying. The implication of hand use in the etiology or exacerbation of a disease is tempting but troublesome. We used to blame wringing out cloth diapers for this condition (washerwoman’s sprain) and the condition persisted long after cloth diapers all but disappeared. Catastrophic thinking in response to nociception and kinesiophobia are some of the strongest determinants of pain intensity and magnitude of disability in this and other hand disorders.3 By advising rest, the authors of this study are reinforcing the misconception that hurt equals harm in the setting of de Quervain tendinopathy; they are exacerbating catastrophic thinking and kinesiophobia. Splints can relieve symptoms, but there is no evidence
r
Vol. 39, June 2014
1233
LETTERS TO THE EDITOR
that they are disease modifying. Patients come to us in the hope that we will reduce disability, but wearing a splint and restricting activities are both inherently disabling. Reinforcement of a sense that pain must be avoided is even more so—no matter how subtle. We should recommend activity restriction only if we have solid scientific evidence that it is helpful to do so.
CSI plus cast group were not charged more than the CSI group. In this academic clinical trial, all patients in both groups were treated free of charge. Therefore, there was no burden of payment in either of group to cause bias. Menendez and Ring considered our primary outcome, treatment success, to be subjective and prone to bias from either the patient or surgeon perspective. We are not sure why they concluded that treatment success is completely subjective, because the primary outcome included pain on the radial side of the wrist (subjective), treatment at the first dorsal compartment (objective), and Finkelstein test (also objective). Therefore, it possessed 1 subjective and 2 objective parts. They also indicated that CSI plus casting had a stronger placebo effect. We were certainly aware of such an effect not only in our study, but also in all clinical trials in which a less invasive or single technique is compared with a more invasive or double technique. More or less, the placebo effect is an inseparable part of such trials. As we mentioned in the last paragraph of our Discussion section, the lack of a control group was 1 of our limitations; however, differences between groups were highly significant, and it seems unlikely that the placebo effect could be the only reason for such marked differences. Despite the high incidence of de Quervain disease, there are a few well-designed trials to challenge therapeutic techniques, and this study may be a source of high quality. Finally, the authors were concerned about whether a cast could be a disease-modifying factor or just a pain-relieving agent. If it is the latter, as orthopedic surgeons, we would undesirably induce kinesiophobia and overburden the patient with another disability. It is hard to respond to this, however, because in de Quervain tendinosis, repeated activity with the wrist in ulnar deviation while the thumb is abducted and extended may lead to micro-tears and cause collagen disorientation and increased myxoid changes.5 Therefore, if immobilizing the involved hand does not cure the underlying disease, it could protect against ongoing micro-tears and decelerate tendinosis, as well as relieve symptoms.
Mariano E. Menendez, MD David Ring, MD, PhD Orthopaedic Hand and Upper Extremity Service Massachusetts General Hospital Boston, MA http://dx.doi.org/10.1016/j.jhsa.2014.03.023 REFERENCES 1. Mardani-Kivi M, Karimi Mobarakeh M, Bahrami F, HashemiMotlagh K, Saheb-Ekhtiari K, Akhoondzadeh N. Corticosteroid injection with or without thumb spica cast for de Quervain tenosynovitis. J Hand Surg Am. 2014;39(1):37e41. 2. Miller FG, Rosenstein DL. The nature and power of the placebo effect. J Clin Epidemiol. 2006;59(4):331e335. 3. Das De S, Vranceanu AM, Ring DC. Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability. J Bone Joint Surg Am. 2013;95(1):76e81.
In Reply: We thank Drs Menendez and Ring for their precise comments regarding our recent publication.1 They considered our findings to be in contrast with the results of other similar studies.2,3 We had mentioned those studies in our article. Those works are most similar with respect to the study design and functional outcomes, yet they differed in kind. For instance, in the Cochrane Review of Peters-Veluthamaningal et al,4 out of 563 studies they only found 1 that was relevant. In that nonrandomized trial, 18 patients (all pregnant or lactating women) were assigned to either corticosteroid injection (CSI) or orthosis, and the results were in favor of the CSI technique. In the study by Mehdinasab et al,2 de Quervain patients were randomized in CSI plus cast or cast-alone groups. The findings of that study supported CSI plus cast over cast alone, and our results advocated CSI plus cast over CSI alone. More important, it was revealed that both CSI alone and CSI plus cast techniques markedly improve the functional outcome. Thus, it seems that the cited articles emphasize 1 point in their own perspective. Menendez and Ring alluded to the concern about the higher cost of CSI plus casting rather than CSI alone, which may raise some biases: When a procedure possesses additional intervention (ie, casting), the patient may be charged more, and this process may interfere with the subjective outcome. To obviate the concern, we would like to add the fact that patients in J Hand Surg Am.
Mohsen Mardani-Kivi, MD Farzaneh Bahrami, MD Orthopedic Research Center School of Medicine Poursina Hospital Guilan University of Medical Sciences Rasht, Iran http://dx.doi.org/10.1016/j.jhsa.2014.03.022 r
Vol. 39, June 2014
LETTERS TO THE EDITOR
study sample reported a score of 90 or better. Six months after surgery, the results were similar; the median MHQ score was 86, and 45% of participants scored 90 or above. There was no reason for us to believe that participants were attempting to portray delayed recovery. Like the authors of the original letter, we are concerned that psychosocial factors are commonly overlooked in hand surgery. The use of one’s hands is central to the human experience, and impairment of that can have devastating physical, psychological, social, and economic effects. Some patients may benefit from a multidisciplinary approach that considers both physical and psychosocial elements. As surgeon investigators, we can help advance patientcentered medicine by including assessments in our studies beyond the traditional objective measures.
University of Michigan Medical School Ann Arbor, MI http://dx.doi.org/10.1016/j.jhsa.2014.03.020
REFERENCES 1. Squitieri L, Reichert H, Kim HM, Chung KC. Application of the brief international classification of functioning, disability, and health core set as a conceptual model in distal radius fractures. J Hand Surg Am. 2010;35(11):1795e1e1805e1. 2. Lovgren A, Hellstrom K. Reliability and validity of measurement and associations between disability and behavioural factors in patients with Colles’ fracture. Physiother Theory Pract. 2012;28(3):188e197. 3. Bot AG, Mulders MA, Fostvedt S, Ring D. Determinants of grip strength in healthy subjects compared to that in patients recovering from a distal radius fracture. J Hand Surg Am. 2012;37(9):1874e1880. 4. MacDermid JC, Donner A, Richards RS, Roth JH. Patient versus injury factors as predictors of pain and disability six months after a distal radius fracture. J Clin Epidemiol. 2002;55(9):849e854. 5. Chung KC, Hamill JB, Kim HM, Walters MR, Wilkins EG. Predictors of patient satisfaction in an outpatient plastic surgery clinic. Ann Plast Surg. 1999;42(1):56e60. 6. Ghori AK, Chung KC. A decision-analysis model to diagnose feigned hand weakness. J Hand Surg Am. 2007;32(10):1638e1643.
Melissa J. Shauver, MPH Kate Wan-Chu Chang, MA Kevin C. Chung, MD, MS Section of Plastic Surgery Department of Surgery
de Quervain Tendinopathy: “Success” and Other Subtleties To the Editor: We appreciate the prospective randomized trial by Mardani-Kivi and colleagues,1 assessing the effectiveness of corticosteroid injection alone and combined with thumb spica casting for de Quervain tendinopathy. It is surprising how few clinical trials have addressed such a common problem. The authors use a primary outcome of “treatment success,” defined as no pain on the radial side of the wrist, no tenderness of the first dorsal compartment, and a negative Finkelstein test. We wonder whether “success” is a reliable and valid measure. It seems to us that the criteria for success are all subjective and prone to bias from both the patient and surgeon perspective. It is well-established that more treatment (ie, adding the splint) would be expected to result in less pain and disability (stronger placebo effect) than injection alone.2 Both the surgeon and the patient would likely expect more treatment to have greater success, creating biases that were not accounted for with blinding or sham treatments. In the absence of placebo controls and adequate blinding of the patients and the surgeons, we would argue that the results of this trial are predictable and indicate nothing about
J Hand Surg Am.
the effectiveness of splints or corticosteroids for de Quervain tendinopathy. We would also like to point out important subtleties in this and other articles that can affect our conception of hand illness. Such conceptions are known to affect symptoms, disability, and treatment choices. Patients were advised to reduce physical activities and rest as much as possible. As the authors correctly pointed out, de Quervain tendinopathy consists of myxoid degeneration rather than acute inflammation. There is no scientific evidence that strict rest is disease modifying. The implication of hand use in the etiology or exacerbation of a disease is tempting but troublesome. We used to blame wringing out cloth diapers for this condition (washerwoman’s sprain) and the condition persisted long after cloth diapers all but disappeared. Catastrophic thinking in response to nociception and kinesiophobia are some of the strongest determinants of pain intensity and magnitude of disability in this and other hand disorders.3 By advising rest, the authors of this study are reinforcing the misconception that hurt equals harm in the setting of de Quervain tendinopathy; they are exacerbating catastrophic thinking and kinesiophobia. Splints can relieve symptoms, but there is no evidence
r
Vol. 39, June 2014
1233
LETTERS TO THE EDITOR
that they are disease modifying. Patients come to us in the hope that we will reduce disability, but wearing a splint and restricting activities are both inherently disabling. Reinforcement of a sense that pain must be avoided is even more so—no matter how subtle. We should recommend activity restriction only if we have solid scientific evidence that it is helpful to do so.
CSI plus cast group were not charged more than the CSI group. In this academic clinical trial, all patients in both groups were treated free of charge. Therefore, there was no burden of payment in either of group to cause bias. Menendez and Ring considered our primary outcome, treatment success, to be subjective and prone to bias from either the patient or surgeon perspective. We are not sure why they concluded that treatment success is completely subjective, because the primary outcome included pain on the radial side of the wrist (subjective), treatment at the first dorsal compartment (objective), and Finkelstein test (also objective). Therefore, it possessed 1 subjective and 2 objective parts. They also indicated that CSI plus casting had a stronger placebo effect. We were certainly aware of such an effect not only in our study, but also in all clinical trials in which a less invasive or single technique is compared with a more invasive or double technique. More or less, the placebo effect is an inseparable part of such trials. As we mentioned in the last paragraph of our Discussion section, the lack of a control group was 1 of our limitations; however, differences between groups were highly significant, and it seems unlikely that the placebo effect could be the only reason for such marked differences. Despite the high incidence of de Quervain disease, there are a few well-designed trials to challenge therapeutic techniques, and this study may be a source of high quality. Finally, the authors were concerned about whether a cast could be a disease-modifying factor or just a pain-relieving agent. If it is the latter, as orthopedic surgeons, we would undesirably induce kinesiophobia and overburden the patient with another disability. It is hard to respond to this, however, because in de Quervain tendinosis, repeated activity with the wrist in ulnar deviation while the thumb is abducted and extended may lead to micro-tears and cause collagen disorientation and increased myxoid changes.5 Therefore, if immobilizing the involved hand does not cure the underlying disease, it could protect against ongoing micro-tears and decelerate tendinosis, as well as relieve symptoms.
Mariano E. Menendez, MD David Ring, MD, PhD Orthopaedic Hand and Upper Extremity Service Massachusetts General Hospital Boston, MA http://dx.doi.org/10.1016/j.jhsa.2014.03.023 REFERENCES 1. Mardani-Kivi M, Karimi Mobarakeh M, Bahrami F, HashemiMotlagh K, Saheb-Ekhtiari K, Akhoondzadeh N. Corticosteroid injection with or without thumb spica cast for de Quervain tenosynovitis. J Hand Surg Am. 2014;39(1):37e41. 2. Miller FG, Rosenstein DL. The nature and power of the placebo effect. J Clin Epidemiol. 2006;59(4):331e335. 3. Das De S, Vranceanu AM, Ring DC. Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability. J Bone Joint Surg Am. 2013;95(1):76e81.
In Reply: We thank Drs Menendez and Ring for their precise comments regarding our recent publication.1 They considered our findings to be in contrast with the results of other similar studies.2,3 We had mentioned those studies in our article. Those works are most similar with respect to the study design and functional outcomes, yet they differed in kind. For instance, in the Cochrane Review of Peters-Veluthamaningal et al,4 out of 563 studies they only found 1 that was relevant. In that nonrandomized trial, 18 patients (all pregnant or lactating women) were assigned to either corticosteroid injection (CSI) or orthosis, and the results were in favor of the CSI technique. In the study by Mehdinasab et al,2 de Quervain patients were randomized in CSI plus cast or cast-alone groups. The findings of that study supported CSI plus cast over cast alone, and our results advocated CSI plus cast over CSI alone. More important, it was revealed that both CSI alone and CSI plus cast techniques markedly improve the functional outcome. Thus, it seems that the cited articles emphasize 1 point in their own perspective. Menendez and Ring alluded to the concern about the higher cost of CSI plus casting rather than CSI alone, which may raise some biases: When a procedure possesses additional intervention (ie, casting), the patient may be charged more, and this process may interfere with the subjective outcome. To obviate the concern, we would like to add the fact that patients in J Hand Surg Am.
Mohsen Mardani-Kivi, MD Farzaneh Bahrami, MD Orthopedic Research Center School of Medicine Poursina Hospital Guilan University of Medical Sciences Rasht, Iran http://dx.doi.org/10.1016/j.jhsa.2014.03.022 r
Vol. 39, June 2014