Effect of eccentric exercise in treatment of De Quervians disease

Authors

Lilian Albert Zaky 1, Nagy Ahmed Zaki Mostafa Sabet 2, Walaa Mohsen
Mohamed3
1Department

of Physical Therapy for Musculoskeletal Disorders and its Surgery, Faculty of

Physical Therapy, Cairo University, Egypt

2 Department of Orthopedic Surgery, Faculty of Medicine, MISR University for science and

technology, Egypt.
3Department

of Physical Therapy for Musculoskeletal disorders and its Surgery, Faculty of

Physical Therapy, MISR University for Science and Technology, Egypt
Corresponding Author

Walaa Mohsen Mohamed

Department of Physical Therapy for Musculoskeletal disorders and its Surgery, Faculty of
Physical Therapy, Misr University for Science and Technology
Email: dr.walaamohsen@yahoo.com Tel.: 02-44468214. Mob: 00201142187779

Abstract
Objective: This study was carried to determine the effect of eccentric exercises in treatment
of De Quervians disease
Methods: Thirty female patients diagnosed as De Quervians tenosynovitis was randomly
distributed into two equal experimental groups. Each patient was treated for twelve sessions
each other day for a total period of four weeks. Patients in the experimental group (A)
received phonophoresis, while patients in the experimental group (B) received a combined
program of phonophoresis identical to those applied to group (A) in addition to eccentric
exercises then visual analogue scale (VAS) was used to assess pain severity. The disability of
arm, shoulder and hand outcome questionnaire (DASH) was used to assess hand functions.
Jamars dynamometer and pinch gauge were used to assess hand grip and pinch strength.
Results: Patients of both groups showed significant improvement in all the measured
variables. In between group difference, the second group showed a significant improvement
than the first group in all the measured variables. Conclusion: Both of phonophoresis and the
combination of phonophoresis with eccentric exercise were effective on decreasing pain
severity, functional disability as well as improving grip and pinch strength. However, the
combination of phonophoresis with eccentric exercise was more effective than phonophoresis
alone in treatment of De Quervians disease.
Keywords: De Quervians disease, Phonophoresis, Eccentric exercises.

The Concept of eccentric exercises as

Introduction

treatment

De Quervain's syndrome or De Quervain's

for

tendinopathy

has

been

described by Stanish and coworkers and is

disease named after the Swiss surgeon Fritz

De Quervain, who identified it in 1895 [1],

based upon the belief that tendon injuries

[2].De Quervains disease (DQ) is described

often occur during the eccentric phase of

muscle work. They also proposed that in

as painful stenosing tenosynovitis of the first

eccentric

dorsal compartmentof the hand [3], [4]. It is

postulated that the mechanism by which

and extensor pollicis brevis (EPB) beneath

eccentric loading is effective the pattern of

the sheath over the styloid process of the

tendon loading, with its force fluctuations,

radius [4], [5]. Patients typically report with

radial

styloid

was

stimulus [9], [10]. Furthermore other study

compartment abductor pollicis longus (APL)

the

tendon

exercises and hence to more re-modeling

gliding of tendons of the first dorsal

over

the

subjected to greater forces than in concentric

usually caused by overuse or repetitive

pain

exercises,

rather than the magnitude of the force. They

process

observed a pattern of sinusoidal loading and

accompanied by first dorsal compartment

unloading

tenderness and marked wrist swelling also it

in

eccentric

loading,

these

fluctuations in force may provide an

is associated with painful abduction of the

important stimulus for the re-modelling of

thumb, decreased grip strength (GS) and

tendon

pinch strength (PS) of affected hand, in

[11].

demonstrated

addition to a positive Finkelsteins test [6].

Eccentric
some

training

application

in

has
the

treatment of De Quervains disease [12],

(DQST) is diagnosed by the clinical

[13].

symptoms and by positive Finkelstein test.

Radiographs are not usually required for

SUBJECTS AND METHODS

diagnosis [7]. One study showed the

Patients

histopathological appearances of the tendon

sheath and synovium in De quervains

Thirty female patients diagnosed as De

disease. The condition was not characterized

Quervians disease. They were randomly

by inflammation, but by thickening of the

distributed into two equal experimental groups.

tendon sheath and most notably by the

The first experimental group consisted of 15

accumulation of mucopolysaccharide, which

females with mean age of 34.47 (7.08) years

is an indicator of myxoid degeneration. [8]

and mean duration of illness of 4.83 (1.08)

2

months;

the

second

experimental

group

treated for twelve sessions each other day for

consisted of 15 females with mean age of 34.60

a total period of four weeks at the out-patient

(7.008) years and mean duration of illness of

clinic of faculty of Physical Therapy, Misr

4.93 (1.17) months. They were referred from

University for Science and Technology. Both

the orthopedic outpatient clinic of the faculty

experimental

of medicine, Misr University for science and

phonophoresis with diclofenac gel 4 g of

technology, Egypt. Exclusion criteria included

Aquasonic gel containing 0.4% Dex-P was

conditions associated intercarpal instabilities,

applied over the wrist chin, and pulsed (20%)

scaphoid fracture, superficial radial neuritis

ultrasound waves (ITO models ES-420

(wartenbergs syndrome) and osteoarthritis of

with5-cm2 probe) were used with an

the 1st CMJ, patients with any previous hand

intensity of 1.0 W/cm2 at a 1MHz frequency

surgery or any rheumatic diseases or receiving

for 5 minutes to transfer the medication, and

corticosteroid or analgesic drugs.

that was 3x/wk for 4weeks. Patients in the

groups

(A,

B)

received

second experimental group (B) received

Instrumentations and Materials

eccentric training protocol.

In this study the severity of De Quervians

disease was

assessed

Ethical consideration

by using visual
All patients were informed of the purpose,

analogue scale (VAS). The disability of arm,

tools, procedures, and duration of the study

shoulder and hand outcome questionnaire

and signed a written consent.

(DASH) was used for the assessment of hand

functions. The hand grip and pinch strength
were

evaluated

by

using

Statistical analysis

Jamars

dynamometer and pinch gauge. Pretreatment

Paired t-test was conducted to detect within

assessment was done within 48 hours before

group difference pretreatment and post

the

posttreatment

treatment for pain severity, grip strength,

assessment was done within 48 hours after

pinch strength and functional disability. The

the last treatment session.

level of significance for all statistical tests

first

session

while

was set at p < 0.05. All statistical analysis

Study protocol

was conducted through SPSS (statistical

package for social sciences, version 19).

They were randomly distributed into two

equal experimental groups. Each patient was
3

Results

Variable

Group (1)
Mean (SD)

Subject characteristics:

Group (2)

t-

Mean

P-value

value

(SD)
Thirty female patients participated in this
study, Table 1 showed the mean SD age,
duration of illness of the study group.
Table (1): Mean age and duration of illness of
both experimental groups:
Variable

First
Second
experimental experimental
tpgroup
group
value value

Age(year) 34.6 7.01

34.47 7.08

Duration 4.93 1.18

of illness
(MO.)

4.83 1.08

Pain

7.467(1.2

7.367(1.06

severity

459)

01)

Grip

12.933(1.

12.833(1.2

strength

5337)

488)

Pinch

2.500(.50

2.400(.783

strength

00)

8)

Functional

90.67(14.

89.27(13.4

disability

281)

30)

0.237

(N.S)
0.196

0.417

0.277

7.467
7.367

7.350
7.300

Comparison between groups before treatment

Group 1

Unpaired t test was used to detect

Group 2

Figure (1): pain severity between groups

difference between groups before treatment.

Grip strength

There was no significant difference between

12.950

groups regarding pain severity (t=0.237,

P=0.815).,

grip

P=0.846).,

pinch

strength

12.850

0.417

12.800

,P=0.680) and functional disability (t=

12.750

(t=

12.933

12.900

0.196,

strength

(t=

12.833

Group 1

Group 2

0.277, P=0.784) as shown in table (2

Figure (2): Grip strength between groups

Table 2: comparison between groups

before treatment

0.784
(N.S)

7.450
7.400

0.680
(N.S)

Pain severity
7.500

0.846
(N.S)

0.959
0.052 (NS)

0.810
0.242 (NS)

0.815

experimental group increased post treatment by

Pinch strength

18.67 (0.4880) and 5.53 (0.2289).

2.600

2.500

2.500

Pain severity

2.400

2.400

4.9

2.300

3.967

4
Group 1

Group 2

2
0

Figure (3): Pinch strength between groups

second experimental group

second experimental group

first experimental group

first experimental group

Functional disability
90.67

91.00
90.00

Fig (5): Between group difference for pain

severity

89.27

89.00

Grip strength

88.00
Group 1

Group 2

20.000

18.667
15.000

15.000
10.000

Figure (4): DASH between groups

5.000

Comparison between pre and post treatment

conditions:

.000
first experimental

The VAS scale and DASH questionnaire

second experimental

Fig (6): Between group difference for grip

strength

consecutively of the first experimental group

decreased post treatment by 4.90 ( 1.105) and

Pinch strength

61.73 (61.73). However, the GS and PS

5.533

6.000

consecutively of the first experimental group

4.000

increased post treatment by 15.0 ( 2.20) and

3.200

2.000

3.20 (0.774).

.000
first experimental

second experimental

The VAS scale and DASH questionnaire

Fig (7): Between group difference for pinch

consecutively of the second experimental

strength

group decreased post treatment by 3.967 (

1.329) and 52.67 (7.613). However, the GS
and

PS

consecutively

of

the

second

improvement in pain and grip strength in

DASH

patients with De Quervain's diseases. They

61.73

65
60
55
50
45

concluded

52.67

that

phonophoresis

with

diclofenac gel has a significant effect on

pain and grip strength in patients with De
first experimental

second experimental

Quervain's diseases [14].

In our current study, there was a

Fig (8): Between group difference for functional

disability

significant increase in grip and pinch

strength in both groups; however, the

Discussion

combination of phonophoresis followed by

In our current study, there was a significant

eccentric exercises was more effective in

decrease in pain severity in both groups, our result

increasing grip and pinch strength rather

was in agreement with numerous previous

researches

which

proved

that

than phonophoresis alone in treatment of De

ketoprofen

Quervian disease.

phonophoresis coupled with a supervised exercise

regime

and

considerable

stretching
improvement

exercise
in

leads

In

to

our

current

study,

there

was

significant reduction of DASH (disability of

De Quervain's

the arm, shoulder and hand) questionnaire in

tenosynovitis [14], [15], [9], [11], [12], [13].

patients treated with phonophoresis, this

Results of this study showed a significant

result was supported by the work of Hiral et

increase in grip and pinch strength in

al. and Tabinda et al [14], [15]. In addition

patients treated with phonophoresis followed

to that, there was a significant decrease in

by eccentric exercises. This has been

this variable within the patients treated with

supported by researches postulating that

phonophoresis

eccentric training led to encouraging results

exercises, As Knobloch et al. [12] and Rabin

in terms of pain reduction and functional

et al.[16] reported that there was a reduction

improvement [12], [13]. In addition to that,

of DASH score following the eccentric

there was a significant increase in this

training program in patients with De

variable

Quervians disease.

in

phonophoresis,

patients
this

treated

finding

was

with
in

agreement on the work of Hiral et al. who

followed

Furthermore,

there

by

was

eccentric

significant

reduction of DASH (disability of the arm,

found that there is highly significant

6

shoulder and hand) questionnaire in patients

design of thumb spica splint using finite

treated

element method.

with

phonophoresis

followed

by

eccentric exercises rather than in patients treated

with phonophoresis.

2006; 44(12):11051111.
2.

treatment of Recalcitrant de Quervain

and hand) questionnaire also was used in

Tenosynovitis

evaluation of disability in patients with De

With

Novel

4-Point

Injection Technique. The American journal

Quervians disease, numerous studies reported

following the eccentric training program in

Pagonis T., Ditsios K., Toli P., Givissis P.,

Christodoulou A.: Improved Corticosteroid

Quick DASH (disability of the arm, shoulder

that there was a reduction of QDASH score

Med Bio Eng Comput.

of sports medicine. 2011;39(2): 398-403.

3. Avci S., Yilmaz C., Sayli U.: Comparison
of nonsurgical treatment measures for de

patients with De Quervians disease [13], [17],

Quervains

[18], [19].

disease

of

pregnancy

and

lactation. Journal of Hand Surgery. 2002;

Acknowledgment

27(2):322324.

We express our thanks to all patients and medical

4. Retig AC.: Athletic injuries of the wrist and

hand. Part II: overuse injuries of the wrist

team participated or helps in this study for their

and traumatic injuries to the hand. American

confidence and collaboration in this study.

Journal of Sports Medicine. 2004; 32(1):

Conclusion

262273.

Both of phonophoresis and the combination of

5. Dawson C and Mudgal CS.: Staged

phonophoresis with eccentric exercise were

description of the Finkelstein test. Journal of

effective on decreasing pain severity, functional

hand surgery. 2010; 35(9):15131515.

disability as well as improving grip and pinch

6. El-Hadidy S., Badran D., Yousef

S.,

of

Ababneh M., El-Hadidy M., Doar H.: De

phonophoresis with eccentric exercise was more

Quervains Tendovaginitis Stenosans in

effective than phonophoresis alone in treatment

Jordanians. JMJ. 2010; 40(3).

strength.

However,

the

combination

7.

of De Quervians disease.

Radial

Suresh SS., Zaki H., Ali A.: Does

Styloid

Abnormality

in

de

Quervains Disease Affect the Outcome of

References
1. Huang TH., Feng CK., Gung YW., Tsai,

Management? American Association for

MW., Chen, CS., Liu, CL.: Optimization

Hand Surgery. 2010; 5:374377.

7

8.

Physiotherapy and Occupational Therapy -

Clarke MT., Lyall HA., Grant

JW.,

Matthewson

MH.:

The

An International Journal. 2014; 8(2):224-

histopathology of de Quervains disease. J H

S Br. 1998; 23(6):732742.
9.

229.
15. Tabinda

and

Quervain's

Stanish WD., Rubinovich RM.,

Mahmood

F.:

Tenosynovitis

De
and

Curwin S.: Eccentric exercise in chronic

Phonophoresis: A Randomised Control Trial

tendinitis. Clin Orthop. 1986; 208: 6568.

in Pregnant Females De Quervain. journal of

Orthopaedics, Trauma and Rehabilitation.

10. Stanish WD., Curwin S., Mandel

S.: Tendinitis: Its Etiology and Treatment.
Oxford: Oxford University Press. 2000.
11. Rees
Wolman

J.D.,

A.M.:

A.,

Physiotherapy

G.A.,

Israeli

T.,

Kozol

Management

of

Z.:

People

Diagnosed with de Quervain's Disease: A

mechanism for efficacy of eccentric loading

Case Series. Physiotherapy Canada. 2015;

in Achilles tendon injury; An in vivo study

67(3): 263-267.

humans.

Wilson

16. Rabin

The

in

R.L.,

Lichtwark

2014; 19(1), 2-6.

Rheumatology.

2008;

17. Shah, F. A., Khan H., Kifayatullah W. A.,

47(10):14931497.

Khan Z., Durrani Z. A., Alam W.:

A., Spies

Efficacy of local corticosteroid injections in

M., Peter M.: Neovascularisation in de

de Quervains tenosynovitis. Pak J Surg.

Quervains disease of the wrist: novel

2012; 28(2): 118-121.

12. Knobloch K .,Gohritz

combined therapy using sclerosing therapy

18. Hadianfard M., Ashraf A., Fakheri M.,

with polidocanol and eccentric training of

Nasiri A.: Efficacy of acupuncture versus

the forearms and wristsa pilot report:

local methylprednisolone acetate injection in

Knee Surg Sports Traumatol Arthrosc. 2008;

de Quervain's tenosynovitis: a randomized

16:803805.

controlled trial. Journal of acupuncture and

13. Papa J.A, FCCPOR(C).: Conservative

management of De Quervains

meridian studies. 2014; 7(3): 115-121.

stenosing

19. Rowland P., Phelan N., Gardiner S.,

tenosynovitis: a case report J Can Chiropr

Linton K. N., Galvin R.: The Effectiveness

Assoc. 2012; 56(2): 112-120.

of

Corticosteroid

Quervains

14. Hiral S., Bhakti D.: A Study to determine

Injection

Stenosing

for

De

Tenosynovitis

the effect of Ultrasound and Phonophoresis

(DQST): A Systematic Review and Meta-

in De Quervain's Diseases. Indian Journal of

Analysis. O O J l. 2015; 9: 437-444.

8