The effect of resisted exercise on pain and function in people with de Quervain's syndrome

Once eligible, all participants will receive a custom-made thermoplastic wrist and thumb orthosis, which will be worn for a period of 2 weeks. Participants will be instructed to wear the orthosis as much as possible including overnight, excluding hygiene activities. They will also receive condition specific education and be instructed in range of motion exercises. Education will be provided in the form of verbal information delivered by their treating clinician and standardized written information that the participant will take home. This education will be reinforced during all clinical contact as required (up to 7 sessions), with the opportunity for participants to ask questions. Range of motion exercises will be active wrist and thumb movements , with specific movements selected at the treating clinician’s discretion. These may include ulnar and radial deviation of the wrist, wrist flexion and extension, thumb flexion, extension, abduction, or circumduction. Participants will be instructed to complete these with no more than mild discomfort experienced during the movement. Participants will record their orthosis wear and exercises in a diary. Prior to receiving any intervention, particiapntsparticipants will be asked to rate their expectation of change with exercise, education and orthosis using a categorical scale of 'Completely recover', 'much improve', 'slightly improve', 'no change' and 'worse'. After 2 weeks, participants will be reassessed. Those no longer meeting the criteria for probable or likely de Quervain’s syndrome based on the de Quervain’s Screening Tool (DQST), will be instructed in graded weaning from the orthosis, and will not be randomised or included in statistical analysis in this trial as they will receive no further intervention as part of this study. We will follow these participants up at 4 and 12 weeks post exclusion from the intervention. Those still meeting the criteria for probable or ‘likely’ de Quervain’s syndrome according to the DQST will be randomised into the 2 intervention arms. Stratified block randomisation with be performed based on whether participants are within a 12 month postpartum period. Arm 1: Low load isometric exercise Participants will be instructed in the performance of low load (25% of 1 repetition maximum) isometric thumb extension. This will be performed using a purpose-built device incorporating a spring gauge. Using the contralateral hand, participants will set the spring gauge to the prescribed load. Participants will then place their affected thumb under the load of the spring gauge and instructed to keep their thumb still whilst maintaining the spring gauge at the prescribed level. Participants will perform this exercise at home daily, with a dosage of 20 second holds, 5 repetitions, with 1 minute rest between each repetition. Participants will be reviewed weekly for 4 weeks by the treating clinician, in an individual session, in an outpatient clinic setting. Should the participant report increasing pain with exercise performance, the duration of the hold will be reduced and the number of repetitions increased. Should the participant not tolerate the adjusted exercise following 1 day, they will be advised to cease the load exercise and resume wearing the orthosis as much as possible for 1 week, at which time the exercise regime will be introduced. Should the participant not tolerate the load exercise in 3 consecutive weeks, intervention will be delivered at the discretion of their treating clinician, or clinician of their choice. Throughout the intervention period, participants will be instructed in pain-free range of motion exercises of the wrist and thumb, and graded weaning from the orthosis. At the conclusion of the intervention period (4 weeks of exercise), participants will be advised to continue treatment at the discretion of their treating clinician, or clinician of their choice. The study intervention will be delivered by a Physiotherapist or Occupational therapist with at least 5 years experience working with people with wrist injuries.