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Consensus on a MultidisciplinaryTreatment Guideline for de QuervainDisease: Results From the EuropeanHANDGUIDE StudyBionka M.A. Huisstede, J. Henk Coert, Jan Friden, Peter Hoogvliet;for the European HANDGUIDE Group

Background. De Quervain disease is a common pathology resulting in paincaused by resisted gliding of the abductor pollicis longus and extensor pollicis brevistendons in the fibro-osseous canal. In a situation of wavering assumptions andexpanding medical knowledge, a treatment guideline is useful because it can aid inimplementation of best practices, the education of health care professionals, and theidentification of gaps in existing knowledge.

Objective. The aim of this study was to achieve consensus on a multidisciplinarytreatment guideline for de Quervain disease.

Design. A Delphi consensus strategy was used.

Methods. A European Delphi consensus strategy was initiated. A systematicreview reporting on the effectiveness of surgical and nonsurgical interventions wasconducted and published and was used as an evidence-based starting point for thisstudy. In total, 35 experts (hand therapists and hand surgeons selected by the nationalmember associations of their European federations and physical medicine and reha-bilitation physicians) participated in the Delphi consensus strategy. Each Delphiround consisted of a questionnaire, an analysis, and a feedback report.

Results. Consensus was achieved on the description, symptoms, and diagnosis ofde Quervain disease. The experts agreed that patients with this disorder shouldalways receive instructions and that these instructions should be combined withanother form of treatment and should not be used as a sole treatment. Instructionscombined with nonsteroidal anti-inflammatory drugs (NSAIDs), splinting, NSAIDsplus splinting, corticosteroid injection, corticosteroid injections plus splinting, orsurgery were considered suitable treatment options. Details on the use of instruc-tions, NSAIDs, splinting, corticosteroid injections, and surgery were described. Mainfactors for selecting one of these treatment options (ie, severity and duration ofthe disorder, previous treatments given) were identified. A relationship between theseverity and duration of the disorder and the choice of therapy was indicated by theexperts and reported in the guideline.

Limitations. One of the limitations of a Delphi method is its inability to forecastfuture developments. It investigated current opinions of the treatment of people withde Quervain disease.

Conclusions. This multidisciplinary treatment guideline may help in the treat-ment of and research on de Quervain disease.

B.M.A. Huisstede, PhD, Depart-ment of Rehabilitation Medicineand Physical Therapy, ErasmusMC-University Medical CenterRotterdam, and Department ofRehabilitation, Nursing Science &Sports, University Medical CenterUtrecht, Building W01.121, POBox 85500, 3508 GA Utrecht, theNetherlands. Address all corre-spondence to Dr Huisstede at:[email protected].

J.H. Coert, MD, PhD, Departmentof Plastic & Reconstructive Sur-gery & Hand Surgery, ErasmusMC-University Medical CenterRotterdam.

J. Friden, MD, PhD, Department ofHand Surgery, Sahlgrenska Uni-versity Hospital, and Institute ofClinical Sciences, SahlgrenskaAcademy, University of Gothen-burg, Gothenburg, Sweden.

P. Hoogvliet, MD, PhD, Depart-ment of Rehabilitation Medicineand Physical Therapy, ErasmusMC-University Medical CenterRotterdam.

The participating organizationsand members of the EuropeanHANDGUIDE Group are presentedon page 1103.

[Huisstede BMA, Coert JH, FridenJ, Hoogvliet P; for the EuropeanHANDGUIDE Group. Consensuson a multidisciplinary treatmentguideline for de Quervain disease:results from the EuropeanHANDGUIDE study. Phys Ther.2014;94:1095–1110.]

© 2014 American Physical TherapyAssociation

Published Ahead of Print:April 3, 2014

Accepted: March 27, 2014Submitted: February 27, 2013

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August 2014 Volume 94 Number 8 Physical Therapy f 1095

De Quervain disease was firstdescribed in 18951 and seemsa relatively straightforward

disease with a straightforward treat-ment. However, all is not as it seems,as there has been much confusionabout its nature2 and diagnosis.3

Additional information about its anat-omy4 and treatment5–8 was pre-sented recently, although the exactmechanism of its occurrence has notbeen determined yet.9

De Quervain disease is a commonpathology resulting in pain causedby resisted gliding of the abductorpollicis longus (APL) and extensorpollicis brevis (EPB) tendons in thefibro-osseous canal.10 The incidenceof de Quervain disease is 2.8 casesper 1,000 person-years for womenand 0.6 cases per 1,000 person-yearsfor men in a young, active popula-tion.11 Its prevalence is 0.5% for menand 1.3% for women among adults ofworking age in the general popula-tion.12 From those patients with deQuervain disease visiting a generalpractitioner, 40% are referred to aphysical therapist.13 Physical thera-pists diagnose about 1% of patientswho visit them with complaints ofthe arm, neck, or shoulder as havingde Quervain disease.14

The primary issue in de Quervaindisease is a degenerative thickeningof the extensor retinaculum cover-ing the first extensor compartment,sometimes combined with second-ary thinning of the tendon within thecompartment and thickening of thetendon outside the compartment.2

Patients with de Quervain diseasedisplay an impaired function of thewrist and hand6 and decreased Dis-abilities of the Arm, Shoulder, andHand (DASH) scores.5

In a situation of wavering assump-tions and expanding medical knowl-edge, a guideline is useful because itcan aid in the implementation of bestpractices, the education of health

care professionals, the identificationof gaps in existing knowledge, andthe recognition of the presence orabsence of the scientific basis of cur-rent therapies. Therefore, de Quer-vain disease was incorporated intothe European HANDGUIDE study,which aimed to achieve consensuson multidisciplinary treatment guide-lines for 5 hand disorders: 2 tendi-nopathies (trigger finger and deQuervain disease), 2 neuropathies(carpal tunnel syndrome and Guyoncanal syndrome), and Dupuytrendisease.

In order to establish an evidence-based starting point for this study,systematic reviews were pub-lished8,15,16 on the evidence for theeffectiveness of nonsurgical, surgi-cal, and postsurgical interventionsfor the 5 above-mentioned hand dis-orders. Because the amount of evi-dence for all disorders was insuffi-cient to create a guideline, Delphiconsensus strategies were used toobtain the additional information. Inthese Delphi consensus strategies, aseries of sequential questionnaires orrounds is presented to a panel ofexperts, interspersed with con-trolled feedback, with the aim ofachieving consensus of opinionabout the diagnosis and treatment ofthe above-mentioned disordersamong these experts.17 This articledescribes the agreement of theexpert panel on the items includedin the multidisciplinary treatmentguideline for de Quervain disease.

MethodSteering Committee andAdvisory TeamA steering committee to initiate andguide the HANDGUIDE study com-prised a hand surgeon, a physicalmedicine and rehabilitation (PM&R)physician, and a physical therapist.All 3 members have PhD degrees aswell as a clinical and a scientific orepidemiological background. Theydesigned the questionnaires, ana-

lyzed the responses, and formulatedthe feedback reports. Furthermore,an advisory team (consisting of 2professors of hand surgery, 1 profes-sor of PM&R, and a PhD-trained handtherapist) was formed, which couldbe consulted at any time and couldgive their opinions and advice asthey saw fit.

Preparation of theStudy—Systematic ReviewTo provide an evidence-based over-view of nonsurgical and surgicalinterventions for de Quervain dis-ease, the Cochrane Library, PEDro,PubMed, EMBASE, and CINAHL upto February 2009 were searched toselect potential relevant studies fromthe title and abstracts of the refer-ences retrieved by the literaturesearch (Appendix 1). RelevantCochrane reviews and randomizedcontrolled trials (RCTs) wereincluded. Two reviewers indepen-dently extracted the data and per-formed a methodological qualityassessment. Because of heterogene-ity of the data, a meta-analysis wasnot possible; therefore, a best-evidence synthesis was performed tosummarize the results of theincluded trials (Appendix 2). Weincluded 3 RCTs reporting on theeffectiveness of physical therapy,and steroid injections were included:low-laser therapy versus placebo, tri-amcinolone versus triamcinoloneplus oral nimesulide, and cortisoneversus splinting in pregnant womenor during breast-feeding were stud-ied. The data extraction and method-ological quality assessment of theincluded studies are described else-where.8 Table 1 shows a summary ofthe evidence found for treatment ofde Quervain disease. The resultswere used as an evidence-based start-ing point for the Delphi consensusstrategy.

Delphi Consensus StrategySelection of experts. The studywas supported by the European Fed-

A Multidisciplinary Treatment Guideline for de Quervain Disease

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eration of Societies for Hand Ther-apy (EFSHT) and the Federation ofEuropean Societies for Surgery of theHand (FESSH). The national memberassociations of these organizationsselected the experts in their respec-tive fields. Each national memberassociation was invited to select amaximum of 3 representativeexperts per Delphi consensus strat-egy. In addition, some EuropeanPM&R physicians specializing inhand rehabilitation were invited toparticipate in this study. All partici-pating experts fulfilled all of the cri-teria listed in Table 2.

Procedure. The web-based ques-tionnaires of the Delphi rounds onde Quervain disease included ques-tions on the description, symptoms,diagnosis, and interventions for thisdisease. Reminders for filling in thequestionnaires were sent by e-mail,partly after fixed intervals and partlyon an “as much as necessary” basis.The Delphi consensus strategystopped if consensus was achievedor a maximum of 4 rounds werefinished.

In this Delphi consensus strategy,only the physicians answered ques-tions on medication and injections,and only the hand surgeonsanswered questions on surgery. Allremaining questions were answeredby all of the experts.

Structured questions were used withanswer formats such as “yes/no/noopinion,” after which the expertswere invited to explain their individ-ual choices. After each round, a feed-back report was made to inform theexperts about the answers and argu-ments of all experts, and on whichitems consensus was achieved.Based on the answers and argumentsof the experts, the Steering Commit-tee formulated the questions for thefollowing questionnaire. Finally, con-clusions were presented andexplained in the feedback report.

To avoid any imprecise definition forconsensus, the experts were con-sulted about the cutoff point for con-sensus.18 A cutoff point of 70% wasproposed in the first round of theDelphi consensus strategy because itis often used in Delphi consensusstrategies.19,20 In case of consensus,this percentage also was calculatedfor each of the 3 participating pro-fessional groups. To reveal any dis-cordant viewpoints among thesegroups, a remark was made in thereport when fewer than 50% of theexperts within a professional groupanswered in accordance with theachieved consensus.

Target population. All physiciansand health care professionals whoare involved in the treatment of

patients with de Quervain diseasecan use this guideline.

Delphi QuestionnairesDescription, symptoms, and diag-nosis of de Quervain disease.The guideline will include shortdescriptions of de Quervain disease;the International Statistical Classi-fication of Diseases and RelatedHealth Problems, 10th Revision21

(ICD-10) code; the symptoms; and itsdiagnostic process. In the first round,we included a description of each ofthese items and asked the experts ifthey agreed with this description.The questions of the subsequentrounds were formulated based onthe results of the previous rounds.

Table 1.Evidence for the Effectiveness of Interventions for de Quervain Diseasea

Interventions Evidence

Nonsurgical

Physical therapy Low-level laser therapy vs placeboShort-term: NC

Oral ND

Injection Triamcinolone vs triamcinolone plus oral nimesulideShort-term: NECortisone vs splinting in pregnant women or during breast-feedingShort-term: NC

Other ND

Surgical ND

Postsurgical ND

a Searches in PubMed, EMBASE, CINAHL, and PEDro up to February 2009. NC�randomized controlledtrial found, but no comparison between the intervention and control group was made, so no evidencewas found; ND�no data; NE�no evidence found for effectiveness of the treatment (randomizedcontrolled trials available, but no differences between intervention and control groups were found).

Table 2.Experts’ Criteria for Participation in the Delphi Consensus Strategy

Criteria

1 The experta should be a medical or health care professional with considerableexperience in treating patients with nontraumatic hand disorders(tendinopathies, Dupuytren disease or neuropathies, respectively)

2 The expert should be considered by his or her own professional specialty to be akey person in the field of nontraumatic hand disorders

3 The expert should have basic knowledge of evidence-based practice

a Participating hand surgeons and hand therapists participated as delegates for their respectiveprofessional association.



Interventions to treat de Quer-vain disease. In the first-roundquestionnaire, the nonsurgical inter-ventions (ie, instructions for thepatient, NSAIDs, splinting, and corti-costeroid injection) and surgicalinterventions often reported in theliterature to be used in treatment ofde Quervain disease were listed. Theevidence for the effectiveness ofeach type of intervention, includingthe “evidence table” and the full-textarticle of the review,8 was incorpo-rated in this questionnaire.

The above-mentioned interventionswere then discussed. For each inter-vention, questions were includedabout the usefulness of the interven-tion and the main factors for startingand discontinuing the intervention.To identify useful combinations oftreatments and a therapeutic hierar-chy of interventions, the expertswere asked if the interventions couldbe used as sole treatment or com-bined with another treatment,whether a specific intervention isthe first choice in treatment, and toidentify the treatment strategy incase the intervention was insuffi-cient. Additional questions wereincluded on the use of instructionsfor the patient, NSAIDs, splinting,corticosteroid injection, and surgery.In all situations where options weresuggested by the Steering Commit-tee, the experts were invited to pro-vide additional options to avoid anylimitations in the experts’ choices.

The treatment options (and theircombinations) mentioned by theexperts were summarized. In thesecond round, the experts wereasked to state (separately for eachtreatment option or combination oftreatment options) whether thistreatment option (or combinationthereof) is applicable in the treat-ment of de Quervain disease.

Based on the answers given by theexperts in the first round, a therapeu-

tic hierarchy was formulated (ie,from the lightest [in the context ofthis article, the term “lightest” con-tains elements of invasiveness aswell as effectiveness] form to themost severe form of treatment), andthe experts were asked if they agreewith this hierarchy. The experts alsowere asked what they consideredthe main factors for choosing a cer-tain treatment option and in whichway these factors influenced theirchoice. For questions relevant foreach specific intervention for whichno consensus was achieved in thefirst round, new questions wereadded in the second round.

In the third round, the main factorsfor choosing a treatment option forde Quervain disease were combined,and the summary of the consensuson the main factors was presented inone table. Any remaining questionson this table, and all other items forwhich no consensus was achieved inthe second or third round, wereadded in the third and fourth rounds,respectively.

Data AnalysisA qualitative and quantitative analy-sis was made of the responses fromthe Delphi rounds. Quantitatively,for each question, we reported thenumber and percentages of expertswho gave a certain answer. Qualita-tively, the rationale for the answersgiven by each expert was reported.

Role of the Funding SourceThe study was funded by FondsNutsOhra, the Netherlands.

ResultsExpert PanelA total of 112 experts (52 hand sur-geons, 47 hand therapists, and 13PM&R physicians) from 17 Europeancountries were selected to partici-pate in 1 of the 3 Delphi consensusstrategies of the HANDGUIDE study,which was performed between June2009 and December 2012.

For the Delphi consensus strategy onde Quervain disease, 38 experts (16hand surgeons, 16 hand therapists,and 6 PM&R physicians) wereselected. Three of the experts (2hand surgeons and 1 PM&R physi-cian) did not complete any of thequestionnaires. Response rates ofthe remaining 35 experts for rounds1 to 4 were 97%, 94%, 91%, and 91%,respectively.

Table 3 lists the participating coun-tries, the total number of experts ofthe HANDGUIDE study, the numberof experts participating in the Delphiconsensus strategy on de Quervaindisease, and years of experiencewith this topic.

Delphi Consensus Strategy onde Quervain DiseaseConsensus. In the first round, con-sensus was achieved to use a cutoffpoint of 70% for consensus for allrounds of this Delphi consensusstrategy. Within the Delphi rounds,there were no discordant viewpointsbetween a professional group andthe general consensus (ie, when�50% agreed with the consensus).Four rounds were needed beforeconsensus on the treatment guide-line for de Quervain disease wasachieved. The guideline is reportedin Appendix 3.

Description, symptoms, and diag-nosis of de Quervain disease. Inthe first round, consensus wasachieved on the short description ofde Quervain disease and its ICD-10code. In the second round, theexperts agreed on the symptoms anddiagnosis of the disorder. The initialdiagnosis of de Quervain disease isusually made on the basis of clinicalsymptoms, in combination withphysical examination. The test usedmost often for treatment of de Quer-vain disease is the Finkelstein test.The experts agreed to include thefollowing text on the Finkelstein testin the guideline: “In his original



paper, Finkelstein described grasp-ing the patient’s thumb and quicklyabducting the hand ulnarward,which elicits an excruciating painover the styloid tip.22 A disadvantageof this method is that the test issomewhat crude and can elicit painin healthy individuals. In practice,less crudely performed variants ofthis test are often used, sometimes incomparison with the healthy hand.”Furthermore, the presence of osteo-arthritis of the first carpometacarpaljoint (CMC-1), a problem with thesuperficial radial nerve (cheiralgiaparesthetica or Wartenberg syn-drome), and intersection syndromeshould be considered.

Interventions to treat de Quer-vain disease. Experts did not addinterventions that should beincluded as “most commonly usedinterventions” to the list of nonsur-gical and surgical interventions (asdescribed in the “Method” section).Consensus was achieved that thelightest form of treatment consists ofNSAIDs, followed by splinting or cor-ticosteroids and, finally, surgery forthe most serious forms of de Quer-vain disease.

In the first round, the experts agreedthat patients with de Quervain dis-ease should always receive instruc-tions and that these instructionsshould always be combined withanother treatment. Consensus wasachieved that instructions combinedwith NSAIDs, splinting, NSAIDs plussplinting, corticosteroid injection,corticosteroid injections plus splint-ing, and surgery are applicable treat-ments for de Quervain disease. Noconsensus was achieved that instruc-tions plus corticosteroid injections,NSAIDs, and splinting is applicableto treat de Quervain disease. Consen-sus was achieved on a therapeutichierarchy (Tab. 4).

For instructions, NSAIDs, splinting,corticosteroid injections, and sur-gery, consensus was achieved on theaim of the treatment. For the latter 4treatments, consensus also wasachieved on when the treatmentshould be adjusted or stopped.Other items for each specific treat-ment are discussed below.

From the remarks provided by theexperts in the first round, it was con-cluded that instructions to the

patient can be given on 3 levels: (1)level 1—activities, (2) level 2—func-tion (force, range of motion, repeti-tive movements), and (3) level3—pain. In the second round, theexperts agreed that, in general,instructions given on all 3 levels willbe most effective. The instructionsare described in Table 5.

Consensus was achieved that treat-ment with NSAIDs should always becombined with another treatment.

Table 3.Experts and Participating Countries in the HANDGUIDE Studya

Profession(European

Federation) Participating Countries

Total No. ofExperts in theHANDGUIDE

Study

Experts in de Quervain Disease

No. ofExperts

Years ofExperienceX (Range)

Hand surgeons(FESSH)

Belgium, Denmark, Estonia,Finland, France, Germany, Italy,Norway, the Netherlands, Spain,Sweden, Switzerland, Turkey,United Kingdom

52 14 15.2 (8–30)

Hand therapists(EFSHT)b

Belgium, Denmark, Finland, France,Italy, Norway, the Netherlands,Slovenia, Sweden, Switzerland,Turkey, United Kingdom

47 16 17.5 (6–33)

PM&R physicians Austria, the Netherlands, Portugal,Slovenia, Switzerland, Turkey

13 5 16.0 (10–20)

Total 112 35 16.5 (6–33)

a FESSH�Federation of European Societies for Surgery of the Hand, EFSHT�European Federation of Societies for Hand Therapy, PM&R�physical medicineand rehabilitation.b Physical therapists and occupational therapists specializing in the treatment of hand disorders.

Table 4.Therapeutic Hierarchy of SuitableTreatments for de Quervain Diseasea

Therapeutic Hierarchy:

1 IN (Instructions plus NSAIDs)

2 IS (Instructions plus splinting)

3 INS (Instructions combined with NSAIDsand splinting)

4 IC (Instructions plus a corticosteroidinjection)

5 ICS (Instructions combined with acorticosteroid injection and splinting)

6 IO (Instructions plus operativetreatment/surgery)

a A therapeutic hierarchy does not mean that allsteps should always be performed for eachpatient. NSAIDs�nonsteroidal anti-inflammatorydrugs.



In the first round, the expertsshowed a clear preference for theuse of diclofenac (Voltaren, NovartisConsumer Health Inc, Parsippany,New Jersey), a cyclo-oxygenase-1(COX-1) inhibitor, for 2 weeks. Onlyone expert reported combiningdiclofenac with a gastrointestinalprotectant (omeprazole). It was pro-posed to include the followingremark for NSAIDs in the guideline:“Preferably in the form of a COX-1inhibitor without additional gastroin-testinal protection. More specifi-cally, diclofenac or Voltaren for 2weeks.” However, no consensus onthis item could be achieved; there-fore, in the guideline, no preferencefor a specific type of NSAIDs wasadded.

In the first-round questionnaire, 4types of splints regularly used in clin-ical practice to treat de Quervain dis-ease were presented to the experts(Tab. 6). The experts considered noadditional splints sufficiently applica-ble. Consensus was achieved for theuse of a long-based splint (ie, incor-porating the wrist) when treatingpatients with de Quervain disease.To decrease the amount of mechan-ical friction of the APL and EPB ten-dons, the joints that are beingcrossed by these tendons have to beimmobilized (ie, only the wrist andthe metacarpophangeal joint). Along lower arm–based (wrist immo-bilized) splint including the interpha-langeal (IP) joint of the thumb(L-IPin) or a long lower arm-basedsplint excluding the IP joint of thethumb (L-IPex) is preferred.Although immobilization of the IPjoint does not affect movement ofthe APL and EPB tendons, it was con-sidered to decrease the functionalityand, therefore, the activity of thehand and the APL and EPB tendonsas wrist and thumb stabilizers. Theexperts agreed that the splint shouldbe worn for 3 to 8 weeks, 24 hours aday, excluding grooming and exceptfor brief periods of pain-free range ofmovement.

The experts agreed thatintermediate-acting corticosteroidinjections, such as methylpred-nisolone or triamcinolone, should beused in the treatment of de Quervaindisease and that a local anestheticshould be added. The maximumnumber of injections is 1 to 3. Con-sensus also was achieved on theadvice that should be given to thepatient after this treatment. Thisadvice should focus on 2 items: (1)possible adverse effects as a result ofthe corticosteroid injection, includ-ing pain should not be present forlonger than 2 days and, in case of thepresence of diabetes, the patientshould monitor his or her blood glu-cose level, and (2) the patient shouldrest the hand for 1 to 7 days andavoid strain on the structuresinvolved in de Quervain disease.

Consensus was achieved on the useof open surgery (in preference topercutaneous or other surgical tech-niques), using a transversal or longi-tudinal incision (in preference toBrunner-type, Lazy S, and other[oblique] incisions), and the use ofnonresorbable sutures under localanesthetic.

The experts also agreed on the rec-ommendations that should be givento the patient for treatment during

Table 6.Kinds of Splints Presented in The First-Round Questionnaire

Kind of Splints Used in Clinical Practicefor de Quervain Disease:

1 Short hand-based (wrist free) splintincluding the interphalangeal (IP) jointof the thumb (S-IPin)

2 Short hand-based splint excluding the IPjoint of the thumb (S-IPex)

3 Long lower arm-based (wrist immobilized)splint including the IP joint of thethumb (L-IPin)

4 Long lower arm based splint excludingthe IP joint of the thumb (L-IPex)

Table 5.Three Levels of Instructions to the Patient With de Quervain Disease

Level of Instruction Goal Description of the Instruction

Level 1: activity To provide specific information oncertain activities that can aggravatethe complaints for this specificpatient

The individual situation of the patient (eg, a youngmother holding her baby in her arms, a laborerhandling a pneumatic drill) should be taken intoaccount if instructions are given related to activities

Level 2: function (force, range ofmotion, repetitive movements)

To instruct on specific loading typesthat should be avoided

Specific instructions on functional aspects can include:● Avoid repetitive thumb movements as much as possible● Avoid repetitive wrist movements as much as possible● Avoid static exercises● Avoid thumb flexion as much as possible● Avoid ulnar deviation as much as possible● Avoid forceful manual movements as much as possible

Level 3: pain Can act as a sort of “emergencybrake”

Painful movements with the hand should be avoided asmuch as possible. Instructions on this level should beadapted to the coping strategies of the individualpatient.



the primary postoperative period (ie,up to 10–14 days after surgery), untilthe sutures are removed. Moreover,consensus was achieved on the maingoal of postsurgical treatment thatcan be given after this period. Post-surgical treatment should includeinstructions to the patient on how touse the hand to prevent further prob-lems. A statement on what to do incase surgery is not successful isincluded in the guideline.

Next to instructions, NSAIDs, splint-ing, corticosteroid injections, andsurgery or a combination of theseinterventions, the experts men-tioned several other additional ther-apeutic modalities, including ultra-sound, exercise therapy, andkinesiotaping. To indicate that theguideline concentrates on the mostcommonly used interventions butthat additional therapeutic modali-ties can be added, consensus wasachieved to include the followingnote in the guideline: “Depending onthe patient’s situation and personalpreferences, additional therapeuticmodalities can be added.”

In the first Delphi round, the expertssuggested that the main factors forchoosing a treatment option are: (1)the severity of the disease, (2) theduration of the disease, and (3) pre-vious treatments given. The latterfactor also was incorporated into thetherapeutic hierarchy. The relation-ship between severity and durationof the disease and the choice of ther-apy was further explored in the con-secutive Delphi rounds. On the basisof the terminology used by theexperts for severity and duration, 5levels were created for both vari-ables. In the first Delphi round, theexperts described the severity of deQuervain disease in terms of theamount of pain or severity of symp-toms (mild, severe, and so on). Theduration of de Quervain disease wasexpressed in terms of “acute, sub-acute, and chronic” or by mention-

ing the exact durations in terms ofnumber of weeks or months. Com-bining these expressions for severityand duration resulted in the identifi-cation of 5 subgroups for both sever-ity and duration (Tab. 7).

In the second round, the expertswere asked which treatment options(listed in Tab. 4) were suitable forthe different subgroups of severity ofsymptoms. Subsequently, the Steer-ing Committee calculated for eachlevel of severity for which treatment(or combination of treatments) thecutoff point of 70% for consensuswas reached or exceeded. The sameprocess took place for the durationof the complaints.

The results for severity and durationwere combined and reported in atable that finally was included in theguideline. In this table, each cell rep-resents a subgroup of patients with acertain severity and duration of deQuervain disease and the corre-sponding treatment options. Afterthe second Delphi round, some cellsin the table remained empty. Onlyafter the fourth Delphi round did allcells contain one or more treatmentoptions (see the Table in the guide-line [Appendix 3]).

DiscussionThe purpose of this study was toachieve multidisciplinary consensuson the treatment for de Quervain dis-ease. Because the systematic reviewinitially conducted for this purposewas insufficient, a Delphi consensus

strategy was applied to gain addi-tional data for a multidisciplinaryconsensus.

It is clear that proportionally fewEuropean PM&R physicians partici-pated in this study. The main reasonfor this finding is that, in contrast tohand surgery and hand therapy,hand rehabilitation is not an estab-lished specialty. Furthermore,because a PM&R physician is seldominvolved with a patient with anuncomplicated hand condition,PM&R physicians specializing inhand rehabilitation are generallyfound only in clinics treating a con-siderable number of patients withcomplicated hand conditions.

This study also was characterized bya surprising absence of discordantviewpoints among the 3 participat-ing professional groups. During ourpreparatory discussions, it was antic-ipated that the largest of thesegroups might exert too much influ-ence on the final outcome; thisproved to be an unwarrantedassumption. A possible explanationfor this finding is that, because thegroups of experts often work inclose collaboration, any major differ-ences have already been discussedand transformed into mutuallyaccepted viewpoints.

Some remarks are warranted aboutthe diagnosis of de Quervain disease.Finkelstein’s test, in his articledescribed as “On grasping thepatient’s thumb and quickly abduct-

Table 7.Subgroups Related to the Severity and Duration of de Quervain Disease

5 Subgroups for Severity 5 Subgroups for Duration

Symptoms Pain Duration (Stage)

1: very mild Very mild pain/other symptoms

2Unbearable pain/other symptoms

1: �1 mo (acute)

2: mild 2: 1�2 mo (subacute)

3: moderate 3: 2�3 mo (subacute)

4: severe 4: 3�6 mo (chronic)

5: very severe 5: �6 mo (chronic)



ing the hand ulnarward, the painover the styloid tip is excruciat-ing,”22 should be distinguished fromthe method conceived by Eichoffwhereby ulnar deviation of the wristwith the thumb gripped in the palmby the other fingers causes severediscomfort in patients with de Quer-vain disease. A disadvantage of bothmethods is that they are somewhatcrude and can elicit pain in healthyindividuals. In daily practice, morecontrolled variants of these tests areoften used, retaining the possibilityto compare the injured side with thehealthy side. The experts of this Del-phi consensus strategy concludedthat instructions for the patient,NSAIDs, splinting, corticosteroidinjections, and surgery are suitabletreatments for de Quervain disease.

Instructions to the PatientThe experts agree that patients withthis disorder should always beinstructed. It was concluded thatinstructions should generally begiven on 3 levels: (1) activities, (2)functions, and (3) pain. This combi-nation of levels is interestingbecause, to some extent, they arecomplementary. Instruction on thelevel of specific activities has theadvantage that it is highly specificbecause it addresses a particularactivity. A disadvantage is that thenumber of instructions necessary forgeneral activity modification is rela-tively large and the nature of theinstructions may vary per person. Incontrast, instructions on the level offunction are less specific and addressmore fundamental aspects of move-ments. An advantage of instructionson this level is that their number isvery limited and they are (at leasttheoretically) widely applicable. Adisadvantage is that these instruc-tions are less practical because it isdifficult for the patient to translatethem into restrictions on the activitylevel. Giving instructions on bothlevels combines their advantages andcompensates for the disadvantages.

Giving instructions on the level ofpain has the combined advantages ofthe other 2 levels of instruction. It isa single instruction that is bothhighly specific and generally applica-ble. However, its major disadvantageis that, when the patient experiencespain, friction between the roof andthe APL and EPB tendons of the firstextensor compartment apparentlybecomes too high. Instructions onthe level of pain can serve a sort of“emergency brake” function thatinforms the patient that “whateveryou do, be sure that it does not causepain.”

NSAIDsNonsteroidal anti-inflammatory drugsare the lightest form of intervention.In the first round, the expertsshowed a clear preference for theuse of diclofenac or Voltaren(COX-1) for 2 weeks. The use of aconventional NSAID (in preferenceto COX-2 inhibitors) is understand-able in view of the limited period inwhich the drug is prescribed. How-ever, no consensus was achieved onthe preferred type of NSAIDs. More-over, because the options of theexperts differed, in the guideline, nopreference for a specific type ofNSAIDs for de Quervain disease ismentioned.

SplintingIn the Delphi consensus strategy, itwas discussed whether the IP jointalso should be immobilized,although the APL and EPB tendonsdo not cross this joint. Consensuswas achieved that the IP joint couldbe included in the splint. Some addi-tional considerations on this topicshould be taken into account whendeciding which splint to use. Theconcept of protecting a tendon andits integuments by immobilizing thejoints it crosses is mechanistic andclear. The concept of providing addi-tional protection by making a limbless functional is less straightfor-ward. When additional joints are

immobilized, the risk of joint stiff-ness or the development ofincreased compensatory movementsincreases when the patient tries tosqueeze any function left out of theaffected hand. This could result in anincrease of existing (or new) symp-toms in the affected or the contralat-eral hand.

Corticosteroid InjectionsAlthough the experts agreed on theapplication of a limited number ofinjections with corticosteroids intothe first extensor tendon compart-ment, there is uncertainty about thenature of its therapeutic effect. Ini-tially, these injections were givenbased on the paradigm that inflam-mation of the tendons exists withinthe first extensor compartment.However, studies on the histology ofde Quervain disease showed no signsof tendon inflammation but rather anoninflammatory thickening of theextensor retinaculum that covers thefirst dorsal compartment of thewrist.23 An alternative explanationcould be that the corticosteroidsmay soften the roof of the first exten-sor compartment or its contents.This deformation could create anincrease in the volume and adecrease of the friction or pressurewithin the first extensor compart-ment. More research on this topic isneeded.

SurgerySurgery is reserved for individualswith the most serious form of deQuervain disease. When surgerydoes not result in a decrease of thesymptoms, the first thing to be ques-tioned is the initial diagnosis. Apartfrom the obvious differential diagno-sis, such as osteoarthritis of theCMC-1 joint and compression of thesuperficial radial nerve (Wartenbergsyndrome), several experts sug-gested that an intersection syndromeshould be considered. In an intersec-tion syndrome, the complaints arelocated on the top of the forearm,



where the APL and EPB tendonscross over with the extensor carpiradialis longus and extensor carpiradialis brevis tendons (4–8 cmproximal to the radial styloid).24

Hierarchy of the TreatmentOptionsTreatment options are described interms of a hierarchy to guide theinvolved therapists and physicianswith respect to the sequence inwhich various therapies are logicallyprescribed. However, not all patientshave to receive all treatments in thehierarchy. For example, when theresponsible health care professionalanticipates (eg, due to the presenceof certain comorbidity or earliercomplications) that some treatmentswill not alleviate the symptoms orgive rise to new ones, one or moretreatments in the hierarchy can beskipped. This approach providestherapeutic guidance but retains theflexibility to adapt to altered medicalsituations.

Delphi Consensus StrategyOne of the limitations of a Delphimethod is its inability to forecastfuture developments. Although thislimitation does not apply to the pres-ent study, which investigated cur-rent opinions on the treatment of deQuervain disease, it stresses the tem-porality of its compilations. New sci-entific developments can alter theparadigm regarding the exact natureof de Quervain disease and, concom-itantly, related opinions.

A main advantage of the Delphi con-sensus strategy is its ability to guidegroup opinion toward a final deci-sion. This advantage is especiallytrue in a highly specialized field suchas hand surgery, with its limitedevidence-based framework to guideclinical decisions.

Use of the Guideline inClinical PracticeThe guideline of de Quervain dis-ease, in our opinion, can improvequality of treatments because itreports how—according to theexperts—patients could be treated.All professionals, including thosewho have to deal with this disorderon an irregular basis, can use theguideline. They can learn from theexperts’ view as reported in theguideline. Moreover, this report cancontribute to the discussion on howto improve treatment, and it canhelp to give direction to futureresearch.

The implications of the guideline forphysical therapists and occupationaltherapists depend on their local sit-uation. When a local guideline isavailable, the current one can beused for comparison and to aid in thediscussion about future improve-ments of the existing one. When nolocal guideline is available, the cur-rent one can be used as such or as abasis for the development of a newlocal guideline. Another importantimplication of this type of guidelineis that it aids in the clarification ofthe responsibilities of the therapistsas well as the physicians in the treat-ment of patients with de Quervaindisease. This subsequently strength-ens the therapists’ professionalidentity and autonomy and demar-cates responsibilities as well asaccountability.

Implementations of theGuideline and Future ResearchIn the Delphi consensus strategy,hand surgeons, hand therapists, andPM&R physicians were includedfrom 17 European countries, consid-ered to be the key people on thistopic within their own countries bytheir own national associations. Inthis way, we created a number of“ambassadors” who may facilitatethe implementation of the guidelineof de Quervain disease in daily prac-

tice. However, despite this result ofthe study, more time and specificimplementation activities, also initi-ated by the FESSH and the EFSHT,are needed to facilitate the guide-line’s acceptance.

In our opinion, future research onthis topic should concentrate onstandardization of the assessment ofde Quervain disease and the effec-tiveness of the different interven-tions, as mentioned in the guideline,in high-quality controlled studies.Because of the low prevalence ofpatients with this disease, we sug-gest that multicenter studies be initi-ated. Furthermore, when the evi-dence for the effectiveness ofinterventions increases or new treat-ment options are developed, theguideline should be re-evaluated andadjusted in view of these newinsights.

In conclusion, this European Delphiconsensus strategy was successful inachieving consensus on the treat-ment of de Quervain disease. Theconsensus is reported in the treat-ment guideline. It can help physicaltherapists, physicians, and otherhealth care professionals in theirclinical practice and aid scientificresearchers in targeting futureresearch on this subject.

All authors provided concept/idea/researchdesign. Dr Huisstede, Dr Coert, and DrHoogvliet provided writing. Dr Huisstedeprovided data collection, project manage-ment, fund procurement, study participants,and institutional liaisons. Dr Huisstede andDr Hoogvliet provided data analysis. DrCoert and Dr Friden provided consultation(including review of manuscript beforesubmission).

The authors thank the following organiza-tions and people for their participation in theHANDGUIDE study:

Selection experts in Delphi consensus strategy:The FESSH, the EFSHT, and the nationalmember associations of the FESSH and theEFSHT.



The European HANDGUIDE Group, consistingof the experts participating in the Delphiconsensus strategy on de Quervain disease.Hand therapists: R. Aukia, H. van den Berg, P.de Buck, C. Carlsson, F. Degez, N. GuldenEdis, L. Evertsson, V. Frampton, D. Giullian,G. Guidi, D. Hoedemaker, M. Marincek, F.Sandford, S. Tocco, S. Turner, Y. Veldhuis,and C. Ayhan. Hand surgeons: K. Drossos, F.Tuzun, J. Gantov, G. Pajardi, A. Heiman, F.Garcia de Lucas, M. Papaloizos, C. Reinholdt,M. Sukru Sahin, N. Schmeizer-Schmied, andE. Strandeness. PM&R physicians: R. Brenner,T. Duruoz, C. Emmelot, M. Konzelmann,and H. van der Linden. Their participation inthis project does not necessarily mean thatthey fully agree with the final achieved con-sensus. The treatment guideline for de Quer-vain disease is the result of a “communisopinio.”

The authors also thank the following individ-uals from Erasmus MC: S.E.R Hovius, MD,PhD, and H.J. Stam, MD, PhD, for being partof the Advisory Team; A.R. Schreuders, PT,PhD, for being part of the Advisory Teamand for his cooperation in initiating thisresearch project; and J. Soeters, PT, for beingour webmaster.

This research was presented at the XVIIthFederation of European Societies for Surgeryof the Hand (FESSH) Congress, June 2012,Antwerp, Belgium; the Annual Conference ofthe Swedish Orthopaedic Association, Sep-tember 2012, Kristianstad, Sweden; andEuropean Hand Therapy Day, organized bythe Belgian Hand Group, June 2012, Ant-werp, Belgium.

This study was funded by Fonds NutsOhra,the Netherlands.

DOI: 10.2522/ptj.20130069

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http://apps.who.int/classifications/icd10/browse/2010/en



Appendix 1.Search Strings Used in the Systemic Reviewa

1. Search strategy for disorders

de Quervain Disease

PubMed (tendinopathy(mh:noexp) OR tenovaginitis OR tendovaginitis OR tendinit* OR tendonitis ORtenosynovitis OR tendinos* OR bursitis[mh:noexp]) OR Quervain* OR DeQuervain* OR “De QuervainDisease”[mh] OR ((abductor AND pollicis) AND (long OR longus)) OR (extensor AND pollicis ANDbrevis)

EMBASE tendinopathy OR tenovaginitis OR tendovaginitis/ OR tendinit* OR tendonitis OR tendinitis/ ORtenosynovitis/ OR tendinos* OR bursitis/ OR ‘De Quervain tenosynovitis’/ OR Quervain* ORDeQuervain* OR ((abductor AND pollicis) AND (long OR longus)) OR (extensor AND pollicis ANDbrevis)

CINAHL Quervain* or DeQuervain* or ((abductor and pollicis) and (long or longus)) or (extensor and pollicis andbrevis)

PEDro De Quervain disease

2. Search strategy for therapy

Therapy

PubMed (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract]AND trial[Title/Abstract]))

EMBASE ‘randomized controlled trial’:it OR (randomized:ti,ab AND controlled:ti,ab AND trial:ti,ab)

CINAHL

PEDro

3. Search strategy for systematic reviews

Systematic Reviews

PubMed ((meta-analysis [pt] OR meta-analysis [tw] OR metanalysis [tw]) OR ((review [pt] OR guideline [pt] ORconsensus [ti] OR guideline* [ti] OR literature [ti] OR overview [ti] OR review [ti]) AND ((Cochrane [tw]OR Medline [tw] OR CINAHL [tw] OR (National [tw] AND LIbrary [tw])) OR (handsearch* [tw] ORsearch* [tw] OR searching [tw]) AND (hand [tw] OR manual [tw] OR electronic [tw] OR bibliographi*[tw] OR database* OR (Cochrane [tw] OR Medline [tw] OR CINAHL [tw] OR (National [tw] ANDLibrary [tw]))))) OR ((synthesis [ti] OR overview [ti] OR review [ti] OR survey [ti]) AND (systematic [ti]OR critical [ti] OR methodologic [ti] OR quantitative [ti] OR qualitative [ti] OR literature [ti] ORevidence [ti] OR evidence-based [ti]))) BUTNOT (case* [ti] OR report [ti] OR editorial [pt] OR comment[pt] OR letter [pt])

EMBASE (‘review’/exp AND (medline:ti,ab OR medlars:ti,ab OR embase:ti,ab OR pubmed:ti,ab) OR scisearch:ti,abOR psychlit:ti,ab OR psyclit:ti,ab OR psycinfo:ti,ab OR psychinfo:ti,ab OR cinahl:ti,ab OR ‘hand search’:ti,ab OR ‘manual search’:ti,ab OR ‘electric database’:ti,ab OR ‘bibliographic database’:ti,ab OR ‘pooledanalysis’:ti,ab OR ‘pooled analyses’:ti,ab OR pooling:ti,ab OR peto:ti,ab OR dersimonian:ti,ab OR ‘fixedeffect’:ti,ab OR ‘mantel haenszel’:ti,ab OR ‘retracted article’:ti,ab) OR (‘meta analysis’/exp OR ‘metaanalysis’ OR ‘meta-analysis’ OR ‘meta-analyses’:ti,ab OR ‘meta analyses’:ti,ab OR ‘systematic review’:ti,ab OR ‘systematic overview’:ti,ab OR ‘quantitative review’:ti,ab OR ‘quantitativ overview’:ti,ab OR‘methodologic review’:ti,ab OR ‘methodologic overview’:ti,ab OR ‘integrative research review’:ti,ab OR‘research integration’:ti,ab OR ‘quantitative synthesis’:ti,ab)

CINAHL (MH “Systematic Review”)

PEDro

(Continued)



Appendix 1.Continued

4. Search strategy for RCTs

RCT

PubMed (randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized controlled trials [mh] ORrandom allocation [mh] OR double-blind method [mh] OR single-blind method [mh] OR clinical trial [pt] ORclinical trials [mh] OR (“clinical trial” [tw]) OR ((singl* [tw] OR doubl* [tw] OR tripl* [tw]) AND (mask* [tw]OR blind* [tw])) OR (“latin square” [tw]) OR placebos [mh] OR placebo* [tw] OR random* [tw] OR researchdesign [mh:noexp] OR comparative study [pt] OR evaluation studies [pt] OR follow-up studies [mh] ORprospective studies [mh] OR cross-over studies [mh] OR control[tw] OR controls [tw] OR controlled[tw]OR controled[tw] OR control*[tw] OR prospectiv* [tw] OR volunteer* [tw]) NOT (animals [mh] NOThumans [mh])

EMBASE (‘controlled clinical trial’/exp OR ‘randomized controlled trial’:ti OR ‘controlled clinical trial’:it OR‘randomization’/OR ‘double blind procedure’/OR ‘single blind procedure’/ OR ‘crossover procedure’/ OR‘clinical trial’:it OR ((‘clinical trial’ OR (singl* OR doubl* OR tripl*)) AND (mask* OR blind*)) OR (‘Latinsquare design’/ OR ‘latin square’ OR ‘latin-square’) OR ’placebo’/ OR placebo* OR ‘random sample’/ OR‘comparative study’:it OR ‘evaluation study’:it OR evaluation/exp OR ‘follow up’/exp OR ‘prospective study’/OR control* OR prospectiv* OR volunteer*) NOT (animals/exp NOT humans/exp)

CINAHL (MH “Clinical Trials�”)

PEDro

a For the review search, strategies 1, 2, and 3 were combined. For the randomized controlled trial (RCT) search, strategies 1, 2, and 4 were combined.

Appendix 2.Levels of Evidence for Effectiveness Used in the Systematic Review

1. Strong evidence for effectiveness: consistent,a positive (significant) findings within multiple higher-qualityrandomized controlled trials (RCTs).

2. Moderate evidence for effectiveness: consistent, positive (significant) findings within multiple lower-quality RCTsor one high-quality RCT

3. Limited evidence for effectiveness: positive (significant) findings within one low-quality RCT

4. Conflicting evidence for effectiveness: provided by conflicting (significant) findings in the RCTs (�75% of thestudies reported consistent findings)

5. No evidence found for effectiveness of the inventions: RCTs available, but no (significant) differences betweenintervention and control groups were reported

6. No systematic review or RCT found

a �75% of the trials reported the same findings.



Appendix 3.Guideline for de Quervain Disease



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