Rehabilitation of wrist injuries

1. Approved 25/11/2025, Swedish Ethical Review Authority (Box 2110, Uppsala, 750 02, Sweden; +46 (0)10-4750800; registrator@etikprovning.se), ref: 2025-07147-02

2. Approved 21/08/2024, Swedish Ethical Review Authority (Box 2110, Uppsala, 750 02, Sweden; +46 010-4750800; registrator@etikprovning.se), ref: 2024-04455-01

All primary outcome measures related to the feasibility of the PROWRST program will be assessed after completion of the program at 12 weeks:
1. The acceptability of the treatment program (PROWRIST) will be assessed through interviews after completion. The interviews will address perceptions of the program content, duration, number of exercises, home-based format, clinical follow-ups with the physiotherapist, and perceived level of difficulty. Participants will also be asked about perceived effects on wrist symptoms, the outcome measures used, experiences of the educational component, and to identify beneficial and less beneficial aspects of the program, any missing components, and potential areas for improvement. Based on the input from the participants, the PROWRIST program will be further refined and developed.
2. The participants’ perceptions of difficulties or barriers encountered during treatment with PROWRIST program will be evaluated with the extended and Swedish version of the Problematic Experiences of Therapy Scale (PETS). The extended PETS comprises six subscales capturing different types of problematic experiences related to therapy. Items are rated on a 5-point Likert scale ranging from 1 to 5, with higher scores indicating more problematic experiences or greater perceived barriers. Subscale scores are calculated by summing or averaging item responses within each domain, with higher scores reflecting greater treatment-related difficulties.
3. Adherence to the PROWRIST program will be assessed with the participants logging their exercise sessions in a training diary. Participants will be classified as adherent if they complete the prescribed number of sets and repetitions in at least 75% of the scheduled sessions, which is the predefined adherence threshold for the feasibility evaluation.
4. Adverse events, such as increased pain, swelling, stiffness, or new symptoms, will be evaluated and registered during the clinical follow-ups with the treating PT to ensure participant safety and to guide any necessary modifications to the program, and at the end of the training period.
5. The need for conversion to other treatments, such as corticosteroid injections or surgery, will be evaluated at the 12-week follow-up.

All secondary objective and patient-reported outcome measures (PROMs) will be evaluated at baseline and at the 12-week follow-up.

Objective outcome measures:
1. Wrist range of movement (extension, flexion, ulnar- and radialdeviation, pro- and supination) will be measured with a goniometer (degrees).
2. Isometric grip strength, three trials for each hand with a mean value (kilograms, kg), will be measured using the Jamar hydraulic hand dynamometer.
3. The wrist’s weight-bearing capacity will be evaluated using the Push-Off Test (POT), performed with a Jamar hydraulic hand dynamometer according to previously described and validated instructions. Three trials for each hand will be recorded and the mean value, recorded in kilograms (kg), for each hand was calculated.
4. Wrist lifting strength will be evaluated using a Kern dynamometer. Three trials will be conducted for each hand, and the mean value of the measurements is calculated and expressed in Newton meters (Nm).
5. The strength component of the Constant score will used to assess shoulder strength. Measurements will be obtained using a digital spring balance dynamometer with force expressed in pounds (lb). Three attempts will be performed for each shoulder, with a minimum rest interval of one minute between trials, and the highest value will be recorded.

Patient- reported outcome measures (PROMs):
1. Pain will be measured using the Numeric Pain Rating Scale (NPRS). The NPRS is an 11-point scale (0–10) where 0 indicates no pain and 10 the worst imaginable pain.
2. Wrist pain and function will be evaluated with the Patient Rated Wrist Evaluation (PRWE). PRWE is a wrist-specific PROM designed to assess pain and disability in daily activities over the past week. It consists of a pain subscale (five items) and a function subscale (10 items), with a total score ranging from 0 to 100, where a higher score indicates greater disability.
3. Self-reported upper extremity physical function and symptoms will be rated with the Swedish version of Disabilities of the Arm, Shoulder, and Hand (DASH). DASH is a PROM assessing upper extremity physical function and symptoms on a scale from 0-100, 100 represents most severe disability, whereas 0 characterise no disability.
4. The Patient Specific Functional Scale (PSFS) will be used for collaborative goal setting, allowing participants to identify and rate personally meaningful activities affected by their wrist condition on a 0–10 scale, with higher scores indicating better function.
5. The Swedish version of the Pain Self-Efficacy Questionnaire short form (PSEQ-2SV) will be used to assess pain-related self-efficacy. The PSEQ-2SV consists of two items that measure an individual’s confidence in performing daily activities despite pain. Each item is rated on a 7-point Likert scale ranging from 0 (“not at all confident”) to 6 (“completely confident”), yielding a total score from 0 to 12, with higher scores indicating greater pain self-efficacy.
6. Health-related quality of life will be assessed using the EQ-5D-5L, a standardized EuroQol questionnaire covering five domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), each rated on five levels. It also includes the EQ Visual Analogue Scale (EQ VAS), a 20 cm vertical scale for self-rated health ranging from “the best health you can imagine” to “the worst health you can imagine.”
7. The Global Rating of Change (GROC) is an 11-point scale (-5 to +5) assessing perceived change since treatment, where -5 means “a very great deal worse,” 0 “about the same,” and +5 “a very great deal better”. Participants will rate: “Considering how your wrist functioned before the treatment, how would you rate your wrist function now?”
8. The Patient Acceptable Symptom State (PASS) will be used to assess whether participants considered their symptom state satisfactory following the intervention. The PASS identifies patients who consider themselves well and is evaluated using a dichotomous (yes/no) anchor question asking participants whether they perceived their current wrist condition as satisfactory, taking into account wrist function in daily activities, sports and recreational activities, pain and other symptoms, and wrist-related quality of life.