The guidelines presented by the New York State Workers Compensation Board provide fundamental principles for addressing Kienböck Disease. These directives are formulated to assist healthcare professionals in determining appropriate interventions for this condition within the context of a comprehensive assessment.
Healthcare experts specializing in managing Kienböck Disease can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic approaches for their patients.
It is crucial to underscore that these guidelines are not intended to replace clinical judgment or professional expertise. The final decision regarding interventions for Kienböck Disease should involve collaboration between the patient and their healthcare provider.
Kienböck Disease
Kienböck disease involves alterations in the lunate, ultimately leading to the collapse of this bone, resulting in ongoing pain and a gradual decline in functionality. Patients experiencing Kienböck disease often endure persistent chronic pain.
Diagnostic Studies
X-Rays
Recommended for diagnosing Kienböck disease. The rationale behind this recommendation is that x-rays are employed to confirm the diagnosis, typically taken for both hands. There is evidence supporting the use of x-rays in this context.
CT
Recommended for diagnosing Kienböck disease when x-rays yield negative or unclear results, and MRI is contraindicated. The rationale is that CT scans assist in diagnosis and management, particularly in cases where x-rays are inconclusive, and MRI is not feasible. There is evidence supporting the use of CT in such situations.
MRI
Recommended for diagnosing Kienböck disease when x-rays provide negative or unclear results. The rationale is that MRIs play a crucial role in assisting with diagnosis and management, justifying their recommendation. There is evidence supporting the use of MRI for this purpose.
Screening for Systemic Disorders
Recommended for patients with Kienböck disease. The rationale is that various disorders are believed to predispose individuals to Kienböck disease. Therefore, there should be a low threshold for evaluating systemic metabolic issues (e.g., diabetes, glucose intolerance), alcoholism, and rheumatological studies. This is especially relevant as potentially modifiable risks may theoretically slow down the rate of disease progression.
Medications
For most patients, ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications. Acetaminophen (or the analog paracetamol) may be a reasonable alternative to NSAIDs for patients who are not candidates for NSAIDs, although most evidence suggests acetaminophen is modestly less effective. There is evidence that NSAIDs are as effective for relief of pain as opioids (including tramadol) and less impairing.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Conditions
Recommended for treatment of acute, subacute, or chronic conditions. Over-the-counter (OTC) agents may suffice and should be tried first.
Frequency/Duration: As needed use may be reasonable for many patients.
Indications for Discontinuation: Resolution of symptoms, lack of efficacy, or development of adverse effects that necessitate discontinuation.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended for concomitant use of cytoprotective classes of drugs for patients at high risk of gastrointestinal bleeding.
Indications: For patients with a high-risk factor profile who also have indications for NSAIDs.
Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers recommended.
Indications for Discontinuation: Intolerance, development of adverse effects, or discontinuation of NSAID.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should have the risks and benefits of NSAID therapy for pain discussed.
Recommended: Acetaminophen or aspirin as the first-line therapy appear to be the safest regarding cardiovascular adverse effects. If needed, non-selective NSAIDs are preferred over COX-2 specific drugs. In patients receiving low-dose aspirin for primary or secondary cardiovascular disease prevention, to minimize the potential for the NSAID to counteract the beneficial effects of aspirin, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.
Acetaminophen for Treatment of Pain
Recommended for treatment of pain, particularly in patients with contraindications for NSAIDs.
Indications: All patients with pain, including acute, subacute, chronic, and post-operative.
Dose/Frequency: Per manufacturer’s recommendations; may be utilized on an as-needed basis. There is evidence of hepatic toxicity when exceeding four gm/day.
Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
Topical Medications
Recommended in select patients for treatment of pain associated with acute, subacute, or chronic conditions, including topical creams, ointments, and lidocaine patches.
Rationale for Recommendation: Topical drug delivery may be an acceptable form of treatment in selected patients. A topical agent should be prescribed with strict instructions for application and maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. For most patients, the effects of long-term use are unknown and thus may be better used episodically. These agents may be used in those patients who prefer topical treatments over oral medications.
Capsaicin offers a safe and effective alternative to systemic NSAIDs, although its use is limited by local stinging or burning sensation that typically disappears with regular use. Patients should be advised to apply the cream on the affected area with a plastic glove or cotton applicator to avoid inadvertent contact with eyes and mucous membranes. Long-term use of capsaicin is not recommended.
Topical Lidocaine is only indicated when there is documentation of a diagnosis of neuropathic pain. In this instance, a trial for a period of not greater than four weeks can be considered, with the need for documentation of functional gains as criteria for additional use.
Topical NSAIDs (e.g. diclofenac gel) may achieve tissue levels that are potentially therapeutic. Overall the low level of systemic absorption can be advantageous, allowing the topical use of these medications when systemic administration is relatively contraindicated.
Topical Salicylates or Nonsalicylates (e.g. methyl salicylate) overall do not appear to be more effective than topical NSAIDs. May be used for a short-term course especially in patients with chronic conditions in whom systemic medication is relatively contraindicated or as an adjuvant to systemic medication.
Not Recommended – for acute, subacute, or chronic Kienböck disease.
Recommended – for limited use (not more than seven days) for postoperative pain management as adjunctive therapy to more effective treatments.
Indications: For post-operative pain management, a brief prescription of opioids as adjuncts to more efficacious treatments (especially NSAIDs, acetaminophen) is often required, especially nocturnally.
Frequency/Duration: Prescribed as needed throughout the day, then later only at night, before weaning off completely.
Rationale for Recommendation: Some patients have insufficient pain relief with NSAIDs, thus judicious use of opioids may be helpful, particularly for nocturnal use. Opioids are recommended for brief, select use in postoperative patients with primary use at night to achieve sleep postoperatively.
Rehabilitation
Rehabilitation (supervised formal therapy) required as a result of a work-related injury should be focused on restoring functional ability required to meet the patient’s daily and work activities and return to work; striving to restore the injured worker to pre-injury status in so far as is feasible.
Active therapy requires an internal effort by the patient to complete a specific exercise or task. Passive therapy are those interventions not requiring the exertion of effort on the part of the patient, but rather are dependent on modalities delivered by a therapist. Generally passive interventions are viewed as a means to facilitate progress in an active therapy program with concomitant attainment of objective functional gains. Active interventions should be emphasized over passive interventions.
The patient should be instructed to continue both active and passive therapies at home as an extension of the treatment process in order to maintain improvement levels. Assistive devices may be included as an adjunctive measure incorporated into the rehabilitation plan to facilitate functional gains.
Therapy: Active
Therapeutic Exercise – Acute Phase
Not Recommended – during acute presentations of Kienböck disease
Therapeutic Exercise – Post-Operative/Recovery
Recommended – for patients post-operatively.
Rationale for Recommendation – Exercise is generally not indicated acutely; however, exercise may be needed in the recovery or post-operative phases. Functional goals should include increased grip strength, key pinch strength, range of motion, advancing work abilities.
Frequency/Dose/Duration –Total numbers of visits may be as few as two to three for patients with mild functional deficits or up to 12 to 15 with more severe deficits with documentation of ongoing objective functional improvement. When there are ongoing functional deficits, more than 12 to 15 visits may be indicated if there is documentation of functional improvement towards specific objective functional goals (e.g., increased grip strength, key pinch strength, range of motion, advancing ability to perform work activities). As part of the rehabilitation plan, a home exercise program should be developed and performed in conjunction with the therapy.
Therapy: Passive
Self-Application of Ice
Recommended – for treatment of acute, subacute, or chronic Kienböck disease.
Self-application of Heat
Recommended – for treatment of acute, subacute, or chronic Kienböck disease.
Splints
Recommended – for treatment of select patients with acute, subacute, or chronic Kienböck disease.
Rationale for Recommendations – A trial may be helpful to assess whether splinting provides symptomatic relief. However, there are concerns over long-term use regarding the potential for accelerated debility, disuse, and weakness of the wrist.
Surgical Treatment
Recommended – as an option for patients with moderate to marked impairment if not improved eight weeks post-injury or after six weeks of non-operative treatment due to Kienböck disease. The choice of surgery is dependent upon staging of disease and discretion of the surgeon.
