De Quervain’s Tenosynovitis

A Review Of Treatment And Biopsychosocial Considerations

By Julia Blackburn

Keywords: De Quervain's tenosynovitis; biopsychosocial; psychology

De Quervain’s disease (DQ) is a stenosing tenovaginitis of the abductor pollicis longus and extensor pollicis brevis tendons at the level of the radial styloid. A survey of the prevalence of de Quervain’s in workingage adults in the United Kingdom found rates of 0.5-0.6% in men and 1.3-2.1% of women.1 Patients report pain on the radial aspect of their wrist that is exacerbated by certain movements or activities.

The options for treatment include analgesia or a splint to help manage their pain, a steroid injection or an operation to decompress the tendons. However, DQ may be a self-limiting condition that does not necessarily require treatment. In one study, 95% of patients who chose neither a steroid injection or surgery for DQ, reported resolution of their symptoms after approximately one year.2 Furthermore, in common with other self-limiting musculoskeletal conditions such as plantar fasciitis and lateral epicondylitis, many other treatments have also been investigated as ways to improve symptoms. These include low level laser therapy (LLLT) and ultrasound, acupuncture, kinesiology tape and platelet-rich plasma injections 3, that are not compared with placebo controls. As the condition may improve by itself, it is also difficult to prove that any intervention provided the relief of symptoms. The aim of this review is to consider the evidence for treatment of DQ and the effect of psychological distress.

Treatments for De Quervain’s There are a large number of studies that evaluate treatments for DQ. A systematic review of non-operative management of DQ found 66 papers 3 with success rates of

It is difficult to prove that any intervention provided the relief of symptoms

Abstract

De Quervain's tenosynovitis (DQ) may be a self-limiting condition that can be treated with analgesia, splints, corticosteroid injections and surgery. However, there is growing awareness that the limitations that patients report correlate more with psychosocial aspects of illness rather than severity of pathology. The aim of this review is to consider the evidence for treatment of DQ and the effect of psychological distress. If we can identify patients with psychological distress, we can offer interventions to improve outcomes for patients. Communication strategies targeting illness perception and encouraging patient engagement can help patients choose a treatment for DQ that reflects their values.

51-100%. Unfortunately, the definition of success is heterogenous with 51% representing those patients who had relief of their symptoms, whilst the 100% represented those patients who were able to avoid having surgery.3 However, the results of the studies can be conflicting. For example, one study found the combination of a steroid injection and a splint produced better outcomes than a splint alone 4 whilst two other studies found splints to offer no benefit over steroid injections alone.5,6 As DQ may be a self-limiting condition, I have looked for randomised studies of treatment options compared to placebo controls where possible.

For patients who choose a splint, only one randomised controlled trial (RCT) compared splint use in patients with DQ. In this study, they compared patients who used a splint full-time use to those that only used the splint.7 They found no difference in limitations, grip strength, pain intensity or treatment satisfaction between the two groups.7

There are only two RCTs of steroid injection compared to placebo injection for DQ.8,9 The first involved just 21 patients (nine with triamcinolone and 12 with saline placebo) and concluded that steroid injections were more effective.8 However, the study was significantly under powered as they needed 50 patients, and they measured improvement in pain at just one week when the steroid injection may only have started to help.8 The other study randomised seventeen patients to a steroid injection with local anaesthetic and five to local anaesthetic alone.9 They found no significant difference in pain intensity or patient reported functional outcome (Disabilities of the Arm Shoulder and Hand DASH score) at one to three months.9 Many other cohort studies have found steroid injections to be effective at reducing pain with DQ, but they often have long follow up periods making it likely that the pain would have subsided over time anyway.

Other patients may choose surgery, if they would like a quick end to their symptoms whilst accepting the risk of complications such as nerve injury or tendon subluxation. The two largest cohort studies of outcomes of surgery for DQ report excellent success rates.10,11 In a study of 74 patients who underwent surgery for DQ in 80 wrists, 78 were satisfied or very satisfied with the outcome at a mean of nearly 10 years.10 In the other study of 94 patients, they

reported 100% success at resolving symptoms, with complications including just one wound infection, one delayed wound healing and four temporary problems with the superficial radial nerve.11

Psychology, hand surgery and De Quervain’s There is growing awareness that the limitations that patients report correlate more with psychosocial aspects of illness rather than severity of pathology, including a large study of patients with upper extremity injuries.12 Some studies of patients with hand problems, did include some patients with DQ.13-15 They found that greater limitations as recorded with a DASH score were associated with more symptoms of depression, worry about pain (Pain Catastrophizing Scale PCS), kinesiophobia and pain anxiety.13,15 Furthermore, a DASH/QuickDASH score of more than 55 was associated with a diagnosis of depression.14

A few studies have considered psychological distress specifically in patients with DQ.7,9,16-19 Worry about pain (PCS) was found to explain 18% of the variation in limitations and 33% of the variation in pain intensity in patients with DQ after treatment.9 In another study, symptoms of depression accounted for 32% of the variability in limitations in patients with DQ after trying a splint.7

In a retrospective study of more than 2000 patients with DQ, patients who had a steroid injection were more likely to go on to have surgery.16 The odds of patients undergoing operative treatment were 1.7 times higher in those patients who had a steroid injection.16 This may be because they have medicalised the condition, feeling that once the steroid wears-off they need the next treatment to resolve their symptoms. However, there may be other explanations and certainly there was a more than 10-fold difference between the rate of surgery offered by the nine doctors involved in the study.16

I have been fortunate to work with the Hand-Wrist Study group in the Netherlands, to study large cohorts of patients treated with DQ. They use clinical data from a longitudinally maintained database, with the aim of improving the treatment of hand and wrist disorders. In our studies of patients with DQ, we looked at how preoperative psychological factors were associated with pain and limitations before and after surgery.17,18 We found that patients with more negative perceptions of the consequences of their condition and more worry about pain (PCS) had worse baseline pain and more limitations.17 In patients who opted for surgery for DQ, those with more negative perceptions about how long their condition would last had more limitations and greater pain intensity three months after surgery.18

This fits with other studies on how illness perceptions were associated with outcomes from treatment. They found that better understanding about their condition was associated with better outcomes three months after non-operative treatment for thumb arthritis 20 and six months after carpal tunnel decompression.21 Whilst patients with a worse perception of the consequences of

Symptoms of depression accounted for 32% of the variability in limitations

their basal thumb arthritis, were more likely to have worse acute postoperative pain after surgery for their conditions.22 Patients who were scheduled for surgery for thumb arthritis were more likely to have worse perceptions of their degree of personal control and emotional response to their condition than those patients who were scheduled for non-surgical treatment.23

We also found that more positive expectations of the treatment in patients opting for surgery for DQ, were associated with better pain and fewer limitations.18 This matches other studies where more positive expectations of treatment are associated with better outcome three months after non-operative treatment for thumb arthritis 20 and six months after carpal tunnel decompression surgery.21 Patients who opted for surgery for basal thumb arthritis had greater expectations of treatment compared to those that chose non-operative management.23

Consequences of psychological distress Other consequences of psychological distress in patients with hand conditions, is reflected not just in more limitations, but greater opioid use and more office visits. Patients with more pain interference and symptoms of anxiety or depression have been found to be more likely to use opioids preoperatively 24,25 and those with greater worry about pain (PCS) were likely to use more opioids after hand surgery.26

Patients who had more symptoms of depression and worse pain interference also had more office visits in a study of over 3000 patients with a variety of hand conditions including some with DQ.27 Greater pain interference scores were also associated with more office visits in a study of over 800 patients with hand trauma.28

Identifying the problem In order to help patients with DQ and psychological distress, there have been a number of studies looking at ways to identify them in hand clinics. These include watching for hand positioning 29, listening for patient word choices 30 and spotting empathic opportunities.31,32

We will all have seen patients for whom the first body part to enter the room is their hand, held in an unusual position. In a study of 149 patients with stiff or painful fingers after trauma, a number of protective hand postures were identified.29 They described seven specific hand postures, including presenting the hand as if it is detached, using the opposite hand to move injured figures, avoiding use of uninjured figures and the thumb obstructing the path of finger flexion.29 Patients who adopted at least one posture were more likely to have greater levels of worry about pain (PCS).29 Spotting these hand postures may offer an opportunity to ask about their pain and how it may worry them.

As clinicians we can also listen to patient word choices. In an interesting study of patients with non-traumatic hand problems, new consultations were recorded and common phrases categorised by two researchers 30. They found six categories, with many of the phrases familiar to clinici-

ans, for example “I have a high threshold for pain”, “it goes up my arm” and “it swells when I use it” (Bot 2012). Most patients used expressions from different categories, and this was associated with more limitations and psychological distress.30 The authors of this study used this study to create a phrases and feelings questionnaire, asking patients to rate how often they would use these expressions from never to frequently.33 The questionnaire scores correlated with both limitations (QuickDASH) and pain self-efficacy scores 33, and could be a useful tool to help identify patients who may struggle with their condition and benefit from psychological help.

A study by the same group looked for clues that patients might give during consultations about their feelings or personal circumstances that can affect their hand symptoms.31 Two researchers spotted these clues or empathic opportunities in 70% of consultations, although only half were responded to by the surgeon.31 Some emotional clues related to the hand problem, for example frustration or fear, whilst others related to concern about life changes such as retiring or seeing their youngest child go off to college.31 Fortunately for clinicians concerned that asking about feelings might lengthen the consultation, in this study it did not.31

Treatments There are a number of interventions that have been studied to try to target psychological distress to improve outcomes for patients. These include coaching, encouraging patient engagement and focused psychological interventions. Simply coaching patients with radial head fractures to stretch despite pain, immediately improves the range of movement they could achieve.34

A study of over 700 patients with fractures to their upper limb, found that those with greater engagement in their care and less psychological distress had fewer limitations at six to nine months after their injury.35 In fact, they found that the extent of participation in their care and psychosocial factors explained 20% of the variation in QuickDASH score and 14% of the variation in PROMIS physical function scores 35 (Patient-Reported Outcome Measurement Information System PROMIS). Therefore, interventions to improve patient engagement such as education or communication strategies, should help patients recover.

Patient engagement can be enhanced with decision aids. These provide information about a condition, giving options for treatment so that patients can make decisions about their care that reflect their values. For example, a patient who has DQ may agree that their condition will get better without treatment, but the value most important to them is to get rid of the pain as quickly as possible, so they may choose surgical decompression despite the risks of complications. A systematic review of Decision Aids found that patients feel better informed, participate more in the decision making process and more accurately understand the risks of treatment.36 This Cochrane review included 105 RCTs with 31,043 participants making 50

A number of interventions targeting psychological distress improve patient outcomes

different decisions involving surgery, screening, genetic testing and medication treatments.36 An RCT comparing a web-based Decision Aid for basal thumb arthritis to an information leaflet, found that patients had less decisional conflict.37

Decision Aids also offer an opportunity to correct misconceptions about a condition, for example addressing illness perceptions in terms of the consequences of the problem or how long it will last. Some patients with DQ are happy to use their hand despite the pain once they know that the condition is not dangerous and will go away by itself in time.2

Even a brief intervention may be helpful. For example, a short mindfulness exercise, lasting just one minute, improved pain intensity, and symptoms of anxiety and depression in patients attending hand clinics when compared to an educational pamphlet.38

Fortunately, feasibility studies of cognitive behavioural therapy interventions have also been shown to improve pain and limitations. A preliminary RCT of a mind-bodyskills intervention in patients with acute orthopaedic trauma, found that 86% of patients stayed with the programme and they recorded a large effect size of improvement in pain intensity and limitations.39 Outcome questionnaires were completed at four to six weeks after initial assessment, so any improvement due to the natural disease course would be the same for each group.39 Another RCT recruited patients with orthopaedic injuries from clinic and trialled a “Toolkit for Optimal Recovery”.40 The programme had good levels of satisfaction and adherence to the treatment sessions.40 So it will be interesting to see the results of future studies of these interventions.

Conclusions There are many treatments for de Quervain’s tenosynovitis but no good placebo-controlled evidence for benefit with either a splint or steroid injections. Whilst surgical decompression has excellent results, it has risks that many patients may choose to avoid if they are aware that the condition may resolve on its own.

Psychological factors such as worry about pain or symptoms of depression, and more negative perceptions of the condition, are associated with more pain and limitations experienced by patients with DQ. Clinicians can look for clues to indicate psychological distress, including the way they hold their hand and the phrases they use. Involving patients in decision making about their DQ, including use of Decision Aids, may improve illness perceptions and help them make choices about treatment that reflect their values. Finally, psychological interventions to help those with psychological distress will be an interesting area of research to watch, as we try to improve outcomes for patients with de Quervain’s.

Conflict of Interest Statement The author declares that she has no conflict of interest in relation to the submitted article.

AUTHOR Julia Blackburn, Locum Consultant Hand & Wrist Surgeon Northern General Hospital, Sheffield, UK Correspondence: jb0777@bristol.ac.uk

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