Abstract
ORAL PRESENTATIONS A systematic review of return to work after carpal tunnel release
1Arthritis Research UK – MRC Centre for Musculoskeletal Health and Work, MRC Lifecourse Epidemiology Unit, Faculty of Medicine, University of Southampton, Southampton, UK
2Hand Therapy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
3Faculty of Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
4Faculty of Health Sciences, University of Southampton, Southampton, UK; Arthritis Research UK Centre of Excellence for Sport, Exercise and Osteoarthritis, Southampton, UK
Objectives
The aim of this review was to compare reported return to work times after carpal tunnel release (CTR), including return to different occupations and working patterns.
Methods
Nine electronic databases, six trials registries and five grey literature repositories were searched from inception to March 2016. Screening and risk of bias assessments were carried out independently by two authors and return to work times were summarised as the median and range. The review process followed our published protocol.
Results
A total of 4,209 studies were identified, of which 55 were included. Return to work times ranged from 4–168 days. For RCTs (n = 13), the median return to work time was 26 days, compared with 35 days for observational studies (n = 37). There was no standardised method of defining or collecting ‘return to work’ data and few studies reported any occupational information.
Manual workers returned to work in a median of 39 days (range 18–101), heavy manual workers in 46.5 days (range 22–101) and non-manual workers in 21 days (range 7–49); as reported by six studies. Four studies compared return to full or modified duties. Median return to work times were 27 days (range 17–82) and 21 days (range 12–50), respectively. For those in receipt of workers’ compensation, the median duration of work absence was 56 days (range 23–160), compared with 19 days (range 3–57) for those without compensation.
Conclusions
This review highlights wide variation in reported return to work times after CTR. Occupational factors are likely to be important, but were poorly reported. A standardised definition of ‘return to work’ is needed, as well as an agreed method of collecting and reporting return to work data. The current literature provides limited evidence to inform individual patients or clinicians of the expected duration of work absence after CTR.
A pilot randomized controlled trial of kinesiology tape to treat hand oedema
1School of Health Sciences, University of East Anglia, Norwich, UK
2Norwich Medical School, University of East Anglia, Norwich, UK
Objectives
Hand oedema after injury or surgery is commonly encountered by hand therapists. Whilst being part of the healing process if left untreated or poorly treated it can lead to significant and long term functional difficulties. There is a lack of high quality evidence to support interventions to reduce oedema. This study aimed to assess the trial methods, patient adherence, and inform a definitive trial.
Methods
A pilot randomized controlled trial was conducted which aimed to recruit 100 participants over 6-months. Compression, elevation and massage (treatment as usual) was compared to kinesiology tape, elevation and massage (trial treatment). The primary efficacy measure was hand volume assessed with a volumeter prior to treatment and 4 and 12 weeks by a blinded assessor. Secondary outcomes included a patient-rated oedema severity scale, function and quality of life. A treatment acceptability questionnaire was completed with participants after their final assessment. Health resource use was also collected. A general linear model was used to estimate the treatment effect.
Results
26 patients were recruited with a range of digit, hand and wrist injuries. Complete data for 4 and 12 weeks follow-up was obtained on 14 participants. Four participants reported adverse effects. Trial treatment showed a greater improvement in hand volume, function and quality of life scores, however no statistically significant difference between groups for any outcome measure was found. Adherence ranged from 39% to 100%. Higher levels of adherence and patient acceptability were seen in the treatment as usual group.
Conclusion
This pilot trial highlights challenges with regards to recruitment and retention of patients over a 12 week trial period, treatment fidelity, and the practicalities of conducting a trial in a busy clinical department which will need to be addressed before a definitive trial.
A systematic review of the factors associated with hand functional disability in people with Rheumatoid Arthritis
1Faculty of Health Sciences, University of Southampton, Southampton, UK
2Faculty of Allied Medical Sciences, Arab American University, Jenin, Palestine
Objective
To systematically review the factors associated with hand functional disability in adults with Rheumatoid Arthritis (RA).
Methods
An extensive systematic literature search was conducted in MEDLINE, EMBASE, CINAL, AMED, PsychINFO, and Web of Science database for peer-reviewed English-language observational studies exploring the factors associated with hand function for people with rheumatoid arthritis. Factors related to hand function were classified under the domains of the International Classification of Functioning, Disability and Health (ICF) framework and health related factors. The methodological quality was determined using the quality of cross-sectional studies (AXIS) tool. Factors related to hand function that were investigated in two or more studies were explored using a best-evidence synthesis.
Results
Twenty articles met the inclusion criteria from 1,271 citations. All presented cross-sectional data (five high quality and 15 low quality articles), resulting in at most limited evidence in the best-evidence synthesis. For the factors classified under the ICF domains, the best-evidence synthesis indicated that a diverse range of positive and negative factors were associated with hand function. However, key factors were hand strength, disease activity, and pain intensity. For personal factors and environmental factors, few factors have been explored for the association with hand function.
Conclusion
Studies focused predominantly on body structure and function factors, highlighting a lack of consideration of, and investigation into personal and environmental factors when considering the impact of RA on hand function. The level of evidence which exists was limited, but identified that modifiable factors such as grip or pinch strength, disease activity and pain are the most influential factors on hand function in people with RA. The review findings suggest that well-designed longitudinal, preferably cohort, studies are now needed to better understand the influence of personal and environmental factors on hand functional disability in people with RA.
Poole traction splint for the management of a pathological digital phalangeal fracture through an enchondroma: A Case Study
Royal Infirmary, Edinburgh, UK
Objectives
Digital phalangeal pilon fractures are difficult to treat, often resulting in joint stiffness. The gold standard treatment is still a source of debate. The most common methods of treatment are currently curettage and bone grafting +/− ORIF or skeletal traction. This case report describes the use of the Poole traction splint (PTS) for an unstable proximal phalanx pilon fracture through an enchondroma.
Methods
A 32-year-old right handed man presented to the Emergency Department (ED) of our trauma centre with a grossly swollen tender left middle finger following a relatively innocuous fall from standing height. Clinical assessment and radiographs demonstrated a pilon type fracture of the proximal phalanx of the middle finger secondary to a large lytic enchondroma. The case was complicated due to the the extent of the enchondroma. The PTS was used to stabilise the fracture and allow controlled movement. The PTS was employed for four weeks. Outcome was assessed using radiographs, range of movement of the finger and the time to return to work.
Results
Range of movement and pain improved immediately upon application of splint. This patient was able to return to work at four weeks post fracture. Four months post injury the arc of movement of the digit was two hundred degrees. Final radiographs demonstrated a united fracture with a congruent joint surface.
Conclusion
The use of a PTS for such cases provides a potential alternative to surgery, which is not only cost effective, but may provide comparable functional results for the patient to skeletal traction and surgery, without the associated risks. In this case, the PTS had the advantage of being a non surgical intervention that allowed fracture alignment and union, along with early mobility.
Association between Neuropathic Pain Phenotype and Outcome of Carpal Tunnel Surgery
1Pain Research Group, Imperial College London, London, UK
2Therapy Department, Imperial College Healthcare NHS Trust, London, UK
3Institute of Child Health, University College London, London, UK
4Plastic Surgery, Imperial College Healthcare NHS Trust, London, UK
5Plastic Surgery, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
Objectives
Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and CTS surgery the most frequently performed procedure in the hand. CTS assessment and treatment are not standardised and surgical outcome is variable; 25% of patients report no improvement. Evidence for the bio-psychosocial evaluation of patients with neuropathic pain is unexplored in CTS surgery patients. Therefore, this study investigated the association of neuropathic pain and concomitant somatosensory function, conditioned pain modulation (CPM), pain parameters and psycho-social state with CTS surgery outcome, aiming to identify clinical features which may predispose patients to poor outcome.
Methods
With NIHR funding, ethical approval (14/LO/36) and consent, this prospective observational study recruited patients from 2 London hospitals. Measures prior to and after surgery included quantitative sensory testing (QST); CPM; pain parameters, insomnia, pain catastrophizing and mood. Primary outcome was patient rated change at 6 months; “worse” or “no change” considered poor outcome; “slightly better”; “much better” or “completely cured” good outcome.
Results
Seventy-six patients aged 58.5 ± 13.5 years enrolled. At baseline, 75% had neuropathic pain. Loss of small and large median nerve fibre function was common, mechanical hyperalgesia less so. 33% had high levels of pain catastrophisation; 64% had clinical insomnia. At 6 months symptom and pain severity scores improved (p < .001); thermal and mechanical sensory loss was recovering (p < .001); mechanical hyperalgesia persisted (p>.05). Pain catastrophising diminished (p < .001); insomnia (p < .001) and anxiety (p = .02) improved, depression did not (p = 0.42). 92% of patients reported good surgical outcome, 8% poor. Baseline physiologic measures of sensory function and pain modulation were not associated with surgical outcome, pain catastrophising; anxiety and functional impairment were (p ≤ .05).
Conclusions
Pre-surgery psychosocial state and function are associated with CTS outcome. This evidence supports the need for changes to care pathways and informs stratified care in the treatment of patients with CTS.
Facilitating the use of research to inform clinical practice. Our experience of collaborating with Keele University’s Critically Appraised Topics (CATs) group
1University Hospitals of Derby and Burton NHS Foundation Trust (formally Derby Teaching Hospitals NHS Foundation Trust), Pulvertaft Hand Centre, Derby, UK
2University Hospitals of Derby and Burton NHS Foundation Trust (formally Derby Teaching Hospitals NHS Foundation Trust, Rheumatology Department, Derby, UK
3Therapies Outpatient Service, University Hospitals of North Midlands NHS Trust, UK
4Impact Accelerator Unit, Keele University, UK
Objectives
There is a drive for clinicians to deliver evidence based practice. However lack of facilities, time or skills to find, appraise and make recommendations from the literature are often challenges. So how do we facilitate academic research findings to inform our clinical practice in Hand Therapy?
Methods
A multi-disciplinary group of midlands based clinicians and researchers have come together to answer clinical questions using critically appraised topic (CAT) methodology. A CAT group was established at Keele University over 10 years ago. Topics are mainly musculoskeletal with few being hand therapy specific until recently (https://www.keele.ac.uk/ebp/).
Two Pulvertaft Hand Centre Therapists were invited to collaborate to answer: Does the Relative Motion Extension Splint (RMES) regime provide improved outcomes compared to usual care in finger extensor tendon repairs (zones IV to VII) rehabilitation?
A literature search strategy was guided by a PICO (Population, Intervention, Comparison, Outcome). Papers were filtered for ability to answer the question and appraised for quality. A clinical bottom line and recommendations were agreed.
Results
27 related studies were found, 5 were included (2 Systematic reviews, 1 scoping review, 1 Randomised Control Trial (RCT) conference abstract, 1 comparative study) each appraised, guided by the CASP tool.
Conclusions
We found limited high-quality evidence to answer our question. However the 2 individual studies demonstrated good/excellent ROM outcomes, less scar tethering, ease of use (smaller/less restrictive splint), earlier return to function, work and reduced therapy attendances. Derby use and audit (2014-17) the RMES regime, confirming its safe (no ruptures) and delivers improved outcomes reflective of the studies found. Others may prefer to await full RCT publication before considering practice change. Outcome measurement standardisation would support future research.
CAT groups are a valuable opportunity to develop networks of clinicians and academics. CAT outcomes findings promote knowledge mobilisation, assist new research question formulation and inform hand therapy practice.
A service evaluation in hand therapy of a conditioning group for end stage rehabilitation
1Pulvertaft Hand Unit, Royal Derby Hospital, Derby, UK
2Nottingham School of Medicine, University of Nottingham, Nottingham UK
3Occupational Therapy Department, University of Derby, Derby, UK
Objectives
The Pulvertaft Hand Unit sees more than 25,000 patients a year, of which a significant number are of working age and physically active prior to sustaining a hand injury (or acquiring a hand condition). Recently, a gap was identified in the rehabilitation process of the general population leading to the development of a conditioning class. The primary objective of this study was to evaluate whether the conditioning class had a positive effect on a range of defined patient rated outcome measures (PROMs).
Method
A progressive weekly conditioning class was designed to improve patients’ strength, stamina and function. Inclusion criteria were based on three key factors; patients must be medically fit, follow instructions in English and require strengthening as part of a rehabilitation programme. PROMs included the QuickDASH and MSK-HQ on entry into and on discharge from the conditioning class. Additionally, grip strength was tested weekly in conjunction with qualitative feedback on patients’ experiences.
Results
In total, eighty patients (42 Male/38 Female) completed the conditioning class over a 12 month period. Average patient age was 38 (range 18–60) with a significant increase in all PROMs (Students paired T-test; p>0.05). On average, MSK-HQ and QuickDash scores improved by 12 and 16 points, respectively. In addition, average grip strength increased 6 kg (24.2 kg to 30.2 kg) in the affected limb, whereas the unaffected limb increased by 3.8 kg (34.5 kg to 38.2 kg).
Conclusion
In summary, the development of a group based conditioning class for the rehabilitation of end stage hand therapy patients had a positive impact on a range of patient outcomes. Specifically, there was a significant improvement in PROMs and qualitative indicators of hand function and patient satisfaction. We believe this represents an effective and efficient method to achieve higher level end stage rehabilitation for hand therapy patients.
The APTIS Distal Radioulnar Joint Arthroplasty: An Audit of Patients
Wythenshawe Hospital, Manchester Foundation Trust, UK
Objectives
Patients presenting with distal radioulnar joint (DRUJ) issues, historically present a challenging problem for surgeons and therapists. This is an audit of patients whom have undergone the APTIS-Scheker DRUJ replacement at Wythenshawe hospital. Interventions such as the Darrach and Sauvé-Kapandji procedures have unpredictable outcomes, a total DRU joint arthroplasty the APTIS-Scheker, may offer a reasonable alternative.
Method
Eighteen patients had pre operative data collected, 14 underwent a APTIS-Scheker DRUJ replacement at Wythenshawe hospital between 2008–2018 and 13 had post- operative data. There were 7 men & 7 women with an age range 20 – 80 years. Pre-operative measures included: active range of movement, grip strength, lifting-capacity, Quick DASH (QD), Patient Rated Wrist Evaluation (PRWE) and the numerical rating scale (NRS) for pain. Patients were re-assessed at 6 and 16 weeks and 1 year after surgery, then yearly.
Results
Active range of movement increased for supination; pronation, flexion and extension remained the same. Grip strength improved from a mean of 17.4 Kg to 23.2 Kg. Lifting capacity, from 2 Kg to 4.2 Kg. Pain decreased from a mean of 4 out of 10 to 0.3 on the NRS. Function improved from a mean of 63.6 QD and 64.2 PRWE, to QD 18 and PRWE 14. There is a 100% survival rate of the prosthesis at present.
Conclusion
Although the number of patients is low, the APTIS arthroplasty does appear to give patients relief from pain, improvement in both range of motion and functional use. On-going follow-up is required to monitor for survival rates, especially in the younger patients.
POSTERSA pilot randomised controlled trial investigating whether an imagined movement regimen improves dexterity, range of motion or pain in adults over 50 years old with a conservatively managed distal radius fracture
Physiotherapy Hand Unit, Royal Gwent Hospital, Newport, South Wales, UK
Objectives
Neuroplastic adaptations of the sensorimotor cortex during immobilisation are thought to negatively affect limb function. Imagined movements are believed to limit these adaptations and may therefore improve functional outcome. A pilot to determine feasibility of a clinic based RCT is required.
Methods
Patients were convenience sampled from two A&E departments in Aneurin Bevan University Health Board, (ABUHB), over two months. There were two groups; standard care, (prophylactic arm exercises); and standard care plus intervention, (imagined wrist movements whilst immobilised). All participants were advised to exercise 4 times daily. Limb function was measured using dexterity, (Purdue peg board), active range of movement, (goniometry) and pain, (visual analogue scale), recorded within 48 hours of removal of cast. Patients and assessor were not blinded for practical reasons.
Results
17 patients were approached, four met inclusion criteria and consented. Participants were randomised, two to each group. All participants successfully followed the trial methodology without difficulty. No trends are reported due to insufficient numbers. Recruitment was the greatest limitation. It seems likely that many potential patients were not approached in A&E. Of those approached, eight declined due to travel costs. The data collected identified potential bias due to age/fracture severity which will need to be included in the data set; NICE guidelines encourages conservative management in severe fractures in those over 65 years of age.
Conclusions
An appropriately powered clinically based RCT is considered feasible with the following recommendations. Recruitment by the research team via the virtual fracture clinic, reimbursing travel costs, blinding of assessors, and adding measures of fracture severity and age for use as covariates in the analysis.
A Case Study Utilising Acupuncture as an Alternative Treatment Method to Resolve Extensor Digitorum Communis Tendinosis of a Right Middle Finger in a Novice Boxer
Hand Therapy Department, Chelsea and Westminster NHS Foundation Trust, London, UK
Objectives
Hypertrophic Interstitial Tendinosis (HIT) with Grade 1 sagittal band injury is a common presentation under semi-professional and novice boxers. The use of acupuncture demonstrates an adjunct to splinting and extrinsic extensor exercises in the treatment of “Boxer’s Knuckle”.
Methods
A client who actively participated in boxing, presented with painful right middle finger (MF) metacarpophalangeal joint (MCP). Symptoms included a MCPJ lag of 10 degrees of the MF and thickening of MF EDC as assessed with ultrasound. Right MF was treated with splinting (finger yoke) and eccentric EDC exercises. Acupuncture dry needling (Herringbone technique) to the EDC tendon of the right MF was introduced 4 weeks following conventional treatment for pain relief and to enhance the pro-inflammatory physiological changes to the tendon. K-taping to the EDC tendon was used for treatment carry over. Outcome measures including PROMs (DASH and PSFS) and objective measurements (ROM and NRS for pain) showed improvement following 5 sessions of dry needling to the EDC.
Results
Minimal improvement was noted with splinting/eccentric exercises. Following introduction of dry needling, improvement was noted in PROMS with DASH score improving 40 points; PSFS improving 100%, objective measurements improving with a 20 degrees increase of MF MPCJ extension and pain score improving 70%.
Conclusions
There is minimal evidence in the use of dry needling to enhance pro-inflammatory physiological changes to tendons in the hand. The application of a technique used in tendinosis in the lower limb was applied with success in this client. This outcome encourages hand therapists to use dry needling as an adjunct to treat tendinopathies in the hand. The method could be used in designing a RCT comparing conventional treatment and acupuncture, maybe in more common presentation such as De Quervains’ disease.
GLOVE 1 (Generation and evaLuation of hand therapy deVices for Epidermolysis bullosa) – Findings from the dressing glove proof of concept study
1Hand Therapy department, 3rd Floor Lambeth Wing, St Thomas’ Hospital, London, UK
2King’s College London, Florence Nightingale School of Nursing and Midwifery, London, UK
Objectives
Epidermolysis bullosa (EB) is a rare genetic skin disorder which causes skin fragility and contractures and fusion of digits, it affects a small population but requires disproportionately large healthcare resources because of the severity and progressive nature of the condition. Hand therapy devices to delay recurrence are often not tolerated which GLOVE addresses using a model of user engagement and co-design to develop: a) a dressing glove; b) a reinforced web spacer glove; c) a Hand Therapy Online (HTO) system comprising an EB hand assessment, clinician and patient recorded outcomes allowing routine data capture.
Methods
An N of 1 study design was adopted to investigate the dressing and reinforced web spacer glove performance. Co-design workshops groups were conducted; these qualitative data were analysed into themes including user needs and design cues guiding development of gloves and HTO.
Results
The dressing glove conforms to the hand in one layer protecting from friction, absorbing blister fluid, allowing frequent changes, promoting hand hygiene. The reinforced Skinnies WEB™ web-spacer glove is compatible with the dressing glove and helps maintain web spaces. HTO can be completed by patients and clinicians, remotely and face to face enabling communication and monitoring from patients’ homes.
Conclusion
GLOVE delivered the aims. We are investigating commercialisation for the dressing gloves and long-term provision of bespoke versions for individuals with hand contractures. Having used HTO as a research tool we will now conduct a one-year evaluation funded by DEBRA UK using HTO as a clinical tool to test its effectiveness. This will enable further data collection on the performance of the dressing glove and Skinnies WEB™ web-spacer glove and investigation into potential use in other hand conditions.
A retrospective audit to evaluate patients’ pain levels post trapeziectomy surgery
Hand Therapy Department, Wrightington Wigan and Leigh NHS Foundation Trust, Wrightington, Lancashire, UK
Objectives
We aimed to look at range of movement and pain levels post trapeziectomy surgery following standardised local protocols utilised within our Trust. We were also interested in the rehabilitative outcomes from splinting. Currently there are various methods of splinting following this procedure and a secondary objective has been to look at potential influence on outcome.
Method
Data collection utilising the therapy records of 21 patients who underwent this procedure over a 4-month period were analysed. The clinical data within the records included pain, hand dominance, side of operation, work and hobbies. Pain was assessed using a Visual Analogue Scale (VAS) of 0–10 at 1 week, 4 weeks and on discharge. Data was collected on range of movement which had been measured using a finger and a wrist goniometer. As a secondary consideration any information relating to clinical choice regarding the type of splinting chosen by the treating therapist was also gathered.
Results
On initial assessment 19% of patients scored 0–3, 71% scored 4–7 and only 10% scored 8–10 on the verbal VAS. By discharge significant improvements were shown with 83% of patients reporting pain levels of 0–3. Within the therapy records there was a wide variation in the amount and quality of range of movement data. All patients were splinted; 3 soft thumb and wrist splints, 12 soft thumb splints, and 6 thermoplastic thumb splints. On initial assessment 67% of patients wearing soft splints reported 4–7 pain rating and by discharge had reduced to 80% of patients scoring 0–3. Similarly, 83% of patients wearing thermoplastic thumb splints reported 4–7 pain and by discharge had improved to 17%. By discharge, 100% of patients reported full return to functional status. It was not possible to analyse range of movement (ROM) data due to inconsistencies involving inter and intra-operator measurement and recording.
Conclusions
We have shown that patients do improve post trapeziectomy surgery however patient expectations, functional demands and pain perception are all factors which contributed to overall outcomes of the audit. It can take several months before pain levels are reported as minimal, but pain is found to improve significantly. The choice of splint based on clinical reasoning is essential for effective treatment. Further research is required to focus on the type of splint worn and the direct impact on ROM within the initial weeks of therapy. Consideration should also be given to the surgical approach used by the consultant.
A qualitative investigation into the rehabilitation experience of patients following wrist fracture
1Occupational Therapy Department, King’s Mill Hospital, Sutton-in-Ashfield, Nottinghamshire, UK
2School of Community Health Sciences, University of Nottingham, Nottingham, UK
Objectives
Explore the lived experience of dominant side wrist fracture by patients who undergo assessment and treatment in Hand Therapy, and explore the impact on their activities of daily living, particularly in areas of work and productivity. Understand the patient perspective on relevance of, and engagement with, outcomes used in Hand Therapy. Investigate the impact that Hand Therapy makes on patients’ recovery from wrist fracture and the impact of their own role in the process.
Methods
Qualitative, phenomenological approach to describe the ‘lived experience’ of the participant, to uncover meanings of day to day experiences following wrist fracture.
Audio recorded, transcribed semi – structured interviews with six participants in the patient’s home environment. Thematic analysis revealed concepts and themes from participant’s descriptions, and a reflexive research diary provided transparency of the therapist as researcher.
Participant verification sheets confirmed accurate interpretation of responses.
Results
Emerging themes included: i) functional ability; ii) attitudes and expectations of self and others; iii) assessment and treatment in therapy.
Conclusions
Hand dominance and adjusting to non-dominant hand use was frequently discussed in maintaining or regaining independence. Support networks were important in early stages of recovery although avoiding dependency on others was important. Return to work was an important milestone and therapist consideration of job demands. Return to work issues were important to the participants, as was relating objective assessment to the individual’s daily tasks. Lack of education on removal of plaster cast resulted in anxiety and low mood during the time period before therapy was initiated, although these were alleviated through education in therapy.
The Conservative Treatment for Osteoarthritis of the 1st Carpometacarpal Joint (1st CMC) as Sourced from 6 Specialist Hand Therapists, a Study to Explore Consensus in Practice.
1Clinical Therapies Department, Bassetlaw District General Hospital, Worksop, UK
2Sheffield Hallam University, Sheffield UK
Objectives
Osteoarthritis of the CMC joint of the thumb affects 22% of the population over the age of 55. The impact and associated disability levels due to pain, deformity and loss of hand function are significant. The aim of the study was to establish whether a consensus in practice between 6 Specialist Hand Therapists existed regarding the conservative management of this condition.
Methods
Therapists were located from a wide area across the country. Semi structured interviews were used to collect data and questions focused on therapist’s treatment pathways and the clinical reasoning underpinning these decisions. A vignette was used to ascertain a specific example of a treatment pathway and allowed a direct comparison of each therapist’s management of the condition in the specific case.
Results
Consensus was evident in specific areas of management and included: joint preservation, activity modification and self management and the need to maintain joint range of motion. Although agreement was reached regarding the need to maintain movement there was little consensus on an exercise regime. In addition there were differences in opinion regarding splint wear schedules but all considered splinting important during periods of exacerbation.
Conclusions
There was some consensus on specific areas of management of OA of the 1st CMC joint; however there were differences in practice (particularly within exercise regimes) which may be due to a lack of standardised models of care for this condition. This reflects a need for more evidence-based recommendations within the non consensus areas. Further research using a quantitative consensus method may assist in the validity of the findings of the study and if concurrence was achieved could help provide best practice for the conservative management of this condition.
The Symptomatic Course of Thumb Osteoarthritis: A Scoping Review
1University Hospitals of Derby & Burton NHS Foundation Trust, Pulvertaft Hand Centre, Derby, UK
2Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire UK
3Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, The University of Nottingham, Nottingham, UK
Objectives
Thumb base osteoarthritis (TBOA) is a chronic painful hand condition affecting 21% of the population. Research demonstrates radiographic progression is common, but the symptomatic course is unclear. Knowing the factors associated with future pain levels can identify patients at risk of poor outcome, and inform better targeting of treatments. A scoping review was undertaken to search for evidence describing the symptomatic course of TBOA.
Methods
Systematic searches of seven electronic databases and four evidence synthesis websites were conducted from inception to January 2018. Predefined criteria were applied to exclude studies; included studies described symptoms over at least six months, without intervention beyond analgesia. Studies were grouped by the methodological design used. Data was extracted on the: populations studied; outcomes used to measure symptoms; and factors associated with pain and function.
Results
The search found 2018 publications, the full texts of 91 were examined, 10 studies satisfied the inclusion criteria. Two control groups from randomised controlled trials, and six case studies which were of poor quality, provided minimal quantitative symptomatic data. Two well conducted cohorts of hand OA had limited data on TBOA as a subset. Follow up ranged from 6 months to 10 years, the sample demographics differed between studies, with the majority being female patients recruited from secondary care. Outcomes measured physical function, impairment and activity limitations; with insufficient data to determine the factors implicated in ongoing pain. The population cohort demonstrated an average small deterioration in pain and function over three years, the secondary care cohort showed variable disease course over 6 years. The case studies suggest TBOA can lead to significant pain and concern over future ability to work.
Conclusion
The scoping review did not identify enough evidence to summarise the course and prognosis of symptomatic TBOA. This chronic condition requires better understanding to enable informed decision-making regarding treatment.
A Therapist-Run Distal Radius Fracture Clinic – Our Experience
Hand Clinic, University Hospital, Southampton, UK
Objectives
We considered that some routine management of distal radius fractures (DRF) in the Hand Clinic might be more effectively delivered by the Extended Scope Practitioner in Hands (ESP) than by Doctors, because an experienced ESP is competent to advise on rates of recovery, provide rehabilitation guidelines, order DEXA Scans, and detect complications.
Methods
In 2005 we established the ESP DRF Clinic. The Surgeon reviewed the patient at 2 weeks to establish fracture position and to check wound healing in those who had surgery. Thereafter the ESP reviewed patients at 6, 12 and 26 weeks. A proforma was developed to collect interval data, range of movement, grip strength, assess pain, complications, and complete a DASH Questionnaire. Patient satisfaction was surveyed.
We contacted our R & D Department and it was confirmed that this work was a Service Evaluation.
Results
196 patients were seen in the Clinic from 2005 – 2009. Management: 143 cast, 45 K-wires, and 8 volar plates. Complications: 26 carpal tunnel syndromes (CTS), 3 EPL ruptures, 14 CRPS, 5 non-unions, 4 infections, 3 TFCC tears. ROM: flexion improved from 40° to 59° between 6 weeks and 6 months, extension 17° to 60°. Grip: 48% of contralateral side at 12 weeks. DASH: 29 at 12 weeks, 17 at 6 months. Pain improved by 3.25/10 between 6 weeks and 6 months. Satisfaction: 77% very satisfied.
Conclusion
It is well reported that ESP’s are taking on more of a traditional orthopaedic role in clinic, allowing senior medical staff to deal with more complex cases.
The ESP effectively managed selected DRF patients with high satisfaction, prompt detection and management of complications. Compared with the literature we had a high complication rate: 13% patients had CTS and 7% had CRPS. We now feel that many of these patients did not have true CRPS; just severe hand stiffness.