Rehabilitation of patients with Kienböck disease underwent proximal row carpectomy

Abstracts

A proposta deste estudo foi a aplicação de um protocolo de avaliação e tratamento desenvolvido no Serviço de Terapia da Mão do Setor de Terapia Ocupacional da Disciplina de Fisiatria do Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo, destinado a pacientes portadores da Doença de Kienböck e submetidos a técnica cirúrgica de ressecção da fileira proximal do carpo. O protocolo de avaliação foi aplicado em 16 pacientes que foram avaliados no pré e pós-tratamento, considerando-se a dor, perímetro do punho, força muscular, amplitude articular do antebraço e punho e a capacidade funcional. Considerou-se também alguns referenciais subjetivos, no que se refere à satisfação pessoal do paciente quanto ao tratamento. Os resultados mostraram que o protocolo de tratamento aplicado foi eficaz na redução da dor, no aumento do arco de movimento da pronação e supinação do antebraço, abdução e adução do punho e favoreceu a melhora da capacidade funcional da mão afetada. Na avaliação subjetiva 90% dos pacientes tratados em nosso protocolo estavam satisfeitos com a sua recuperação.

ARTIGO ORIGINAL

Rehabilitation of patients with Kienböck disease underwent proximal row carpectomy

Lima, S.M.P.F.^I; Leite, V.M.^II; Masiero, D.^III; Santos, J.B.G.^IV; Laredo Filho, J.^V

^ISimone Maria Puresa Fonseca Lima: Terapeuta Ocupacional, Chefe do Setor de Terapia Ocupacional da Disciplina de Fisiatria do Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo, Mestre em Reabilitação

^IIVilnei Mattioli Leite: Livre Docente da Disciplina de Cirurgia da Mão e Membros Superiores do Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo

^IIIDanilo Masiero: Livre Docente e Chefe da Disciplina de Fisiatria do Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo

^IVJoão Baptista Gomes dos Santos: Doutor e Assistente da Disciplina de Cirurgia da Mão e Membros Superiores do Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo

^VJosé Laredo Filho: Titular e Chefe do Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo.

^{Endereço para correspondência}

SUMMARY

The aim of this study was to apply an evaluation and treatment protocol developed by the Hand Therapy Department of the Occupational Therapy Group of Physiatrics Medicine, Department of Orthopedics and Traumatology, University of São Paulo, to patients with Kienböck disease underwent proximal row carpectomy. The protocol was applied to 16 patients who were assessed in the pretreatment and post-treatment periods concerning some objective parameters, such as pain, wrist circumference, muscular strength, forearm / wrist articular range of motion and functional capacity. Patients' satisfaction with their evolution was evaluated through a questionnaire according to the treatment.

Results have shown that the group underwent a rehabilitation approach showed better outcomes concerning pain, muscle strength, supination, abduction and adduction range of motion and an improved hand functional efficacy. Subjective evaluation showed 90% satisfaction in the rehabilitation group.

INTRODUCTION

Robert Kienböck has developed several studies on Kienböck disease since its discovery in 1910.¹² Conservative or surgical approaches are described in order to designate the best management to the disease. Among surgical procedures we emphasize the proximal row carpectomy, which is discussed and used by different Orthopedics Departments.^{1,2,4,5,6,8,9,11,12,15}

Postoperative approaches, which describe the rehabilitation process that is followed by an expert therapist, are very uncommon.

The authors developed an assessment and treatment protocol to be applied to this population of patients with Kienböck disease underwent proximal row carpectomy.

MATERIAL AND METHOD

Data from 16 patients with Kienböck disease who were surgically treated by proximal row carpectomy were evaluated. Two Groups were formed. Ten (10) patients who were treated and followed from May 1994 to July 1995 formed Group I.

These tem patients were treated according to a treatment protocol, which consisted of kinesiotherapy, thermotherapy, massotherapy, eletrotherapy, therapeutic activities and domiciliary guiding.

Group II was formed by 6 patients who were treated by other non-specialized Departments in Hand Therapy and under therapeutic approaches, such as thermotherapy and exercises without a direct actuation of the therapist.

In all patients we applied a protocol which had a pre-operative and a post-rehabilitation treatment evaluation.

The pre-operative protocol included the patient identification (name, sex, age, professional activity, race, dominant hand, damaged hand and principal symptoms). It also included pain (visual analogic scale from REVIL et al., published in 1984¹⁵) and edema (circumference measure¹⁷) assessment, as well as the prehension force (dynamometry, described by MATHIOWETZ et al. in 1984¹⁴) assessment and the articular forearm and wrist range of motion (goniometry, measures standardized by COLE in 1986³). We applied the same references postoperatively, including the manual function evaluation (tests of manual function, described by JEBSEN et al. in 1969¹⁰). Finally, we elaborated 3 questions to evaluate subjectively patient's satisfaction in relation to the treatments which they underwent (table 2)¹³.

The protocol of treatment applied to patients of Group I was divided in 10 weeks, including the patient's first week with immobilization (table 1).

The authors applied a questionnaire to patients of Group II for investigating the rehabilitation treatment that they underwent. They were asked some simple questions with no use of technical terms, including a pre-determined guiding for the therapist.¹³

For the analysis of results Wilcoxon's tests were applied for both non-independent samples (SIEGEL, 197516), with the purpose of comparing Group I and Group II separately with relationship to the values of the preoperative and post-treatment period. We also applied Mann-Whitney's test for two independent samples (SIEGEL, 197516), with the objective of comparing the percentile differences of both Groups (D%) calculated from values measured in the preoperative and post-treatment period. In all tests a value of 0.05 or 5% for the rejection level of the nullity hypothesis was established.

RESULTS

After the application of the rehabilitation treatment protocol in Therapy of Hand to patients from Group I, some significant results (p < 0.05) for several variables were found. These variables included pain, muscular strength, prehension force, forearm articular range of motion for pronation and supination movements, wrist articular range of motion in abduction and adduction movements and manual function performance (JEBSEN manual function test¹⁰) in the specific subtests of writing and piling up checkers. In the subjective evaluation, 90% of patients from Group I were satisfied with the results of the treatment versus 66% of those from Group II, who reported being satisfied with the treatment offered by other Departments.

DISCUSSION

The Kienböck disease is still included in the group of idiopathic pathologies. In spite of several theories that try to explain it, it is not possible to affirm its cause.^{2, 12,15} There are several treatments proposed and the proximal row carpectomy is the surgical option, which sometimes allows the early recovery of patients¹⁵. The rehabilitation of these patients depends on a specialized therapeutic approach to help their ocupacional reintegration.¹³

The major need to study and attend this population was due to the demand for the Hand Therapy Department of the Occupational Therapy Group of Physiatrics Medicine, Department of Orthopedics and Traumatology, University of São Paulo, from Hospital São Paulo, Discipline of Surgery of the Hand and Superior Limb.

From clinical and therapeutic practice, we designed an evaluation and treatment protocol and the care was addressed to the scar, edema, pain, and articular range of motion of the arm, muscular strength and functional capacity.

Protocols were designed and after their practical application, some results were noted.

Group I and II patients' mean age showed that the population that was studied was in the productive age (36.7 and 43.5 years old, respectively), which justified the efficient rehabilitation in order to reintegrate them to their previous occupations or new functions.

Household work was the predominant occupation in both groups. On the contrary, in the literature there was a prevalence of manual work.^2,7,11,12 Women performing household activities were in larger number and among us, such activity is not recognized as manual work.

In the treatment itself, the therapeutic approach was based on the disease symptoms (table 1).

It was emphasized the introduction of graduate activities to stimulate the use of the manual function as soon as possible, once patients showed functional restrictions for more than one year after the initial symptom¹³. The initial symptom was mainly referred to as pain^11,13 , which was alleviated from the first week to encourage patients. Also, activities of returning to normal functions were encouraged.

In the subjective evaluation, 80% of patients from Group I and 66.6% from Group II continued exercising their activities previous to the disease. According to pain 70% of patients from Group I showed lesser pain; All patients from Group II (100%) still showed some pain. According to patients' satisfaction concerned with the treatment that was received, 90% and 66.6% of Group I and Group II patients were satisfied, respectively. The mean time to return to previous activities and for therapy follow-up were 3.2 months and 4.1 months for Group I and 4 months and 4.2 months for Group II, respectively.

Our results were significantly better relating to pain, muscular strength (prehension force), articular range of motion of the forearm (pronation and supination) and wrist (abduction and adduction), as well as some aspects of the hand function (to write and to pile up checkers).

In conclusion, this study did not allow a statistical analysis of comparison between Groups I and II. However, results are suggestive of best evolution of Group I with relationship to Group II, which allows conclude the efficiency of the protocol that was applied.

REFERENCES

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Endereço para correspondência

Lar Escola São Francisco. Disciplina de Fisiatria.

Rua dos Açores, 310 - Jardim Luzitânia

CEP: 04032-060 São Paulo - SP

Tel: [phone] R:222 - Tel /fax: [phone]

Publication Dates

• Publication in this collection
  22 May 2007
• Date of issue
  June 2000