(Dewing et al., 2012). Individuals also might have a mechanical inclination toward developing the condition, as when there is a positive ulnar variance (Rubin et al., 2012). SLAC wrist, SNAC wrist, and Kienbock’s disease have similar presentations regard- Conservative management Prior to surgical intervention, nonsurgical treatments of symptom- atic OA of the wrist in any of the forms described might include wrist immobilization, anti-inflammatory medication, and cortico- steroid injection (Shah & Stern, 2013). When symptoms can no longer be managed with conservative methods or at the point when functional decline is no longer acceptable, the client might opt for surgical intervention. Pain leading to disuse is the primary problem in those with severe OA of the wrist, regardless of the diagnosis (e.g., Kienbock’s, SLAC wrist). Since the primary role of therapy is to preserve function and occupational engagement, preventing or reducing pain within the hand and wrist during ac- tivities is the target of intervention. Pain reduction and enhanced functional use of the hand are accomplished through multiple methods, including physical agent modalities, orthosis wear, joint protection, work simplification techniques, and adaptive equip- ment. Some individuals choose a conservative approach as a per - manent method of dealing with pain of the wrist; others eventu- ally opt for surgical intervention to reduce pain permanently. Therapists first determine the extent of pain in the wrist and then gain an understanding of how it affects daily occupations for a cli- ent. Several assessment tools, described previously, can be used for this occupational profile (AOTA, 2020). When a therapist un- derstands how a client needs to use their hand and analyzes the motions required, they can offer suggestions regarding work sim- plification aids or tools that will do work and decrease the amount of force on the wrist. For example, a client can be instructed to use a rolling trivet when cooking to move heavy pots along a kitchen counter, rather than place undue force on the wrist by car- rying the pot (Cooper, 2020). Work simplification techniques can also be suggested, such as using a cart when cleaning to avoid carrying cleaning items or items needing to be relocated. (See Appendix A.) A client should also be instructed to use ice packs to dull pain when possible. Ice packs can be applied for a maximum of 20 minutes at a time, with the skin covered by a layer of toweling to prevent damage to the skin. Other physical agent modalities such as transcutaneous electrical stimulation (TENS) can also be Proximal row carpectomy (PRC) is a surgical treatment for severe arthritis of the wrist. The procedure involves removing the first row of wrist bones and relying on the remaining bones for move- ment. In comparison to other forms of joint fusion, PRC is a sim- ple procedure that does not require permanent immobilization of the wrist or placement of indwelling hardware. Rehabilitation following the procedure is straightforward and progresses quickly because no bone healing is required. PRC is appropriate for mod- erate and early-stage SLAC and SNAC wrists when the articular surfaces of the head of the capitate, and the lunate facet of the distal radius, have not been destroyed (Wall & Stern, 2013). The radioscaphocapitate ligament must also be intact to prevent post- operative ulnar shifting of the carpus. The procedure is effective in cases of Kienbock’s disease with carpal collapse (Cannon, 2020; Wall & Stern, 2013). Good results have been achieved with PRC, which provides most clients with total, pain-free, active motion in flexion and extension of 72 degrees (Cannon, 2020). Average grip strength following PRC varies. Several studies suggest average grip strength is 71%
ing client symptoms and dysfunction. Each results in pain both with movement and at rest, and they limit movement and overall function of the wrist.
suggested and should be applied and provided to the client for home use by a PT/OT familiar with their indications and use. TENS used intermittently throughout the day reduces pain and decreas- es the need for pain medications (Bellew et al., 2016). A wrist immobilization orthosis should be provided to a client to reduce movement of the wrist and the painful impact of force. Orthoses can be fabricated from thermoplastic such as those in Figure 23, or can be purchased from a vendor. Either meth- od is acceptable as long as it performs appropriately and does not cause harm to the client. Regardless of whether the device is custom-made or prefabricated, it should be rigid and able to hold up against the demands of a client’s daily occupations. A circumferential or clamshell orthosis offers the most stability of the wrist. These volar- and dorsal-based devices can be purchased or fabricated by a practitioner. Leather orthoses are available com- mercially and resist dirt, grime, and wear experienced in jobs in industries such as construction, auto mechanics, and farming. Figure 23: Volar-Based Thermoplastic Wrist Immobilization Orthosis
Note: Photograph provided courtesy of Dr. Lucinda Dale.
Surgical management and postsurgical therapeutic intervention Several types of surgery can be executed based on the medical diagnosis and mechanics of the joint/bone breakdown resulting from OA. Each procedure has its own postsurgical therapy pro- tocol. This section outlines the protocols for therapy following proximal row carpectomy and partial- and total-wrist arthroplasty. Proximal row carpectomy
to 79% compared to the contralateral noninvolved hand (Bednar et al., 2011), and other studies show that as much as 91% to 100% of grip strength is regained, but this might take up to a year to achieve (Wall & Stern, 2013.) Therapeutic intervention following proximal row carpectomy According to Cannon (2020), approximately 10 to 14 days follow- ing removal of the proximal carpal row, the client is fitted with a short arm cast in the surgeon’s office. If there are no concerns for client compliance, the client can instead use a custom-fabricated and clamshell design forearm-based wrist immobilization ortho- sis. The orthosis is worn full time, with removal only for careful hygiene. A referral for therapy is made, during which active and passive ROM exercises are initiated to the shoulder, elbow, digits, and thumb. These movements are safe because the healing wrist is immobilized securely in the circumferential cast or orthosis. In addition to ROM, edema control methods such as retrograde massage, positioning, and compression garments can be provid- ed as needed to the forearm and hand. At three weeks postsurgery, and while the client is still wearing the orthosis or cast, AROM exercises for the forearm can begin. It is important for clients to only perform short arc motion initially, then progress to mid arc, followed by full arc over the course of a week (Cannon, 2020).
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