. 2018 Jan 8;23(1):38–47. doi: 10.1177/1758998317748800
Hand Ther. 2018 Jan 8;23(1):38–47.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
Accurate assessment of oedema is important in order to assess the effectiveness of therapy interventions. The aim of this study was to compare the relative responsiveness of the Volumeter and the figure of eight tape measure, as well as two patient rated measures of hand swelling.
Methods
Patients referred to hand therapy with hand oedema were assessed prior to treatment and at two and four weeks. The location of oedema was documented. Objective measures were taken with a Volumeter and figure of eight tape measure. Patients completed the patient evaluation measure (PEM) and a six-point ordinal oedema rating scale (ORS). Responsiveness was quantified using effect sizes and standardized response means (SRM). A Pearson’s correlation coefficient was used to assess the association between objective and patient reported outcome measures.
Results
A total of 100 patients were recruited with a variety of finger, hand and wrist injuries. Complete data were obtained on 73 participants. Responsiveness statistics presented represent baseline-four-week assessments as larger statistics were seen at this time point for all O/M’s. Responsiveness statistics for n = 73 for the Volumeter were ES=0.16, SRM = 0.37, for the Fo8: ES = 0.13, SRM = 0.59, the PEM: ES=1.12, SRM=0.82 and the ORS ES=1.11, SRM=0.91. For the sub-group with global hand oedema (n = 41) responsiveness statistics for the Volumeter were ES=0.17, SRM = 0.46, Fo8: ES = 0.13, SRM = 0.72, PEM: ES=1.10, SRM=0.75 and ORS ES=0.95, SRM=0.88. For n = 32 with isolated digit oedema responsiveness statistics for the Volumeter were ES=0.15, SRM = 1.06, Fo8: ES = 0.10, SRM = 0.27, PEM: ES=1.07, SRM=0.46 and ORS ES=1.28, SRM=0.95. The association between objective measures of volume and patient-reported measures was very weak (Pearson coefficient ≤0.3 p ≤ 0.03).
Conclusions
The location of oedema plays an important part when deciding which outcome measure to use. The figure of eight was more responsive than the Volumeter in patients with general hand oedema whereas the Volumeter was far superior in detecting change over time compared with the figure of eight in patients with isolated digit oedema. The Oedema Rating Scale should be considered in addition to an objective outcome measure when assessing hand oedema.
Funding acknowledgment: Leanne Miller is funded by a National Institute for Health Research and Health Education England Clinical Doctoral Research Fellowship (CDRF-2014–05-064). Christina Jerosch-Herold is funded by a National Institute for Health Research Senior Research Fellowship (SRF2012–05-119). This article presents independent research funded by the National Institute for Health Research (NIHR) and Health Education England. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
Proprioceptive assessments of the wrist inform clinical decision making. In wrist rehabilitation, joint position sense (JPS) has emerged as a way of assessing conscious proprioception with varying methods and minimal psychometric analysis reported. The purpose of this study was to standardise the wrist JPS test method for clinical use and to determine test-retest reliability in a healthy population.
Methods
Healthy volunteer subjects were tested twice (test-retest) on the same day. Four wrist JPS positions (20° and 45° flexion, 20° and 45° extension) were measured twice in a random order, by a single rater, using a universal goniometer with volar/dorsal placement. The absolute error (AE) in degrees between each position and reposition was calculated. For relative reliability analysis, intraclass correlation coefficient (ICC 3,1) of the mean AE for test and retest was calculated. For absolute reliability, standard error of the measurement (SEM) and Bland–Altman plots were applied.
Results
Fifty-five subjects (mean age 31.1 SD ± 10.25 years) were tested. Mean AE, summarised for all angles for test and retest, was 3.97°. The ICCs were poor to fair (0.07–0.47), and SEM was 2° (rounded) for all position angles. The position of 20° flexion achieved the highest ICC (0.47) and lowest SEM (1.96°). The limits of agreement were fairly narrow, and the Bland–Altman plots showed random distribution of errors for each position angle, therefore the measurement error was clinically acceptable.
Conclusions
The active wrist JPS test using goniometry was shown to have poor to fair test-retest reliability and acceptable measurement error in healthy subjects. The factors related to the variability in findings are discussed. The wrist JPS angle of 20° flexion was found to be the most reliable and could be considered as part of clinical proprioceptive assessment.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objective
The objective of this longitudinal, repeated-measures study was to assess the measurement properties of the impact of hand nerve disorders (I-HaND ©) scale.
Methods
A total of 132 patients with hand nerve disorders were recruited. Construct validity was assessed using principal components analysis (PCA) and internal consistency examined using Cronbach’s alpha (α). Using the Quick-DASH as a comparator measure, a moderate to strong (Pearson’s r ≥ 0.6) correlation was hypothesized, as evidence of criterion-related validity. Test-retest reliability was calculated using intraclass correlation coefficients (ICC) from repeated administration over a two-week interval. Responsiveness was tested over a 12-week interval using Cohen’s effect size (ES) and the standardized response mean (SRM). A global rating of outcome was used to dichotomize patients into improvers and non-improvers and receiver operating characteristic (ROC) curves used to calculate the area under the curve (AUC).
Results
A single factor structure was confirmed by the PCA. A very high internal consistency (α = 0.98) and good criterion-related validity with the Quick-DASH (r = 0.87) were demonstrated. The test-retest reliability was excellent (ICC = 0.97; 95% CI = 0.94–0.98). The I-HaND was able to detect change in a group of patients where change was expected (ES = 0.51; SRM = 0.60) and was marginally more responsive relative to the Quick-DASH (ES = 0.42; SRM = 0.56). Furthermore it discriminated between improvers (ES = 0.75; SRM = 1.2) and non-improvers (ES=−0.03; SRM=−0.04). The AUC was 0.85 (95% CI = 0.74–0.96), marginally higher than the Quick-DASH (AUC = 0.81; 95% CI = 0.63–0.93).
Conclusions
Initial validation of the I-Hand indicates that this new measure is relevant for patients and psychometrically robust. Further prospective work, using a larger sample size, over a longer time period is required to independently confirm study findings.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
Early mobilisation following open reduction and internal fixation (ORIF) is important for restoring function however there is scant literature on optimum timeframes to initiate mobilisation; patients experience variation in care. We aimed to improve the management and outcome of patients with DR-ORIF using Quality Improvement tools, clinical audit and implementation of an early mobilisation pathway (EMP).
Methods
Stakeholder engagement and focus group were used to obtain patients’ perspectives of DR-ORIF care pathway. Adults post DR-ORIF were included, those with concomitant wrist injuries excluded. Baseline data were collected for ten months. EMP (wrist mobilisation initiated within three weeks of surgery) was implemented and post-pathway data re-audited. Primary outcome was Patient Rated Wrist Evaluation. Secondary outcomes were days to achieve functional wrist range of movement, days from surgery to hand therapy discharge and return to work or hobby, patient satisfaction, grip strength, complications and number of hand therapy appointments.
Results
Prospective data were analysed for 79 patients at baseline and 13 patients post EMP implementation with SPSS version 24. Spearman’s correlation coefficients were used to explore association of days immobilised and outcome variables. Outcomes were compared for baseline and post EMP pathway patients with Mann–Whitney U test. At baseline immobilisation was median 25 days (IQR 22). Correlation of immobilisation time and outcome variables (days to regain functional ROM [r = 0.7, p = <0.01]; days to return to work or hobby [r = 0.54, p = <0.01] and days from surgery to discharge [r = 0.53, p = <0.01]) were statistically significant. Post EMP implementation median days immobilisation was 14 (IQR 8). There was a significant reduction in days to achieve functional ROM (p = <0.01) and days from surgery to discharge (p = 0.03).
Conclusion
Stakeholder engagement and pathway implementation contributed to reduced variation in wrist immobilisation after DR-ORIF. Earlier mobilisation appears to be associated with improved patient outcomes in our setting and warrants investigation.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
To evaluate the impact of iSARAH on the adoption of the SARAH programme into clinical practice by hand therapists.
Methods
iSARAH is a free online training for NHS hand therapists on the NICE recommended SARAH (strengthening and stretching for rheumatoid arthritis of the hand) programme for people with rheumatoid arthritis (RA) affecting their hand function. The training is available at https://isarah.octru.ox.ac.uk since April, 2017 and a mixed-methods evaluation on the impact of iSARAH is ongoing. On completion of iSARAH, therapists complete an online questionnaire. They rate their perceived competence and intention to deliver the SARAH programme and identify any foreseeable barriers to its implementation in clinical practice. We aim to enroll 250 therapists with 70% providing six-month follow-up data. A six-month follow-up phase is currently ongoing. Therapists are asked to report their actual use of the SARAH progamme, its clinical usefulness, and patient satisfaction with the programme. We will also explore therapists’ (n = 30) experiences with implementing the programme in their practice.
Results
As of 14 November 2017, there were 501 registrants (Males: 56; Females: 445; Occupational therapists: 360; Physiotherapists: 141) and 243 therapists (Males: 28; Females: 215; Occupational therapists: 173; Physiotherapists: 70) have provided end-of training feedback. We found: (1) 242 therapists were confident in implementing the SARAH programme; (2) 202 therapists intend to use the programme in their practice; (3) 218 therapists were ‘very’ or ‘extremely’ satisfied with iSARAH and (4) 172 therapists identified lack of time, not seeing enough number of RA patients, and lack of exercise equipment as main barriers of implementation in their departments.
Conclusions
iSARAH is an effective dissemination tool in reaching the targeted knowledge users and improving their confidence to deliver the SARAH programme. Findings from our six-month follow-up phase would inform the actual adoption of SARAH programme in clinical practice.
Acknowledgements: We thankfully acknowledge all the therapists involved in the development and testing of iSARAH. We thank the Patient & Public Involvement (PPI) contributor featured in the iSARAH exercise videos. Our special thanks to the British Association of Hand Therapists (BAHT) for their advertising support.
Funding: This research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Oxford at Oxford Health NHS Foundation Trust. This work was supported by the NIHR Biomedical Research Centre, Oxford. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
The effect of a traumatic hand injury on an individual can be wide ranging and include both physical and psychological dimensions. Getting back to work following such an injury is often challenging. This study aimed to explore individuals’ experiences of returning to work following a traumatic hand injury and to use insights gained to develop and pilot a return to work intervention.
Methods
The study comprised two stages. A reflective lifeworld research methodology, with a longitudinal perspective, was used to underpin the first stage. Seven adults in full-time work were interviewed at three distinct time points following their traumatic hand injury. Many participants initially expected to make a full and speedy recovery. It was with this view that participants made decisions concerning their return to work. Once back at work it became clear that the impact of the injury was wider ranging than they anticipated and difficulties arose with managers and colleagues.
The second stage used findings from stage one to extend the scope of the rehabilitation interventions, moving away from a hand therapy programme that focused solely on the healing structure to a rehabilitation programme that also included patient concerns. A return to work intervention was developed which was integrated with the existing rehabilitation programme. This intervention was piloted with seven people in full-time employment. Reflective lifeworld research was used to analyse their experiences within the context of the phenomenon under investigation.
Results
Results indicated that participants’ return to work experience was more positive and controlled following the return to work intervention. Therapists’ involvement in the development of the return to work plan provided an authoritative and independent way for managers and participants to implement the return to work intervention. An ability to manage their return to work and their exercise programme at the same time was reported by participants.
Conclusions
This research has illuminated the complexity of the life and work journey of individuals with traumatic hand injury, the stages of the adaptation process and their rehabilitation needs. The return to work intervention could be developed further through a randomised control trial.
Funding: This study was part funded by Barts and the London research and development department as part of a PhD done at London South Bank University.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
Reported sick leave after carpal tunnel release (CTR) varies from a few days to several months and there is limited evidence suggesting when and how patients should return to work (RTW) post-operatively. Our aim was to explore the advice given to CTR patients and to examine any variation between surgeons and therapists.
Methods
Data were collected via pre-piloted paper-based and e-surveys. Paper questionnaires were given to delegates at the joint BSSH/BAHT conference in October, 2016 and electronic mail-outs were subsequently sent to all members. The survey link was also emailed to members of the Association for Surgeons in Primary Care and the Reconstructive Surgical Trials Network. The survey contained both tick-box and free text questions. A combination of descriptive statistics and qualitative thematic synthesis were used to analyse the data.
Results
Responses from 155 surgeons and 118 therapists were available for the analyses. The median recommended time for return to desk-based duties was seven days for surgeons and 10 days for therapists. This increased to 14 days and 16 days for repetitive light manual duties. Both clinical groups recommended 30 days for return to heavy manual duties. Clinicians treating >70 CTR patients in the previous year recommended earlier RTW times for all three work categories. Four broad themes arose from the content of the RTW advice: things to avoid, driving, graded return to function and work and pain.
Conclusion
There was wide variation in the recommended RTW times and in the content of RTW advice. Differences occurred both within and between the two clinical groups. It is possible that CTR patients are receiving varied, and possibly conflicting information. Further research is required to explore the clinical implications of returning to work at different timescales and to examine the return to work experience of patients undergoing CTR.
Declaration of conflicting interests: Lisa Newington is Chair of the BAHT Clinical Evidence Committee.
Funding: Lisa Newington is funded by an NIHR Doctoral Research Fellowship. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
Virtual fracture clinics (VFC) are increasingly common across the UK. Imperial College Healthcare NHS Trust (ICHNT) is undertaking a project to deliver a Hand & Wrist VFC, aiming for virtual review within 72 h, first clinician review within two weeks and avoidance of unnecessary fracture clinic appointments. This service evaluation seeks to determine whether virtual triage can identify patients suitable for a hand therapy pathway without traditional fracture clinic review, quantify resource use and evaluate hand therapist and patient satisfaction.
Methods
Prospective data (January–August 2017) were collected for patients’ managed by the VFC. Time from A&E to VFC review and hand therapy diagnosis, and number of hospital appointments were captured via routine clinical data systems. Deviations from VFC hand therapy pathway (review in fracture clinic despite hand therapy triage) were identified and investigated. Pathway satisfaction was captured using bespoke questionnaires. Historical records (August 2015–December 2017) from a traditional fracture clinic model with referral to hand therapy were also reviewed.
Results
Between January and August 2017, 1394 cases were reviewed virtually, of which 269 were referred directly to hand therapy. Average time to VFC review was 1.4 days and time to hand therapy was 17.9 days. Interphalangeal joint injuries (36%), mallet injuries (20%) and metacarpal fractures (19%) were most frequently referred diagnoses. Patients required less hospital visits (median = 2.0, IRQ = 2) via VFC hand therapy pathway compared to historic data (median = 3, IRQ = 4). Twenty four patients (9%) patients deviated from the pathway, of which four were at hand therapist request and 20 were due to booking errors. No patients underwent corrective surgery. Hand therapists indicated confidence in the VFC pathway and patients were highly satisfied.
Conclusions
A virtual review system can successfully identify patients to be managed by hand therapy without face to face surgeon review in a fracture clinic. This reduces number of hospital appointments required for simple closed hand and wrist injuries.
Disclaimer: This abstract presents independent research commissioned by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for North West London.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
To find out what patients felt to be important about proximal interphalangeal joint replacements. This investigation sought rich and valid personal accounts of the perioperative experience.
Methods
The sample population included those with osteoarthritis and two-part implants. Ethical approval was obtained from East Midlands Derby REC (reference 15/EM/0397). Face to face, semi structured interviews were recorded and transcribed verbatim. The tenet of the interview was phenomenological; perceptions and emotions of participants were explored and chronicled. A framework analysis was used to scrutinize results.
Results
Data collected from seven interviews generated five main themes. Several subthemes were identified from in depth and varied findings. Matched set linkage charts illustrated the following relationships between subthemes: Joint pain improvement by midterm recovery was associated with descriptions of elevated mood. Function involves more than the operated joint; function remains limited from osteoarthritic changes and frustrations continue. Surgery was elected into based on consent to operate; information on recovery, complications and therapy was lacking. Patients understood therapy advice issued and valued exercises and progression. Self-maintained therapy after the midterm was accepted.
Conclusions
The findings recommend therapists are to retain realistic expectations throughout rehabilitation and encourage restoring pain free range at the operated joint rather than improving power and function. Function as an outcome measure remains difficult to capture owing to the individuality of tasks and roles. Postoperative care, especially complex and regular therapy interventions for those experiencing complications with an implant, were not anticipated. Improving information for patients and managing expectations may enhance recovery. Delivering preoperative information may offer additional layers of consent and could maximized outcomes by reflecting expectations.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
To present the outcomes and rehabilitation challenges post arthroscopic Scapholunate ligament reconstruction (Corella) via a tendon loading and proprioceptive rehabilitation regime in a 35-year-old female, International American Footballer.
Methods
The patient attended and completed a structured tendon loading and proprioceptive rehabilitation regime, adapted from published guidance. Grip strength ratio (GSR) and quick disability of arm, shoulder and hand questionnaire (Quick-DASH) scores were collected pre-surgery and on discharge. Patient goals were recorded and included return to play 70° wrist extension, being able to do press ups and 90% GSR.
Results
The patient attended 18 appointments over an eight-month period post operatively. Active range of motion of wrist achieved 80° extension and 50° flexion. Quick-DASH scores demonstrated only a 2% change, but the patient had a low pre-existing disability pre-surgery (11%). Quick-DASH sports score indicated a 75% improvement (MCID 14%). GSR achieved 100%, showing a 17% improvement but was not clinically important (MCID 19%). Patient goals were achieved and patient returned to American Football at eight months post-surgery. Rehabilitation challenges included replicating higher level rehabilitation in a gym environment, incorporating advice on strength and conditioning training to athlete due to no formal input via sport and managing athlete expectations and training load. These were addressed via patient education on training principles and injury prevention strategies and video research into American Football.
Conclusions
This poster reflects the challenges of rehabilitating a high-level athlete in the NHS and represents functional outcomes. Standard Quick-DASH may not be sensitive enough to demonstrate a clinical change in this population. Quick-DASH sports scores can be used for higher-level patients. The patient was able to achieve low levels disability and return to play at international level sport following the intervention. The published rehabilitation guidance may need to be adapted to meet the needs of elite athletes.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
There is a paucity of recommended guidelines on the management of closed central slip (CS) injuries. Indeed within the team, the opinion of how to best manage a closed CS injury was inconsistent. Previous guidelines and practice data were vague and not in line with current evidence. Literature searches using online databases identified that the majority of literature on CS focuses on post-operative management. Only one study presented clinical outcomes for closed CS management; however, this did not address potential issues such as compliance, co-morbidities or delay to treatment. All other literature were expert opinion pieces.
Methods
Using a standard data collection form, we collected retrospective data for all known closed CS injuries managed through our department in 2015–16 pre-development of the guidelines. Data included; type of CS injury, intervention (immobilisation period methods of weaning the splint), range of motion and complications experienced. We retrospectively analysed our outcomes (n = 12) and found that the majority of outcomes were grouped in the ‘fair’ range applying the Strickland criteria. The team were appraised of the proposed guidelines, we commenced formal prospective data collection for all closed CS injuries being treated within the team from July to Dec 2017. Data were collected using the same outcome measures and will aim to benchmark the new guidelines for the therapeutic management of closed CS injuries.
Results
Retrospective data demonstrated that pre-guideline hand therapy treatment for closed CS injuries was varied. The auditors recognise that the process of weaning an injured tendon out of immobilisation is unique to each individual patient; however, we hope that the new guidelines will standardise the initial period of immobilisation and further guide therapists’ clinical reasoning during the wean down process.
Conclusions
After collecting prospective data using the new guidelines, we expect that outcomes will improve.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
The aim of this audit was to find out how the occupational therapy (OT) team are currently addressing return to work (RTW) issues with hand injured patients across three UHL sites with the following objectives: (1) to optimise a timely RTW for all hand trauma patients seen by OT across three hospital sites; (2) to formalise the RTW process in order to maximise equity of service for patients across sites.
Methods
A ‘baseline’ audit of 46 sets of notes was carried out in 2011 following the introduction of 10 evidenced based vocational rehabilitation (VR) standards. A re-audit of 37 sets of notes using the same set of standards was completed in 2014 in order to measure therapist’s adherence to these. Subjects were included anonymously across all three sites if they had a job to return to following hand trauma and if they attended six or more times – (this was to ensure they had attended enough sessions to have received a rehabilitation program). A data collection questionnaire were designed and results transferred onto an Excel spread sheet for analysis and comparison with, 2011 baseline audit outcomes.
Results
Significantly improved adherence to the standards was demonstrated in the re-audit, particularly in the following areas: Evidence that therapists routinely record patient occupation (100% achieved); evidence of occupational analysis (62% – improved from 41% at baseline); evidence of work related assessment (57% from 17%), and treatment (89% from 39%), and advice/education (78% from 28%).
Conclusions
Increased team awareness regarding RTW together with using set VR standards are felt to have helped in the achievement of the original project objectives. Documentation changes and the addition of another standard relating to the use of the Disabilities of the Arm, Shoulder and Hand outcome measure has been recommended. Re-audit of cross site OT team adherence to the revised standards is recommended in 2018/19, following implementation of the suggested documentation changes.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objective
It was observed that visible scarring in some patients has a detrimental effect on their psychological health and wellbeing and is a barrier to social inclusion and return to work. Currently, there are very limited treatment options available to overcome this problem.
Methods
In order to address this, an Occupational Therapist at the Pulvertaft Hand Centre was trained in skin camouflage techniques and a pilot programme was introduced offering advice and products to patients affected by visible scarring. Patients were referred to the programme by any health professional in the department and patient benefit was assessed by verbal feedback and photographs from the patient pre and post camouflage intervention.
Results
A total of patients were seen by the skin camouflage therapist; 14 presented with self-harm scarring and 1 had visible scarring from surgery. Prior to the camouflage intervention, patients verbally reported that the scarring had a negative impact on their lives and affected their confidence in social and work situations. All the patients received a single session of skin camouflage to achieve a skin colour match; complete full application and advice for use and a prescription for specialised waterproof camouflage products. Once the scarring had been concealed using the camouflage products, patients reported an increase in their confidence to return to activities of daily living and a reduction in their anxiety of the appearance of the scar particularly in a work environment.
Conclusions
Visible scarring negatively impacts some patients and therapists currently have limited options after acute scar management to address the longer term psychological effects but this can be overcome using camouflage as an intervention. All patients reported a positive impact on their mental wellbeing. This service is currently being extended and the effectiveness of the treatment on a wider population is being audited.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
To examine the complications following surgery and treatment for this injury via a case study and to explore evidence on Zone V tendon repairs via a literature review. Also to identify how problems could have been prevented.
Method
A case study of a 73 year old gentleman with a Zone V laceration was completed by analysing notes and protocols. Literature review using flexor tendon injury, trauma, rupture, therapy, rehabilitation, Zone V, tendon adhesion, sensory re-education and nerve repair as search terms was carried out in AMED, Medline, Embase, Scopus and CINAHL.
Results
One hundred percent divisions of APL, EPB, FCR, FPL, FDP (index, middle and ring), FCU, all FDS and PL were repaired. Median nerve, superficial radial nerve and ulnar artery were repaired and carpal tunnel was released. Literature on flexor tendons mainly focuses on zone II. Most studies at Zone V were small with poorly described splinting and rehabilitation however one good prospective study had excellent results using early active movement (EAM). EAM may aid adhesion prevention by increasing differential glide however specific techniques have not been suggested. Splinting with a neutral wrist protected the nerve repair however optimal MCP position for tendon excursion at Zone V needs further research. Quick DASH was 16% and grip was 16 kg at seven months showing a good functional outcome. As nerve injury largely dictates functional outcome in Zone V these scores may improve in time. A clearer ‘spaghetti wrist’ definition, separating nerve injuries into groups may aid future research.
Conclusions
This isolated case study highlights the complex nature of ‘spaghetti wrist’ injuries. Thumb abduction which is vital for daily function was prioritised due to lack of median nerve supply to APB and repair of APL. In future I would start sensory re-education at week one and focus more on early differential glide of the tendons.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
The purpose of this audit was to review treatment outcomes using updated rehabilitation guidelines for flexor tendon repairs and to compare these outcomes with other major hand trauma centres and against current published research and literature.
Methods
The first prospective data collection (phase one) was completed between June 2014 and November 2014; clinical guidelines which were previously developed in 2009 were used during this phase of data collection. Outcomes were obtained on patient demographics, total active motion (TAM), grip strength, return to work time frames and complications (scar adherence, flexion deformities and CRPS). Following the initial data collection, flexor tendon clinical guidelines for the team were reviewed & updated based on results of the initial audit. New guidelines aimed to reflect recent updates regarding tendon rehabilitation which included changes to splint design and exercise prescription. A second prospective data collection (phase two) was undertaken from November 2015 to April 2016. Information collected was as above, however was based on patient outcomes achieved following the introduction of the new rehabilitation guidelines developed by the team.
Results
Phase One (n = 48) TAM across all tendon zones was 210°; on average, movement was 83.56% on the affected hand when compared to the contralateral side. Complications recording included rupture rate (4%) and development of a fixed flexion deformity (n = 15). Phase Two (n = 37) TAM across all tendon zones was 203.9°; on average, movement was 81% on the affected hand when compared to the contralateral side. No ruptures occurred and there were no reports of patients who developed a fixed flexion deformity.
Conclusions
Overall, our rupture rate was ∼4% which is consistent with other published research. Our movement outcomes are also similar to other published studies for early active mobilisation for zone II flexor tendon repairs. Despite a smaller patient cohort in the second phase of data collection, our TAM outcomes appear slightly worse than previous data would suggest even in spite of changes to our rehabilitation guidelines. However it is positive to note that no complications were identified in the second phase of data collection, which suggests that a change in clinical guidelines has assisted with early identification and management of potential complications in managing flexor tendon repairs.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
To develop and evaluate the web version of the SARAH programme (mySARAH).
Methods: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) programme is an evidence-based 12-week hand and arm exercise programme for people with hand problems due to rheumatoid arthritis (RA). A web version of the programme (mySARAH) has been developed for people with RA to have direct access to the programme. The SARAH programme was mapped to create the paper prototype of mySARAH. The prototype was reviewed by five patient volunteers and suggestions on the content and features of mySARAH were collected to inform the design of preliminary version of mySARAH. mySARAH has online assessment and exercise sessions, exercise videos, downloadable materials, self-monitoring tools, exercise plan form and e-calendar. An iterative evaluation of mySARAH was conducted in two separate cycles to identify and resolve usability issues. Think aloud protocol, subjective reports on usefulness, ease of use and confidence in using mySARAH, and observations for correct execution of exercises were used.
Results
Five participants (four female and one male; mean age 61 years) and four participants (four female; mean age 61.3 years) participated in the first and second cycles respectively. The need for a navigation tutorial video, feedback report on pain levels, and a task progression bar across sessions were identified in Cycle one and were rectified prior to Cycle two. The need for more instructions for filling mySARAH forms was identified in Cycle two and was rectified. All participants perceived mySARAH useful and easy to use and were confident in their ability to navigate the website themselves. Eight participants correctly demonstrated all the exercises. One required some assistance.
Conclusions
mySARAH has been developed to suit end-users’ specific needs and preferences. Our usability evaluation has shown mySARAH as an efficient and user-friendly programme.
Acknowledgements: We thankfully acknowledge all the patient volunteers involved in the development and testing of mySARAH.
Funding: This research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Oxford at Oxford Health NHS Foundation Trust. This work was supported by the NIHR Biomedical Research Centre, Oxford. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
A set of outcome measures (OMs) that include physical and patient rated outcome measures (PROMs) are to be taken at the point of the patient’s discharge from hand therapy. The aim of this study is to identify whether the measures used is an effective way of determining a patient’s outcome in terms of the results achieved, the relationship between these and the compliance in completing this set of OMs.
Methods
A descriptive quantitative design including a correlational approach was used in a single hand therapy department over a six-week period. Thirty two patients with traumatic hand injuries made up the sample. OMs included total active motion (TAM), dynamometry and pinchmeter readings together with the patient evaluation measure and the Manchester Modified DASH (M2 DASH).
Results
Good outcomes were achieved with a mean TAM of 93.6%; mean grip strength of 91.8%; mean pinch strengths of 86% of the unaffected side. The mean PEM (part 2) score was 16.6 (11%) and the mean M2 DASH score was 4. No correlations were found between the physical measures and the PROMs. These scores compared favourably with similar published studies, although it is evident that there is inconsistency in scoring the PEM within the literature. Correlation was found between the PEM (part 2) and M2 DASH (Spearman’s coefficient 0.359; significance 0.048). There was good completion of the set of measures although a large number of patients (81) were excluded having not attended their final appointment.
Conclusions
It is practicable to collect a broad set of measures in this clinical setting and they show that patients are discharged with good outcomes. The low numbers in this study may account for the lack of correlation with the physical measures and a larger study is necessary to determine if there is any correlation between the OMs.
Funding: The author received a grant from the Elizabeth Casson Trust as part funding of an MSc programme.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
Is there consistency in the prescription of strengthening exercises amongst hand therapist in the United Kingdom following distal radius fracture?
Methods
The study is a descriptive quantitative study that allows for comparison between groups of participants. No previously published data exists specifically looking at type strategies UK therapists are using and as such the data will not be comparable to other studies. Incidental sampling with snowballing has been used to recruit participants. The study has been supported by BAHT, and circulated via e-bulletin, social media and via the website. The participants have been asked to complete a questionnaire looking at knowledge of general understanding of strengthening and upper limb strengthening knowledge. Demographic information has been collected including profession, number of distal radius fractures treated in the last 12 months, and training undertaken. Participants gave information on the specific strengthening strategies they use for conservatively managed, internally fixated and also k-wired distal radius fractures. The data will be analysed using SPSS.
Results
To date, 105 participants commenced the questionnaire. Fourteen of these did not qualify to be participants and another 30 failed to complete the questionnaire. Sixty-one participants completed the questionnaire. 54.3 % of participants were occupational therapists with the remaining 44.1% being physiotherapist. Seventy-one percent of participants treated between 1 and 40 distal radius fractures and there was an even distribution across years of experience. The data collection period is open for a further two weeks and as such full results are yet to be analysed. Detailed results will be available on the following data: (1) is there a difference in the knowledge base between OTs and PTs? (2) When strengthening is commenced and if this varies with the type of initial treatment conducted and between professions and (3) common types of strengthening exercises and equipment used.
Conclusions
No conclusions are available at present.
Hand Ther. 2018 Jan 8;23(1):38–47.
Short abstract
Objectives
To compare the outcome measures of using the disability of the arm, shoulder, and hand (DASH) to those of the Canadian Outcome Performance Measures (COPM) in determining patient-rated outcomes before and after a course of hand therapy group rehabilitation.
Methods
The DASH and the COPM were used during a six-month period for ten patients starting hand rehabilitation group sessions. Both outcome measures were used prior to commencement and again at the completion of their block of sessions. Two patients submitted two sets of measurements.
Results
The changes in score of the two outcome measures were compared to test the sensitivity to change in this cohort. Five of these patients showed significant change in their performance score with COPM, four of who also demonstrated significant progress in the DASH. Seven of these patients showed significant change in the satisfaction scores with COPM. In total, five patients showed significant change in the DASH. Due to repeat readings, 58% of patients showed a significant change in their COPM satisfaction scores, and 41% showed a significant change in both their COPM performance and DASH scores. The Pearson correlation coefficient between individual average performance scores and the individual DASH scores was −0.59 with a p value of 0.004. This shows a moderate negative correlation between COPM performance and the DASH. The Pearson correlation coefficient between the individual average satisfaction score and the individual DASH scores was −0.51 with a p value of 0.015. Again, this shows a moderate negative correlation between the COPM satisfaction and the DASH.
Conclusions
Results suggest that the COPM can be used successfully as a patient rated outcome in hand therapy. There appears to be a moderate negative correlation between COPM and DASH scores. In terms of sensitivity to change within a varied, complex client group, the COPM appears to have as much sensitivity as the DASH.