Scapholunate instability is a common form of carpal instability that can cause wrist pain, weakness, and functional limitations during daily activities. Conservative rehabilitation approaches are frequently recommended in the early stages; however, there is no standardized rehabilitation protocol, and the effects of different neuromuscular rehabilitation methods have not been sufficiently investigated. The primary aim of this study is to comparatively examine the effects of conventional physiotherapy approaches and virtual reality-supported neuromuscular rehabilitation on forearm muscle activation patterns assessed using surface electromyography, wrist proprioceptive function (joint position sense), pain intensity, and functional improvement in individuals with scapholunate instability, and to identify clinically applicable rehabilitation protocol approaches for this population. In this single-blind randomized controlled trial, participants with pre-dynamic or dynamic scapholunate instability will be randomly assigned to either a conventional rehabilitation group or a virtual reality-supported rehabilitation group. Both groups will receive an 8-week rehabilitation program administered twice per week. Primary outcome measures will include electromyographically assessed forearm muscle activation and wrist proprioception. Secondary outcome measures will include pain intensity, grip strength, wrist muscle strength, and upper extremity functional outcomes assessed using validated clinical instruments. All outcome assessments will be performed before and after the intervention period by an assessor blinded to group allocation.
Scapholunate instability is the most common form of carpal instability and is characterized by disruption of the scapholunate interosseous ligament, leading to altered wrist kinematics, pain, reduced grip strength, proprioceptive deficits, and functional limitations. In the early (pre-dynamic and dynamic) stages of the condition, conservative management is recommended; however, standardized, evidence-based rehabilitation protocols are lacking. In particular, the neuromuscular mechanisms underlying wrist stabilization, muscle activation patterns, and proprioceptive control have not been sufficiently investigated using objective measurement methods. This randomized, single-blinded controlled trial is designed to compare the effects of conventional physiotherapy and virtual reality-supported neuromuscular rehabilitation in individuals with scapholunate instability. Participants diagnosed with pre-dynamic or dynamic scapholunate instability will be randomly allocated to either a conventional rehabilitation group or a virtual reality-supported rehabilitation group. Both groups will receive an 8-week intervention program consisting of two supervised sessions per week. The conventional rehabilitation program will focus on strengthening "scapholunate-friendly" wrist and forearm muscles, improving neuromuscular control, and enhancing wrist proprioception through progressive strengthening and proprioceptive exercises. The intervention group will receive the same conventional program supplemented with virtual reality-based rehabilitation games designed to promote task-oriented movement, sensorimotor integration, and real-time feedback. Outcome assessments will be conducted before and after the intervention by a blinded evaluator. Primary outcome measures will include wrist proprioception (joint position sense) and forearm muscle activation patterns assessed using surface electromyography. Secondary outcome measures will include pain intensity, grip strength, wrist muscle strength, pressure pain threshold, and upper extremity functional performance assessed using validated clinical outcome measures. The study aims to objectively evaluate neuromuscular and proprioceptive changes associated with different rehabilitation approaches and to determine whether virtual reality-supported rehabilitation provides additional benefits over conventional physiotherapy alone. The findings of this study are expected to contribute to the development of clinically applicable, evidence-based rehabilitation protocols for individuals with scapholunate instability and to provide insight into muscle activation strategies involved in wrist stabilization.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
36
Participants assigned to the conventional physiotherapy group will receive a structured neuromuscular rehabilitation program focusing on wrist and forearm stabilization. The intervention will include supervised strengthening exercises targeting scapholunate-friendly muscles, neuromuscular control exercises, and proprioceptive training aimed at improving wrist stability and functional movement patterns. Progressive resistance and task-oriented exercises will be used according to individual tolerance. The rehabilitation program will be administered twice per week for 8 weeks by a licensed physiotherapist.
Participants in the virtual reality-supported rehabilitation group will receive the same conventional physiotherapy program as the control group. In addition, this group will participate in virtual reality-based therapeutic exercises delivered through sensor-based interactive games designed for upper extremity rehabilitation. These exercises will aim to enhance wrist and forearm motor control, proprioceptive feedback, and functional task performance by promoting controlled and task-oriented movement patterns. Virtual reality sessions will be supervised by a physiotherapist and integrated into the rehabilitation program with the same frequency and duration as the conventional intervention, administered twice per week over an 8-week period.
Biruni University
Istanbul, Turkey (Türkiye)
RECRUITINGWrist Proprioception
Wrist proprioception will be assessed by evaluating joint position sense using both a universal goniometer and an electrogoniometer. Assessments will be performed in a standardized sitting position with the forearm supported. Predetermined wrist joint angles will be set by the assessor, and participants will be asked to actively reproduce the target positions without visual feedback. Wrist joint angles will be recorded using both measurement tools, and the absolute angular error between the target angle and the reproduced angle will be calculated to determine proprioceptive accuracy.
Time frame: Baseline and after 8 weeks of intervention
Forearm Muscle Activation
Forearm muscle activation will be assessed using surface electromyography during standardized wrist and forearm tasks. Electromyographic activity of selected forearm muscles involved in wrist stabilization will be recorded and analyzed to evaluate neuromuscular activation patterns.
Time frame: Baseline and after 8 weeks of intervention
Pain Intensity
Pain intensity will be assessed using the Visual Analog Scale (VAS). Participants will rate their wrist pain on a 10-cm horizontal line, where higher scores indicate greater pain intensity.
Time frame: Baseline and after 8 weeks of intervention
Pressure Pain Threshold
Pressure pain threshold will be measured using a pressure algometer applied to predefined and standardized anatomical sites around the wrist. Gradually increasing pressure will be applied perpendicular to the skin at a constant rate, and participants will be instructed to indicate the point at which the sensation first becomes painful. The pressure value at this point will be recorded as the pressure pain threshold, with higher values indicating lower pain sensitivity.
Time frame: Baseline and after 8 weeks of intervention
Grip Strength
Grip strength will be measured using a hand dynamometer under standardized testing conditions. Participants will be seated with the shoulder adducted, elbow flexed at 90 degrees, and the forearm in a neutral position. Each participant will be instructed to perform a maximum voluntary grip contraction. Three consecutive measurements will be taken, and the highest value will be recorded to evaluate changes in hand strength.
Time frame: Baseline and after 8 weeks of intervention
Wrist Muscle Strength
Wrist muscle strength will be assessed using standardized strength testing of wrist flexion, extension, radial deviation, and ulnar deviation. Strength measurements will be performed in a standardized sitting position with the forearm supported, and resistance will be applied manually by the assessor. Participants will be instructed to perform maximum voluntary contractions for each movement, and the obtained strength values will be recorded to evaluate changes in wrist strength following the intervention.
Time frame: Baseline and after 8 weeks of intervention
Upper Extremity Function (QuickDASH)
Upper extremity function and symptoms will be evaluated using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. This self-reported outcome measure consists of 11 items assessing physical function and symptoms related to upper extremity activities. Participants will rate their level of difficulty in performing daily activities over the previous week. Scores range from 0 to 100, with higher scores indicating greater disability.
Time frame: Baseline and after 8 weeks of intervention
Wrist Pain and Disability (PRWE)
Wrist-specific pain and disability will be assessed using the Patient-Rated Wrist Evaluation (PRWE) questionnaire. The PRWE is a self-reported instrument consisting of pain and function subscales that evaluate wrist-related pain intensity and functional difficulty during daily activities. Participants will complete the questionnaire based on their symptoms over the previous week. Scores range from 0 to 100, with higher scores indicating greater wrist pain and functional disability.
Time frame: Baseline and after 8 weeks of intervention
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