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Effect of weight-bearing wrist movement with carpal-stabilizing taping on pain and range of motion in subjects with dorsal wrist pain: A randomized controlled trial
Journal of Hand Therapy xxx (2019) 1e8
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Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Effect of weight-bearing wrist movement with carpal-stabilizing taping on pain and range of motion in subjects with dorsal wrist pain: A randomized controlled trial Geun-Su Kim PT, MSc a, Jong-Hyuck Weon PT, PhD b, Moon-Hwan Kim PT, PhD c, Eun-Kyung Koh PT, PhD d, Do-Young Jung PT, PhD b, * a
Department of KEMA Therapy, Graduate School of Humanities Industry, Joongbu University, Geumsan, Republic of Korea Department of Physical Therapy, College of Health & Welfare, Kinesiopathologic Science Institute, Joongbu University, Geumsan, Republic of Korea Department of Rehabilitation Medicine, Wonju Christian Hospital, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea d Department of Physical Therapy, Masan University, Changwon, Republic of Korea b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 March 2018 Received in revised form 12 January 2019 Accepted 12 February 2019 Available online xxx
Study Design: Randomized control trial. Introduction: During weight-bearing wrist movement, potential stabilizing forces caused by carpal stabilizing taping (CST) may restrict movement of the carpal bones, allowing greater wrist joint extension. Purpose of the Study: The purpose of study was to investigate the effect of CST during weight-bearing wrist movement on pain intensity and range of motion (ROM) of wrist extension in subjects with dorsal wrist pain. Methods: Thirty participants with dorsal wrist pain when weight bearing through the hand were randomly allocated into 2 groups: (1) a CST group using rigid tape and (2) placebo taping (PT) group using elastic tape. Subjects performed weight-bearing wrist movements with CST or PT in 6 sessions for 1 week. Active and passive ROM (AROM and PROM), and the visual analog scale (VAS) were assessed at baseline and after the intervention. Results: The AROM and PROM of wrist extension increased significantly in both groups compared with preintervention values (P < .01). Comparing the PT and CST groups, the differences between preintervention and postintervention AROM (mean difference [MD] ¼ þ8.6 ) and PROM (MD ¼ þ6.8 ) were significantly greater in the CST group than in the PT group (P < .01). The CST group also showed greater improvement in VAS compared with the PT group (MD ¼ 18 mm) (P < .01). Conclusion: We recommend CST during weight-bearing wrist movement as an effective intervention for both increasing wrist extension ROM and decreasing pain in patients with dorsal wrist pain during weight bearing through the hand. Ó 2019 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Carpal bones Carpal-stabilizing taping Dorsal wrist pain Joint mobilization Wrist extension range of motion
Introduction The wrist joint is biaxial, allowing flexion, extension, and radial and ulnar deviation for positioning the hand in functional activities.1 During noneweight- and weight-bearing activities, the wrist commonly is exposed to various types of stresses, such as repetitive
No funds were received in support of this study. Conflict of interest: none. * Corresponding author. Department of Physical Therapy, Joongbu University, 201 Daehak-ro, Chubu-myeon, Geumsan-gun, Chugnam 312-702, Republic of Korea. Tel.: þ82 41 750 6764. E-mail address: [email protected] (D.-Y. Jung).
motion, high-impact loading, axial compression, torsional forces, and distraction.2,3 Dorsal wrist pain caused by axial compression is worse with weight-bearing extension.3,4 This symptom is found in various diagnoses, such as distal radial physical stress injuries, scaphoid impaction syndrome, and dorsal impingement syndrome.3-5 For these conditions, conservative interventions including resting, avoiding extension, joint mobilization, splinting, and taping, as well as invasive techniques such as steroid injection and surgery, have been frequently performed to decrease dorsal wrist pain.3-6 Especially, joint mobilization or mobilization with movement techniques are commonly used to relieve pain and improve mobility of the wrist joint in physical therapy.7,8
0894-1130/$ e see front matter Ó 2019 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jht.2019.02.001
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The radiocarpal joint is articulated with proximal carpal bones including the scaphoid, lunate, and triquetrum and the distal end of the radius.1,9 Kaltenborn10 proposed the convexconcave rule: if the moving joint surface is convex, gliding is in the opposite direction of the angular movement of the bone, whereas if the moving surface is concave, gliding is in the same direction as the angular movement of the bone. According to the convex-concave rule, wrist extension occurs as the convex surface of proximal carpal bones rolls dorsally and simultaneously glides palmarly on the radius.9,11 A restriction in the palmar gliding of proximal carpal bones biomechanically leads to both compression and gapping during end-range movements.12 These incongruences of the joint surfaces may lead to dorsal wrist pain and limitation of both passive and active range of motion (PROM and AROM, respectively).12 From this point of view, some researchers have demonstrated the effectiveness of joint mobilization and mobilization with movement techniques on wrist pain and ROM.5,12-15 Wrist extension takes place at the radiocarpal and midcarpal joints. Some radiographic studies have found that the ratio of radiocarpal (radio-lunate) angle to midcarpal (lunate-capitate) angle motion is approximately 2:1 during wrist extension.16-18 Thus, restriction of the midcarpal joint would improve motion of the radiocarpal joint during weight-bearing wrist extension. Moreover, motions of proximal carpal bones relative to the radius occur along the longitudinal axis of the radius during wrist flexion or extension.18-20 While being loaded during wrist extension, the scaphoid supinates, as well as the lunate pronates, functionally separating these bones.21,22 It is possible that restricting these motions encourages further extension at the wrist joint. It is inferred that the potential stabilization force caused by carpalstabilizing taping (CST) may restrict extension at the midcarpal joint and supination-pronation of proximal carpal bones during weight-bearing wrist extension, which leads to further extension at the wrist joint in subjects with limited wrist extension. Therefore, the purpose of this randomized control trial was to compare the effects of weight-bearing wrist movement with CST using rigid tape (intervention group) with that of using placebo tape (control group) for a 1-week period on pain intensity and wrist extension ROM in subjects with dorsal wrist pain. It was hypothesized that the intervention using rigid tape would result in increased wrist extension ROM and reduced wrist pain compared with the control group using elastic tape.
Methods Subjects This study was conducted in the heath-care center and was approved by the Institutional Review Board of Joongbu University (JIRB-2016070101-01-160810). Thirty subjects (15 men and 15 women) with dorsal wrist pain participated in this study. Participants were recruited via poster and word of mouth from the Joongbu University. Although a priori sample size calculation was not performed to guide recruitment of participants, the power was calculated from the results of this study using the G*power 3.1 software (Franz Faul, Kiel University, Kiel, Germany). The calculated power was above 95%, indicating the selection of appropriate sample sizes for each group in this study. Inclusion criteria were <50 PROM in wrist extension (normal values: 60 to 70 ) and >2 months of nonspecific dorsal wrist pain due to joint hypomobility not accompanied by ligamentous instability when engaging in activities that involve weight bearing on
the hands, such as pushing up from a chair or assuming a quadruped position on the floor. Exclusion criteria were a past or present history of surgery, fracture, or tenosynovitis (intersection syndrome) around the wrist, dorsal wrist ganglion, scapholunate ligament injury, neurological symptoms such as carpal tunnel syndrome, and skin sensitivity to taping. Dorsal wrist ganglion was confirmed by palpation or observation of swelling on the dorsum of the wrist. The scaphoid shift test (Watson’s test) was used to determine the presence of a scapholunate ligament injury or instability.23 Intersection syndrome was diagnosed if passive wrist flexion alone, passive wrist flexion combined with ulnar deviation, and resisted wrist extension combined with radial deviation caused pain or discomfort at the first and second dorsal compartments.23 All subjects read and signed an informed consent form before participation. The subjects eligible for the study were randomized to either the CST group or placebo taping (PT) group (A, CST group; B, PT group). Randomization was performed using random permuted blocks to ensure equal distribution between the 2 groups, with block for gender (female: B,B,A,A; male: A,A,B,B). For each gender, subjects are assigned to each group in the block in order. Allocation was performed by the second author of this study. The characteristics of the subjects in the CST and PT groups are listed in Table 1. Instrumentation An ultrasound-based motion-analysis system (Zebris CMS20, Zebris Medical GmbH, Isny im Allgau, Germany) (resolution, 0.1 ; sampling rate, 50 Hz) was used to measure the angle of wrist extension in the sagittal plane. The device consists of 3 single markers and an ultrasound receiver. Using the WinData 2.22 software (Zebris Medical GmbH, Isny im Allgau, Germany), the angle of wrist extension was measured before and after intervention. This system has been previously validated in number of studies for measuring the movements of other body parts (eg, spine, shoulder, and hand).24-27 The rigid tape (Perform Plus; Mueller Sports Medicine) and elastic tape (Kinematics Tex; SPOL, Korea) were used in CST and PT, respectively, to stabilize the wrist. The width of the tape was 1 to 2 cm, and the tape length was adjusted according to the width and circumference of each subject’s wrist. A visual analog scale (VAS) was used to measure the intensity of dorsal wrist pain in preintervention and postintervention sessions. The VAS consisted of a 100-mm horizontal line on which the left end (0 mm) indicated no symptom and the right end (100 mm) indicated the worst imaginable symptom.28 All subjects were asked to draw a vertical line to represent the intensity level of dorsal wrist pain during a weight-bearing push-up session. Experimental procedure To measure the AROM and PROM of wrist extension, 3 ultrasonic single markers were placed on each participant as follows: on the Table 1 Characteristics of subjects in the PT and CST groups (mean SD) Variables
PT group (N ¼ 15)
Age (y) Gender (M, F) Height (cm) Mass (kg) BMI (kg/m2)
24.5 7, 8 167.7 61.3 21.7
3.5 7.7 11.6 2.9
CST group (N ¼ 15) 22.4 8, 7 166.6 64.3 23.1
1.6 7.4 12.6 3.4
PT ¼ placebo taping; CST ¼ carpal-stabilizing taping; SD ¼ standard deviation; M ¼ male; F ¼ female; BMI ¼ body mass index.
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Fig. 1. Measurements of AROM (A) and PROM (B) of wrist extension using an ultrasound-based motion-analysis system. AROM ¼ active range of motion; PROM ¼ passive range of motion.
ulnar side of the fifth metacarpal head, the ulnar styloid process, and the midpoint of the lateral midline between the olecranon and fifth metacarpal head (Fig. 1A). Subjects were instructed to sit so that the ultrasonic markers, placed on the ulnar side of the tested upper limb, would face the ultrasound receiver at a distance of 1 m. To measure the AROM of wrist extension, the subjects grasped a pencil lightly to maintain a constant tension of finger flexor muscles during active wrist extension. Subjects were asked to extend their wrist maximally without radial or ulnar deviation of the wrist and within a pain-free range of motion for active wrist extension (Fig. 1A). To measure PROM of wrist extension, the forearm was stabilized to keep the elbow stationary, and an experimenter extended the participant’s wrist by pushing evenly across the palmar surface of the metacarpals until the resistance to further motion felt hard to the experimenter (Fig. 1B).9 The AROM and PROM of wrist extension were measured 3 times, and the pain intensity was measured in each subject before the intervention. The examiner was blinded to the interventions to minimize any measurement bias. The tapes that were used in CST and PT were applied by physical therapists with 4 years of experience in orthopedic physical therapy, who were certified Kinesio Taping practitioners and had applied elastic or rigid tape to patients with various types of musculoskeletal pain. For CST or PT, subjects were instructed to place the forearm on the treatment table, with the wrist flexed over the edge. Four bony landmarks in the proximal carpal row were palpated and marked as follows (Fig. 2): dorsal ridge (just distal to the radial styloid when the wrist is in ulnar deviation) and tubercle of the scaphoid (prominent and palpable
anteriorly on the wrist when extending the wrist), pisiform (distal to the most medial end of the distal wrist crease on the anterior side of the wrist), and the triquetrum (distal to the ulnar styloid process and palpable more easily in radial deviation).29,30 Then, the examiner attached rigid or elastic tape around the carpal bones, connecting the 4 marked areas, with the wrist flexed at approximately 45 (Fig. 2). The elastic tape was applied with 0% stretch, without tension, around the wrist. Rigid tape was applied tightly to the circumference of the subject’s wrist, eliminating wrist pain during weight bearing through the hand. The tape was worn only during the intervention. To perform the weight-bearing wrist movement with CST or PT, the subjects were instructed to sit on the side of the table with their hand grasping the edge of the table but not stretching the finger flexor muscles. Moving from sit to stand, subjects actively performed weight-bearing wrist extension, maintaining full extension of the elbow while keeping the wrist in a neutral position without ulnar or radial deviation. When the subject felt any discomfort or pain, the subject was asked to stop the wrist movement and hold their wrist at the moment of pain for 10 seconds. Then, subjects returned to the starting position from stand to sit (Fig. 3). Once per day for 1 week, this movement was repeated 10 times with a 5seconds rest period between trials. After six 1-week sessions of performing the weight-bearing wrist movement with CST or PT, the AROM and PROM of wrist extension were reassessed 3 times, and the pain intensity was measured. Before the subjects signed an informed consent, it was emphasized that they must complete the intervention appointments. Also, subjects were advised to avoid weight-bearing activities that exacerbated their symptoms and to
Fig. 2. Application of CST using bony landmarks. CST ¼ carpal-stabilizing taping.
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Fig. 3. Weight-bearing wrist movement with CST from sit to stand. CST ¼ carpal-stabilizing taping.
avoid other interventions such as pain medications during the course of the study. Statistical analysis For statistical analysis, averaged data were calculated from 3 measurements of AROM and PROM, before and after intervention. The intrarater reliability of AROM and PROM values calculated using the motion-analysis system was assessed using intraclass correlation coefficients (ICCs) (3,1) (95% confidence interval) and standard errors of measurement (SEM) before and after intervention. The minimal detectable change (MDC95) in the measurements was calculated to assess the minimal measurement change that could be interpreted as a true difference.31 The formulas for the SEM and MDC95 calculations were as follows: SEM ¼ standard deviationO(1 ICC); MDC95 ¼ SEM 1.96O2.31 To assess the difference at baseline in AROM, PROM, and VAS score between the groups, independent-sample t-tests were used. A two-way mixed-model analysis of variance was used to compare within-group (before and after intervention) and between-group (CST and PT) data in terms of AROM, PROM, and VAS score of the participants. If a significant interaction in response to an intervention for a group was found, post hoc paired t-tests were performed. To reduce the type I error rate, statistical significance for the post hoc paired t-tests was set at a ¼ .01. Independent-sample t-tests were used to compare the mean difference [MD] in AROM, PROM, and VAS score between the CST and PT groups.
interventions in either group, and all 30 participants were able to complete this study. There were significant interactions by group for AROM (F1,28 ¼ 28.83, P < .01), PROM (F1,28 ¼ 32.54, P < .01), and VAS score (F1,28 ¼ 16.84, P < .01). The results of the post hoc paired t-test showed that AROM of wrist extension increased significantly in both the PT (difference ¼ 4.0 ; P < .01) and CST (difference ¼ 12.6 ; P < .01) groups; PROM results also showed significant increases in both the PT (difference ¼ 3.1 ; P < .01) and CST (difference ¼ 9.9 ; P < .01) groups. The VAS intensity decreased significantly in both the PT (difference ¼ 7 mm; P < .01) and CST (difference ¼ 24 mm; P < .01) groups (Table 3, Fig. 5). An independent t-test revealed significant differences between groups, with mean changes of 8.6 and 6.8 greater AROM and PROM in the CST group compared with the PT group, respectively (P < .01). The VAS score was significantly higher in the CST group than in the PT group, with a MD of 18 mm (P < .01) (Table 3). Discussion Effects of CST on AROM, PROM, and VAS The AROM and PROM of wrist extension significantly increased after intervention in the CST (difference ¼ 12.6 for AROM; 9.9 for PROM) and PT groups (difference ¼ 4.0 for AROM; 3.1 for PROM) compared with those in baseline. When comparing preintervention values with postintervention values, the changes in AROM (MD ¼ 8.6 ) and PROM (MD ¼ 6.8 ) were significantly greater in the
Results Motion-analysis measures of the AROM and PROM of wrist extension showed good reliability (ICC3,1 ¼ .99). The SEM ranged from 0.48 to 0.53 for AROM and from 0.57 to 0.65 for PROM of wrist extension (Table 2). The MDC95 ranged from 1.32 to 1.47 for AROM and from 1.57 to 1.80 for PROM of wrist extension (Table 2). There was no statistically significant difference between the groups at baseline in AROM, PROM, and VAS score (P < .05). A diagram of the procedural flow of study is shown in Figure 4. Most participants adhered to their appointment schedules. The adherence to the intervention for 1 week was 97% (174 of 180 sessions; n ¼ 30 6 sessions). No adverse events were reported after
Table 2 The ICC, 95% CI, SEM, and MDC95 for measurement of the wrist AROM and PROM by motion analysis Variable
Group
ICC
95% CI
SEM
MDC95
AROM (degrees)
PT CST PT CST
0.996 0.997 0.995 0.994
0.993-0.998 0.994-0.998 0.992-0.998 0.989-0. 997
0.48 0.53 0.57 0.65
1.32 1.47 1.57 1.80
PROM (degrees)
PT ¼ placebo taping; CST ¼ carpal-stabilizing taping; AROM ¼ active range of motion; PROM ¼ passive range of motion; ICC ¼ intraclass correlation coefficient; MDC95 ¼ minimal detectable change; SEM ¼ standard error of measurement; CI ¼ confidence interval.
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Fig. 4. Consort diagram. CST ¼ carpal-stabilizing taping; PT ¼ placebo taping.
CST group than in the PT group. The SEM ranged from 0.48 to 0.53 for AROM and from 0.57 to 0.65 for PROM of wrist extension. The MDC95 ranged from 1.32 to 1.47 for AROM and from 1.57 to 1.80 for PROM of wrist extension. The MDC95 represents the true difference in measurement.31 Therefore, there were statistically significant differences between groups and between preintervention and postintervention values for AROM and PROM. Although the use of ultrasound-based motion-analysis system has been not validated for measuring the wrist motion in previous study, the present study
demonstrated excellent intrarater reliability in both wrist AROM and PROM. The present study showed that the MD between preintervention and postintervention values for AROM and PROM was significantly greater in the CST group than those in the PT group. These results can be explained by the property of rigid and elastic tapes. Commonly, rigid tape is used to limit unwanted joint movements or to protect and support a joint structure because it provides greater stiffness and more stability than does elastic tape.32,33 Rigid tape
Table 3 Main outcome measures by group at preintervention and postintervention assessments (mean SD) Variable
Group
Intervention
AROM (degrees)
PT CST PT CST PT CST
31.6 32.5 36.0 37.3 3.4 4.4
Before
PROM (degrees) VAS (cm)
Within-group difference (95% CI)a
Between-group difference (95% CI)b
P valuec
After 8.4 7.2 8.5 7.0 1.4 1.5
35.6 45.1 39.0 47.2 2.7 2.0
6.4 7.8 7.7 6.8 1.1 1.4
4.0 12.6 3.1 9.9 0.7 2.4
(1.9 to 6.1) (9.9 to 15.4) (1.7 to 4.4) (5.1 to 14.7) (1.1 to 0.3) (3.2 to 1.6)
8.6 (11.9 to 5.3)
<.01d
6.8 (9.3 to 4.4)
<.01d
1.8 (0.9 to 2.6)
<.01d
PT ¼ placebo taping; CST ¼ carpal-stabilizing taping; AROM ¼ active range of motion; PROM ¼ passive range of motion; VAS ¼ visual analog scale; SD ¼ standard deviation; CI ¼ confidence interval. a Within-group differences are calculated by subtracting the value obtained before intervention from value obtained after intervention. b Between-group differences are calculated by subtracting the difference in the CST group from that in the PT group. c P value refers to the between-group differences in AROM, PROM, and VAS between the CST and PT groups. d P < .05 indicates significant between-group differences.
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A
B
60
60
*
50
PROM (º)
AROM (º)
50
* 40 30
* *
* *
40 30
20
20 PT
Pre
CST
Post
PT
Pre
CST
Post
C 8
*
VAS (cm)
6
* 4 2 0 PT
Pre
CST
Post
Fig. 5. AROM (A), PROM (B), and VAS (C) in PT and CST groups. *Significant difference in AROM, PROM, and VAS between before and after intervention (P < .01). PT ¼ placebo taping; CST ¼ carpal-stabilizing taping; AROM ¼ active range of motion; PROM ¼ passive range of motion; VAS ¼ visual analog scale. Error bars indicate 1 standard deviation of the mean.
restricts extension at the midcarpal joint and supination-pronation of proximal carpal bones more than elastic tape does. We believe that rigid tape contributed more to the stabilization of carpal bones than elastic tape did during weight-bearing wrist extension. Thus, the use of rigid tape led to greater increases in AROM and PROM at the wrist joint than elastic tape did. Greater restriction of movement in the sagittal plane at the midcarpal joint and in the transverse plane of the proximal carpal bones results in greater palmar gliding of the proximal carpal bones at the radiocarpal joint during weight-bearing wrist movement. In this study, owing to congruence in the radiocarpal joint caused by improved palmar gliding of the proximal carpal bones, the CST group experienced a greater reduction in pain intensity than the PT group did. In the present study, VAS intensity decreased significantly, by 24 mm, in the CST group, corresponding to a 54.5% reduction. This 24-mm decrease in the VAS score indicates clinically significant pain reduction according to previous studies, which noted that a minimum reduction of 20 mm in VAS score and a percentage pain reduction of 33% are necessary to conclude that clinically significant pain reduction has occurred.34-36 The wrist biomechanics of a CST intervention cannot be explained only by the movements of the carpal bones during active wrist motion. Recent studies determined the biomechanical changes in the carpal bones during axial loading of the wrist.37-39 The researchers reported that forces applied to the axis of the third metacarpal with a neutrally positioned wrist result in flexionpronation of the scaphoid and extension-supination of the lunate.37-39 However, in our study, axial loading in the carpal bones was applied with weight-bearing wrist extension. Thus, because of different wrist positions during axial loading, the recent biomechanical insights regarding the axial loading of the wrist do not explain the mechanism of CST intervention in our study. Future
studies should compare the biomechanical changes of carpal bones with various wrist positions during axial loading. Previous studies of wrist mobilization Some studies reported that the gliding of the carpal bones can be used to increase the ROM of wrist extension and decrease pain intensity in subjects with dorsal wrist pain.5,13-15 A pilot study13 found that palmar gliding of the proximal carpal bones increased PROM and AROM of wrist extension by 15 and 18 , respectively, and decreased dorsal wrist pain after undergoing treatment twice a week for 6 weeks in patients with poststroke hand hemiplegia. Furthermore, Walker15 reported that, after eight sessions, anterior-posterior gliding and ulnar transverse gliding of the proximal carpal bones decreased the VAS score for dorsal wrist pain by 3 cm. Tal-Akabi and Rushton14 demonstrated that applying anterior-posterior carpal bone mobilization in subjects with carpal tunnel syndrome increased AROM of wrist extension by 11.1 after a 3-week intervention. It is not possible to directly compare the results of the present study with those of the aforementioned studies due to different sample sizes, conditions, and treatment durations. Choung et al5 determined the efficiency of wrist movement using self-mobilization with a strap on wrist joint pain and ROM during weight-bearing hand activities after 5 treatment sessions in patients with dorsal wrist pain. Similar to our study, wrist movement with self-mobilization with a strap consisted of sustained palmar gliding of the carpal bones induced by pulling the strap toward the palmar side, allowing active movement of the extended arm in sit-to-stand exercises. In the present study, the results showed that PROM and AROM of wrist extension increased significantly, by 9.9 and 12.6 , respectively, in the CST group. Previous research showed that PROM
G.-S. Kim et al. / Journal of Hand Therapy xxx (2019) 1e8
(difference, 12.2 ) improved more than AROM of wrist extension (difference ¼ 10.3 ). In that study, subjects were instructed to rest the palm of the active hand on a table; in our study, the subjects were instructed to grasp the edge of the table to minimize the stretch effect of the finger flexor muscles during wrist movement in a weight-bearing position. Thus, we predicted that PROM would improve more than AROM due to the stretching effect of finger flexor muscles combined with the volar gliding of carpal bones noted in the previous study. Further study is required to compare wrist ROM and pain between CST alone and CST combined with stretching of the finger flexor muscles during wrist extension in weight-bearing hand activities. Application of CST There are biomechanical reasons for application of CST in the wrist-flexed position, as mentioned in the Methods section. Previous studies reported that the ratio of radiocarpal to midcarpal angle motion was approximately 4:6 during wrist flexion.17 The greater restriction of the carpal bones in the wrist-flexed positions using CST than that in a wrist-neutral or wrist-extended position causes more compensatory movement at the radiocarpal joint in the sagittal plane. Another reason for taping in the wrist-flexed position is restriction of movement in the proximal carpal rows. During wrist flexion, the scaphoid pronates and the lunate supinates, as mentioned earlier.21,22 This closes an anterior gap between the scaphoid and lunate, reducing the distance between the 2 bones. The application of tape to the wrist in a flexed position can effectively stabilize the carpal bones because it prevents supination and pronation of the scaphoid and lunate from wrist flexion to extension during weight-bearing tasks. Limitations There are several limitations to this study. First, it is difficult to generalize our results to all patients with dorsal wrist pain. Although dorsal wrist ganglions, scapholunate ligament injury, and tenosynovitis with dorsal wrist pain were excluded in this study, the intervention used in this study should be carefully applied. Also, this study has a potential weakness for whether diagnostic tests on exclusion criteria can provide high falsenegative results. Second, outcome measurements were performed after 6 sessions over 1 week of intervention and did not include any functional assessment to validate the clinical meaningfulness of the treatment effect. Further study, including functional assessment, is required to determine the long-term effects of wrist movement with CST. Finally, although CST improved ROM of extension and reduced pain, we did not prove the mechanisms underpinning the benefits of CST application. To better understand underlying mechanisms associated with clinical outcomes, further studies are required to investigate changes in arthrokinematic and osteokinematic motions at the radiocarpal and midcarpal joints after CST application. Conclusion In subjects with dorsal wrist pain during weight-bearing wrist movement, CST resulted in significantly greater improvement in the ROM of wrist extension and reduction in pain intensity than did PT after a 1-week intervention. Therefore, we suggest that rigid tape can be used to increase wrist ROM and decrease wrist pain in patients with dorsal wrist pain during weight-bearing hand activities.
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Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jht.2019.02.001. References 1. Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 6th ed. Philadelphia: F. A. Davis Company; 2012. 2. DiFiori JP, Puffer JC, Mandelbaum BR, Mar S. Factors associated with wrist pain in the young gymnast. Am J Sports Med. 1996;24(1):9e14. 3. Webb BG, Retting LA. Gymnastic wrist injuries. Curr Sports Med Rep. 2008;7(5): 289e295. 4. Boucher B, Smith-Young B. Examination and physical therapy management of a young gymnast with bilateral wrist pain: a case report. Phys Ther Sport. 2017;27:38e49. 5. Choung SD, Kwon OY, Park KN, Kim SH, Cynn HS. Short-term effects of selfmobilization with a strap on pain and range of motion of the wrist joint in patients with dorsal wrist pain when weight bearing through the hand: a case series. Man Ther. 2013;18(6):568e572. 6. Kim BJ, Lee JH. Efficacy of kinesiology taping for recovery from occupational wrist disorders experienced by a physical therapist. J Phys Ther Sci. 2014;26(6): 941e943. 7. Heiser R, O’Brien VH, Schwartz DA. The use of joint mobilization to improve clinical outcomes in hand therapy: a systematic review of the literature. J Hand Ther. 2013;26(4):297e311. 8. Vicenzino B, Paungmali A, Teys P. Mulligan’s mobilization-with-movement, positional faults and pain relief: current concepts from a critical review of literature. Man Ther. 2007;12(2):98e108. 9. Norkin CC. Measurement of Joint Motion: A Guide to Goniometry. 4th ed. Philadelphia, PA: F. A. Davis Company; 2009. 10. Kaltenborn FM. Manual Mobilization of the Joints, Vol. 1: The Extremities. 7th ed. Oslo: Norli; 2011. 11. Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd ed. St. Louis: Mosby; 2010. 12. Gallego PH, Moreno JMT, López OL, Polo SC, Garcia CH, De Miguel EE. Indirect influence of specific Kaltenborn glide mobilizations of the carpal joint on a subject with neurological impairments. J Bodyw Mov Ther. 2007;11:275e284. 13. Smedes F, van der Salm A, Koel G, Oosterveld F. Manual mobilization of the wrist: a pilot study in rehabilitation of patients with a chronic hemiplegic hand post-stroke. J Hand Ther. 2014;27(3):209e215. 14. Tal-Akabi A, Rushton A. An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome. Man Ther. 2000;5(4):214e222. 15. Walker MJ. Manual physical therapy examination and intervention of a patient with radial wrist pain: a case report. J Orthop Sports Phys Ther. 2004;34(12): 761e769. 16. Kawashima H, Tada K, Suganuma S, Tsuchiya H, Sanada S. Wrist rhythm during wrist joint motion evaluated by dynamic radiography. Hand Surg. 2014;19(3): 343e347. 17. Sarrafian SK, Melamed JL, Goshgarian GM. Study of wrist motion in flexion and extension. Clin Orthop Relat Res. 1977;126:153e159. 18. Foumani M, Strackee SD, Jonges R, et al. In-vivo three-dimensional carpal bone kinematics during flexion-extension and radio-ulnar deviation of the wrist: dynamic motion versus step-wise static wrist positions. J Biomech. 2009;42(16):2664e2671. 19. Rainbow MJ, Kamal RN, Leventhal E, et al. In vivo kinematics of the scaphoid, lunate, capitate, and third metacarpal in extreme wrist flexion and extension. J Hand Surg Am. 2013;38(2):278e288. 20. Wolfe SW, Neu C, Crisco JJ. In vivo scaphoid, lunate, and capitate kinematics in flexion and in extension. J Hand Surg Am. 2000;25(5):860e869. 21. Kauer JM. Functional anatomy of the wrist. Clin Orthop Relat Res. 1980;149:9e 20. 22. Kobayashi M, Berger RA, Nagy L, et al. Normal kinematics of carpal bones: a three-dimensional analysis of carpal bone motion relative to the radius. J Biomech. 1997;30(8):787e793. 23. Porretto-Loehrke A, Schuh C, Szekeres M. Clinical manual assessment of the wrist. J Hand Ther. 2016;29(2):123e135. 24. Illyés A, Kiss RM. Shoulder joint kinematics during elevation measured by ultrasound-based measuring system. J Electromyogr Kinesiol. 2007;17(3):355e 364. 25. Malmström EM, Karlberg M, Melander A, Magnusson M. Zebris versus Myrin: a comparative study between a three-dimensional ultrasound movement analysis and an inclinometer/compass method: intradevice reliability, concurrent validity, intertester comparison, intratester reliability, and intraindividual variability. Spine. 2003;28(21):E433eE440. 26. Moutzouri M, Billis E, Strimpakos N, Kottika P, Oldham JA. The effects of the mulligan sustained natural apophyseal glide (SNAG) mobilisation in the lumbar flexion range of asymptomatic subjects as measured by the zebris CMS20 3-D motion analysis system. BMC Musculoskelet Disord. 2008;9:131. 27. Pötter-Nerger M, Habben A, Herzog J, et al. Kinematic effects of subthalamic stimulation on reach-to-grasp movements in Parkinson’s disease. Park Relat Disord. 2013;19(1):32e36.
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28. Phan NQ, Blome C, Fritz F, et al. Assessment of pruritus intensity: prospective study on validity and reliability of the visual analogue scale, numerical rating scale and verbal rating scale in 471 patients with chronic pruritus. Acta Derm Venereol. 2012;92(5):502e507. 29. Skirven T. Clinical examination of the wrist. J Hand Ther. 1996;9(2):96e107. 30. Srinivas Reddy R, Compson J. (i) Examination of the wristdsurface anatomy of the carpal bones. Curr Orthop. 2005;19:171e179. 31. Beckerman H, Roebroeck ME, Lankhorst GJ, Becher JG, Bezemer PD, Verbeek AL. Smallest real difference, a link between reproducibility and responsiveness. Qual Life Res. 2001;10(7):571e578. 32. Chen SM, Lo SK, Cook J. The effect of rigid taping with tension on mechanical displacement of the skin and change in pain perception. J Sci Med Sport. 2018;21(4):342e346. 33. Yasukawa A, Patel P, Sisung C. Pilot study: investigating the effects of kinesio taping in an acute pediatric rehabilitation setting. Am J Occup Ther. 2006;60(1): 104e110.
34. DeLoach LJ, Higgins MS, Caplan AB, Stiff JL. The visual analog scale in the immediate postoperative period: intrasubject variability and correlation with a numeric scale. Anesth Analg. 1998;86(1):102e106. 35. Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003;4(7):407e414. 36. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005;14(7):798e804. 37. Esplugas M, Garcia-Elias M, Lluch A, Llusá Pérez M. Role of muscles in the stabilization of ligament-deficient wrists. J Hand Ther. 2016;29(2): 166e174. 38. Salva-Coll G, Garcia-Elias M, Hagert E. Scapholunate instability: proprioception and neuromuscular control. J Wrist Surg. 2013;2(2):136e140. 39. Salva-Coll G, Garcia-Elias M, Leon-Lopez MT, Llusa-Perez M, RodríguezBaeza A. Effects of forearm muscles on carpal stability. J Hand Surg Eur. 2011;36(7):553e559.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Effect of weight-bearing wrist movement with carpal-stabilizing taping on pain and range of motion in subjects with dorsal wrist pain: A randomized controlled trial Geun-Su Kim PT, MSc a, Jong-Hyuck Weon PT, PhD b, Moon-Hwan Kim PT, PhD c, Eun-Kyung Koh PT, PhD d, Do-Young Jung PT, PhD b, * a
Department of KEMA Therapy, Graduate School of Humanities Industry, Joongbu University, Geumsan, Republic of Korea Department of Physical Therapy, College of Health & Welfare, Kinesiopathologic Science Institute, Joongbu University, Geumsan, Republic of Korea Department of Rehabilitation Medicine, Wonju Christian Hospital, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea d Department of Physical Therapy, Masan University, Changwon, Republic of Korea b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 March 2018 Received in revised form 12 January 2019 Accepted 12 February 2019 Available online xxx
Study Design: Randomized control trial. Introduction: During weight-bearing wrist movement, potential stabilizing forces caused by carpal stabilizing taping (CST) may restrict movement of the carpal bones, allowing greater wrist joint extension. Purpose of the Study: The purpose of study was to investigate the effect of CST during weight-bearing wrist movement on pain intensity and range of motion (ROM) of wrist extension in subjects with dorsal wrist pain. Methods: Thirty participants with dorsal wrist pain when weight bearing through the hand were randomly allocated into 2 groups: (1) a CST group using rigid tape and (2) placebo taping (PT) group using elastic tape. Subjects performed weight-bearing wrist movements with CST or PT in 6 sessions for 1 week. Active and passive ROM (AROM and PROM), and the visual analog scale (VAS) were assessed at baseline and after the intervention. Results: The AROM and PROM of wrist extension increased significantly in both groups compared with preintervention values (P < .01). Comparing the PT and CST groups, the differences between preintervention and postintervention AROM (mean difference [MD] ¼ þ8.6 ) and PROM (MD ¼ þ6.8 ) were significantly greater in the CST group than in the PT group (P < .01). The CST group also showed greater improvement in VAS compared with the PT group (MD ¼ 18 mm) (P < .01). Conclusion: We recommend CST during weight-bearing wrist movement as an effective intervention for both increasing wrist extension ROM and decreasing pain in patients with dorsal wrist pain during weight bearing through the hand. Ó 2019 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Carpal bones Carpal-stabilizing taping Dorsal wrist pain Joint mobilization Wrist extension range of motion
Introduction The wrist joint is biaxial, allowing flexion, extension, and radial and ulnar deviation for positioning the hand in functional activities.1 During noneweight- and weight-bearing activities, the wrist commonly is exposed to various types of stresses, such as repetitive
No funds were received in support of this study. Conflict of interest: none. * Corresponding author. Department of Physical Therapy, Joongbu University, 201 Daehak-ro, Chubu-myeon, Geumsan-gun, Chugnam 312-702, Republic of Korea. Tel.: þ82 41 750 6764. E-mail address: [email protected] (D.-Y. Jung).
motion, high-impact loading, axial compression, torsional forces, and distraction.2,3 Dorsal wrist pain caused by axial compression is worse with weight-bearing extension.3,4 This symptom is found in various diagnoses, such as distal radial physical stress injuries, scaphoid impaction syndrome, and dorsal impingement syndrome.3-5 For these conditions, conservative interventions including resting, avoiding extension, joint mobilization, splinting, and taping, as well as invasive techniques such as steroid injection and surgery, have been frequently performed to decrease dorsal wrist pain.3-6 Especially, joint mobilization or mobilization with movement techniques are commonly used to relieve pain and improve mobility of the wrist joint in physical therapy.7,8
0894-1130/$ e see front matter Ó 2019 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jht.2019.02.001
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The radiocarpal joint is articulated with proximal carpal bones including the scaphoid, lunate, and triquetrum and the distal end of the radius.1,9 Kaltenborn10 proposed the convexconcave rule: if the moving joint surface is convex, gliding is in the opposite direction of the angular movement of the bone, whereas if the moving surface is concave, gliding is in the same direction as the angular movement of the bone. According to the convex-concave rule, wrist extension occurs as the convex surface of proximal carpal bones rolls dorsally and simultaneously glides palmarly on the radius.9,11 A restriction in the palmar gliding of proximal carpal bones biomechanically leads to both compression and gapping during end-range movements.12 These incongruences of the joint surfaces may lead to dorsal wrist pain and limitation of both passive and active range of motion (PROM and AROM, respectively).12 From this point of view, some researchers have demonstrated the effectiveness of joint mobilization and mobilization with movement techniques on wrist pain and ROM.5,12-15 Wrist extension takes place at the radiocarpal and midcarpal joints. Some radiographic studies have found that the ratio of radiocarpal (radio-lunate) angle to midcarpal (lunate-capitate) angle motion is approximately 2:1 during wrist extension.16-18 Thus, restriction of the midcarpal joint would improve motion of the radiocarpal joint during weight-bearing wrist extension. Moreover, motions of proximal carpal bones relative to the radius occur along the longitudinal axis of the radius during wrist flexion or extension.18-20 While being loaded during wrist extension, the scaphoid supinates, as well as the lunate pronates, functionally separating these bones.21,22 It is possible that restricting these motions encourages further extension at the wrist joint. It is inferred that the potential stabilization force caused by carpalstabilizing taping (CST) may restrict extension at the midcarpal joint and supination-pronation of proximal carpal bones during weight-bearing wrist extension, which leads to further extension at the wrist joint in subjects with limited wrist extension. Therefore, the purpose of this randomized control trial was to compare the effects of weight-bearing wrist movement with CST using rigid tape (intervention group) with that of using placebo tape (control group) for a 1-week period on pain intensity and wrist extension ROM in subjects with dorsal wrist pain. It was hypothesized that the intervention using rigid tape would result in increased wrist extension ROM and reduced wrist pain compared with the control group using elastic tape.
Methods Subjects This study was conducted in the heath-care center and was approved by the Institutional Review Board of Joongbu University (JIRB-2016070101-01-160810). Thirty subjects (15 men and 15 women) with dorsal wrist pain participated in this study. Participants were recruited via poster and word of mouth from the Joongbu University. Although a priori sample size calculation was not performed to guide recruitment of participants, the power was calculated from the results of this study using the G*power 3.1 software (Franz Faul, Kiel University, Kiel, Germany). The calculated power was above 95%, indicating the selection of appropriate sample sizes for each group in this study. Inclusion criteria were <50 PROM in wrist extension (normal values: 60 to 70 ) and >2 months of nonspecific dorsal wrist pain due to joint hypomobility not accompanied by ligamentous instability when engaging in activities that involve weight bearing on
the hands, such as pushing up from a chair or assuming a quadruped position on the floor. Exclusion criteria were a past or present history of surgery, fracture, or tenosynovitis (intersection syndrome) around the wrist, dorsal wrist ganglion, scapholunate ligament injury, neurological symptoms such as carpal tunnel syndrome, and skin sensitivity to taping. Dorsal wrist ganglion was confirmed by palpation or observation of swelling on the dorsum of the wrist. The scaphoid shift test (Watson’s test) was used to determine the presence of a scapholunate ligament injury or instability.23 Intersection syndrome was diagnosed if passive wrist flexion alone, passive wrist flexion combined with ulnar deviation, and resisted wrist extension combined with radial deviation caused pain or discomfort at the first and second dorsal compartments.23 All subjects read and signed an informed consent form before participation. The subjects eligible for the study were randomized to either the CST group or placebo taping (PT) group (A, CST group; B, PT group). Randomization was performed using random permuted blocks to ensure equal distribution between the 2 groups, with block for gender (female: B,B,A,A; male: A,A,B,B). For each gender, subjects are assigned to each group in the block in order. Allocation was performed by the second author of this study. The characteristics of the subjects in the CST and PT groups are listed in Table 1. Instrumentation An ultrasound-based motion-analysis system (Zebris CMS20, Zebris Medical GmbH, Isny im Allgau, Germany) (resolution, 0.1 ; sampling rate, 50 Hz) was used to measure the angle of wrist extension in the sagittal plane. The device consists of 3 single markers and an ultrasound receiver. Using the WinData 2.22 software (Zebris Medical GmbH, Isny im Allgau, Germany), the angle of wrist extension was measured before and after intervention. This system has been previously validated in number of studies for measuring the movements of other body parts (eg, spine, shoulder, and hand).24-27 The rigid tape (Perform Plus; Mueller Sports Medicine) and elastic tape (Kinematics Tex; SPOL, Korea) were used in CST and PT, respectively, to stabilize the wrist. The width of the tape was 1 to 2 cm, and the tape length was adjusted according to the width and circumference of each subject’s wrist. A visual analog scale (VAS) was used to measure the intensity of dorsal wrist pain in preintervention and postintervention sessions. The VAS consisted of a 100-mm horizontal line on which the left end (0 mm) indicated no symptom and the right end (100 mm) indicated the worst imaginable symptom.28 All subjects were asked to draw a vertical line to represent the intensity level of dorsal wrist pain during a weight-bearing push-up session. Experimental procedure To measure the AROM and PROM of wrist extension, 3 ultrasonic single markers were placed on each participant as follows: on the Table 1 Characteristics of subjects in the PT and CST groups (mean SD) Variables
PT group (N ¼ 15)
Age (y) Gender (M, F) Height (cm) Mass (kg) BMI (kg/m2)
24.5 7, 8 167.7 61.3 21.7
3.5 7.7 11.6 2.9
CST group (N ¼ 15) 22.4 8, 7 166.6 64.3 23.1
1.6 7.4 12.6 3.4
PT ¼ placebo taping; CST ¼ carpal-stabilizing taping; SD ¼ standard deviation; M ¼ male; F ¼ female; BMI ¼ body mass index.
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3
Fig. 1. Measurements of AROM (A) and PROM (B) of wrist extension using an ultrasound-based motion-analysis system. AROM ¼ active range of motion; PROM ¼ passive range of motion.
ulnar side of the fifth metacarpal head, the ulnar styloid process, and the midpoint of the lateral midline between the olecranon and fifth metacarpal head (Fig. 1A). Subjects were instructed to sit so that the ultrasonic markers, placed on the ulnar side of the tested upper limb, would face the ultrasound receiver at a distance of 1 m. To measure the AROM of wrist extension, the subjects grasped a pencil lightly to maintain a constant tension of finger flexor muscles during active wrist extension. Subjects were asked to extend their wrist maximally without radial or ulnar deviation of the wrist and within a pain-free range of motion for active wrist extension (Fig. 1A). To measure PROM of wrist extension, the forearm was stabilized to keep the elbow stationary, and an experimenter extended the participant’s wrist by pushing evenly across the palmar surface of the metacarpals until the resistance to further motion felt hard to the experimenter (Fig. 1B).9 The AROM and PROM of wrist extension were measured 3 times, and the pain intensity was measured in each subject before the intervention. The examiner was blinded to the interventions to minimize any measurement bias. The tapes that were used in CST and PT were applied by physical therapists with 4 years of experience in orthopedic physical therapy, who were certified Kinesio Taping practitioners and had applied elastic or rigid tape to patients with various types of musculoskeletal pain. For CST or PT, subjects were instructed to place the forearm on the treatment table, with the wrist flexed over the edge. Four bony landmarks in the proximal carpal row were palpated and marked as follows (Fig. 2): dorsal ridge (just distal to the radial styloid when the wrist is in ulnar deviation) and tubercle of the scaphoid (prominent and palpable
anteriorly on the wrist when extending the wrist), pisiform (distal to the most medial end of the distal wrist crease on the anterior side of the wrist), and the triquetrum (distal to the ulnar styloid process and palpable more easily in radial deviation).29,30 Then, the examiner attached rigid or elastic tape around the carpal bones, connecting the 4 marked areas, with the wrist flexed at approximately 45 (Fig. 2). The elastic tape was applied with 0% stretch, without tension, around the wrist. Rigid tape was applied tightly to the circumference of the subject’s wrist, eliminating wrist pain during weight bearing through the hand. The tape was worn only during the intervention. To perform the weight-bearing wrist movement with CST or PT, the subjects were instructed to sit on the side of the table with their hand grasping the edge of the table but not stretching the finger flexor muscles. Moving from sit to stand, subjects actively performed weight-bearing wrist extension, maintaining full extension of the elbow while keeping the wrist in a neutral position without ulnar or radial deviation. When the subject felt any discomfort or pain, the subject was asked to stop the wrist movement and hold their wrist at the moment of pain for 10 seconds. Then, subjects returned to the starting position from stand to sit (Fig. 3). Once per day for 1 week, this movement was repeated 10 times with a 5seconds rest period between trials. After six 1-week sessions of performing the weight-bearing wrist movement with CST or PT, the AROM and PROM of wrist extension were reassessed 3 times, and the pain intensity was measured. Before the subjects signed an informed consent, it was emphasized that they must complete the intervention appointments. Also, subjects were advised to avoid weight-bearing activities that exacerbated their symptoms and to
Fig. 2. Application of CST using bony landmarks. CST ¼ carpal-stabilizing taping.
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Fig. 3. Weight-bearing wrist movement with CST from sit to stand. CST ¼ carpal-stabilizing taping.
avoid other interventions such as pain medications during the course of the study. Statistical analysis For statistical analysis, averaged data were calculated from 3 measurements of AROM and PROM, before and after intervention. The intrarater reliability of AROM and PROM values calculated using the motion-analysis system was assessed using intraclass correlation coefficients (ICCs) (3,1) (95% confidence interval) and standard errors of measurement (SEM) before and after intervention. The minimal detectable change (MDC95) in the measurements was calculated to assess the minimal measurement change that could be interpreted as a true difference.31 The formulas for the SEM and MDC95 calculations were as follows: SEM ¼ standard deviationO(1 ICC); MDC95 ¼ SEM 1.96O2.31 To assess the difference at baseline in AROM, PROM, and VAS score between the groups, independent-sample t-tests were used. A two-way mixed-model analysis of variance was used to compare within-group (before and after intervention) and between-group (CST and PT) data in terms of AROM, PROM, and VAS score of the participants. If a significant interaction in response to an intervention for a group was found, post hoc paired t-tests were performed. To reduce the type I error rate, statistical significance for the post hoc paired t-tests was set at a ¼ .01. Independent-sample t-tests were used to compare the mean difference [MD] in AROM, PROM, and VAS score between the CST and PT groups.
interventions in either group, and all 30 participants were able to complete this study. There were significant interactions by group for AROM (F1,28 ¼ 28.83, P < .01), PROM (F1,28 ¼ 32.54, P < .01), and VAS score (F1,28 ¼ 16.84, P < .01). The results of the post hoc paired t-test showed that AROM of wrist extension increased significantly in both the PT (difference ¼ 4.0 ; P < .01) and CST (difference ¼ 12.6 ; P < .01) groups; PROM results also showed significant increases in both the PT (difference ¼ 3.1 ; P < .01) and CST (difference ¼ 9.9 ; P < .01) groups. The VAS intensity decreased significantly in both the PT (difference ¼ 7 mm; P < .01) and CST (difference ¼ 24 mm; P < .01) groups (Table 3, Fig. 5). An independent t-test revealed significant differences between groups, with mean changes of 8.6 and 6.8 greater AROM and PROM in the CST group compared with the PT group, respectively (P < .01). The VAS score was significantly higher in the CST group than in the PT group, with a MD of 18 mm (P < .01) (Table 3). Discussion Effects of CST on AROM, PROM, and VAS The AROM and PROM of wrist extension significantly increased after intervention in the CST (difference ¼ 12.6 for AROM; 9.9 for PROM) and PT groups (difference ¼ 4.0 for AROM; 3.1 for PROM) compared with those in baseline. When comparing preintervention values with postintervention values, the changes in AROM (MD ¼ 8.6 ) and PROM (MD ¼ 6.8 ) were significantly greater in the
Results Motion-analysis measures of the AROM and PROM of wrist extension showed good reliability (ICC3,1 ¼ .99). The SEM ranged from 0.48 to 0.53 for AROM and from 0.57 to 0.65 for PROM of wrist extension (Table 2). The MDC95 ranged from 1.32 to 1.47 for AROM and from 1.57 to 1.80 for PROM of wrist extension (Table 2). There was no statistically significant difference between the groups at baseline in AROM, PROM, and VAS score (P < .05). A diagram of the procedural flow of study is shown in Figure 4. Most participants adhered to their appointment schedules. The adherence to the intervention for 1 week was 97% (174 of 180 sessions; n ¼ 30 6 sessions). No adverse events were reported after
Table 2 The ICC, 95% CI, SEM, and MDC95 for measurement of the wrist AROM and PROM by motion analysis Variable
Group
ICC
95% CI
SEM
MDC95
AROM (degrees)
PT CST PT CST
0.996 0.997 0.995 0.994
0.993-0.998 0.994-0.998 0.992-0.998 0.989-0. 997
0.48 0.53 0.57 0.65
1.32 1.47 1.57 1.80
PROM (degrees)
PT ¼ placebo taping; CST ¼ carpal-stabilizing taping; AROM ¼ active range of motion; PROM ¼ passive range of motion; ICC ¼ intraclass correlation coefficient; MDC95 ¼ minimal detectable change; SEM ¼ standard error of measurement; CI ¼ confidence interval.
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5
Fig. 4. Consort diagram. CST ¼ carpal-stabilizing taping; PT ¼ placebo taping.
CST group than in the PT group. The SEM ranged from 0.48 to 0.53 for AROM and from 0.57 to 0.65 for PROM of wrist extension. The MDC95 ranged from 1.32 to 1.47 for AROM and from 1.57 to 1.80 for PROM of wrist extension. The MDC95 represents the true difference in measurement.31 Therefore, there were statistically significant differences between groups and between preintervention and postintervention values for AROM and PROM. Although the use of ultrasound-based motion-analysis system has been not validated for measuring the wrist motion in previous study, the present study
demonstrated excellent intrarater reliability in both wrist AROM and PROM. The present study showed that the MD between preintervention and postintervention values for AROM and PROM was significantly greater in the CST group than those in the PT group. These results can be explained by the property of rigid and elastic tapes. Commonly, rigid tape is used to limit unwanted joint movements or to protect and support a joint structure because it provides greater stiffness and more stability than does elastic tape.32,33 Rigid tape
Table 3 Main outcome measures by group at preintervention and postintervention assessments (mean SD) Variable
Group
Intervention
AROM (degrees)
PT CST PT CST PT CST
31.6 32.5 36.0 37.3 3.4 4.4
Before
PROM (degrees) VAS (cm)
Within-group difference (95% CI)a
Between-group difference (95% CI)b
P valuec
After 8.4 7.2 8.5 7.0 1.4 1.5
35.6 45.1 39.0 47.2 2.7 2.0
6.4 7.8 7.7 6.8 1.1 1.4
4.0 12.6 3.1 9.9 0.7 2.4
(1.9 to 6.1) (9.9 to 15.4) (1.7 to 4.4) (5.1 to 14.7) (1.1 to 0.3) (3.2 to 1.6)
8.6 (11.9 to 5.3)
<.01d
6.8 (9.3 to 4.4)
<.01d
1.8 (0.9 to 2.6)
<.01d
PT ¼ placebo taping; CST ¼ carpal-stabilizing taping; AROM ¼ active range of motion; PROM ¼ passive range of motion; VAS ¼ visual analog scale; SD ¼ standard deviation; CI ¼ confidence interval. a Within-group differences are calculated by subtracting the value obtained before intervention from value obtained after intervention. b Between-group differences are calculated by subtracting the difference in the CST group from that in the PT group. c P value refers to the between-group differences in AROM, PROM, and VAS between the CST and PT groups. d P < .05 indicates significant between-group differences.
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A
B
60
60
*
50
PROM (º)
AROM (º)
50
* 40 30
* *
* *
40 30
20
20 PT
Pre
CST
Post
PT
Pre
CST
Post
C 8
*
VAS (cm)
6
* 4 2 0 PT
Pre
CST
Post
Fig. 5. AROM (A), PROM (B), and VAS (C) in PT and CST groups. *Significant difference in AROM, PROM, and VAS between before and after intervention (P < .01). PT ¼ placebo taping; CST ¼ carpal-stabilizing taping; AROM ¼ active range of motion; PROM ¼ passive range of motion; VAS ¼ visual analog scale. Error bars indicate 1 standard deviation of the mean.
restricts extension at the midcarpal joint and supination-pronation of proximal carpal bones more than elastic tape does. We believe that rigid tape contributed more to the stabilization of carpal bones than elastic tape did during weight-bearing wrist extension. Thus, the use of rigid tape led to greater increases in AROM and PROM at the wrist joint than elastic tape did. Greater restriction of movement in the sagittal plane at the midcarpal joint and in the transverse plane of the proximal carpal bones results in greater palmar gliding of the proximal carpal bones at the radiocarpal joint during weight-bearing wrist movement. In this study, owing to congruence in the radiocarpal joint caused by improved palmar gliding of the proximal carpal bones, the CST group experienced a greater reduction in pain intensity than the PT group did. In the present study, VAS intensity decreased significantly, by 24 mm, in the CST group, corresponding to a 54.5% reduction. This 24-mm decrease in the VAS score indicates clinically significant pain reduction according to previous studies, which noted that a minimum reduction of 20 mm in VAS score and a percentage pain reduction of 33% are necessary to conclude that clinically significant pain reduction has occurred.34-36 The wrist biomechanics of a CST intervention cannot be explained only by the movements of the carpal bones during active wrist motion. Recent studies determined the biomechanical changes in the carpal bones during axial loading of the wrist.37-39 The researchers reported that forces applied to the axis of the third metacarpal with a neutrally positioned wrist result in flexionpronation of the scaphoid and extension-supination of the lunate.37-39 However, in our study, axial loading in the carpal bones was applied with weight-bearing wrist extension. Thus, because of different wrist positions during axial loading, the recent biomechanical insights regarding the axial loading of the wrist do not explain the mechanism of CST intervention in our study. Future
studies should compare the biomechanical changes of carpal bones with various wrist positions during axial loading. Previous studies of wrist mobilization Some studies reported that the gliding of the carpal bones can be used to increase the ROM of wrist extension and decrease pain intensity in subjects with dorsal wrist pain.5,13-15 A pilot study13 found that palmar gliding of the proximal carpal bones increased PROM and AROM of wrist extension by 15 and 18 , respectively, and decreased dorsal wrist pain after undergoing treatment twice a week for 6 weeks in patients with poststroke hand hemiplegia. Furthermore, Walker15 reported that, after eight sessions, anterior-posterior gliding and ulnar transverse gliding of the proximal carpal bones decreased the VAS score for dorsal wrist pain by 3 cm. Tal-Akabi and Rushton14 demonstrated that applying anterior-posterior carpal bone mobilization in subjects with carpal tunnel syndrome increased AROM of wrist extension by 11.1 after a 3-week intervention. It is not possible to directly compare the results of the present study with those of the aforementioned studies due to different sample sizes, conditions, and treatment durations. Choung et al5 determined the efficiency of wrist movement using self-mobilization with a strap on wrist joint pain and ROM during weight-bearing hand activities after 5 treatment sessions in patients with dorsal wrist pain. Similar to our study, wrist movement with self-mobilization with a strap consisted of sustained palmar gliding of the carpal bones induced by pulling the strap toward the palmar side, allowing active movement of the extended arm in sit-to-stand exercises. In the present study, the results showed that PROM and AROM of wrist extension increased significantly, by 9.9 and 12.6 , respectively, in the CST group. Previous research showed that PROM
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(difference, 12.2 ) improved more than AROM of wrist extension (difference ¼ 10.3 ). In that study, subjects were instructed to rest the palm of the active hand on a table; in our study, the subjects were instructed to grasp the edge of the table to minimize the stretch effect of the finger flexor muscles during wrist movement in a weight-bearing position. Thus, we predicted that PROM would improve more than AROM due to the stretching effect of finger flexor muscles combined with the volar gliding of carpal bones noted in the previous study. Further study is required to compare wrist ROM and pain between CST alone and CST combined with stretching of the finger flexor muscles during wrist extension in weight-bearing hand activities. Application of CST There are biomechanical reasons for application of CST in the wrist-flexed position, as mentioned in the Methods section. Previous studies reported that the ratio of radiocarpal to midcarpal angle motion was approximately 4:6 during wrist flexion.17 The greater restriction of the carpal bones in the wrist-flexed positions using CST than that in a wrist-neutral or wrist-extended position causes more compensatory movement at the radiocarpal joint in the sagittal plane. Another reason for taping in the wrist-flexed position is restriction of movement in the proximal carpal rows. During wrist flexion, the scaphoid pronates and the lunate supinates, as mentioned earlier.21,22 This closes an anterior gap between the scaphoid and lunate, reducing the distance between the 2 bones. The application of tape to the wrist in a flexed position can effectively stabilize the carpal bones because it prevents supination and pronation of the scaphoid and lunate from wrist flexion to extension during weight-bearing tasks. Limitations There are several limitations to this study. First, it is difficult to generalize our results to all patients with dorsal wrist pain. Although dorsal wrist ganglions, scapholunate ligament injury, and tenosynovitis with dorsal wrist pain were excluded in this study, the intervention used in this study should be carefully applied. Also, this study has a potential weakness for whether diagnostic tests on exclusion criteria can provide high falsenegative results. Second, outcome measurements were performed after 6 sessions over 1 week of intervention and did not include any functional assessment to validate the clinical meaningfulness of the treatment effect. Further study, including functional assessment, is required to determine the long-term effects of wrist movement with CST. Finally, although CST improved ROM of extension and reduced pain, we did not prove the mechanisms underpinning the benefits of CST application. To better understand underlying mechanisms associated with clinical outcomes, further studies are required to investigate changes in arthrokinematic and osteokinematic motions at the radiocarpal and midcarpal joints after CST application. Conclusion In subjects with dorsal wrist pain during weight-bearing wrist movement, CST resulted in significantly greater improvement in the ROM of wrist extension and reduction in pain intensity than did PT after a 1-week intervention. Therefore, we suggest that rigid tape can be used to increase wrist ROM and decrease wrist pain in patients with dorsal wrist pain during weight-bearing hand activities.
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