tion sheet explaining she or he hassuffered a low-trauma fracture that isdiagnostic of osteoporosis, (ii) a letterfrom the orthopedic surgeon who ismanaging the fracture to the patient’sfamily physician alerting the physi-cian to the recent low-trauma frac-ture (iii), a follow-up reminder call atfour to six weeks to return to thefamily doctor for assessment. Finally,(iv) the family physician was faxeda letter referring the patient forassessment and management of oste-oporosis. The control group receivedusual care and a telephone call at fourto six weeks to ask questions aboutthe fracture and her or his generalhealth. All participants were tele-phoned at six months to ask if sheor he has been investigated forosteoporosis and what ‘‘Best Prac-tice’’ assessment/intervention wasoffered.

Types of data analyses: Descriptivedata were compared using mean(95% CI) for normally distributedvariables. Proportions of participantsreceiving appropriate management(yes/no) were compared using a23 2 chi square statistic.

Results: To date, baseline measure-ments have been completed in 50subjects. There are 42 women andeight men. Mean age (95% CI) 69.46(65.15–73.77) Only 28 subjects havecompleted the six-month follow-upmeasures—nine intervention and 19control. Of the nine interventionsubjects, one was excluded becauseof a previous diagnosis of osteo-porosis. Seven of the eight remainingparticipants were investigated forosteoporosis (87.5%). In the controlgroup, four subjects were excluded;three because of previous diagnosisof osteoporosis and one subject died.Of the remaining 15 control subjects,four (26.6%) were investigated forosteoporosis by the family phy-sician. This is a significant difference(p # 0.01).

Conclusion: This simple inexpen-sive tool has potential to increase therate of osteoporosis investigation inan at-risk population.

Relevance to hand therapy: Thisintervention tested the effectivenessof a low-cost intervention that couldimprove delivery of health care toa population at risk of further frac-ture. The topic is particularly rele-vant to hand therapists who can play

a key role in screening for osteopo-rosis risk.

Arthritis: A Broader Approach. Mel-anie A. Trook, OTR/L, CHT, S. MarisaNew, OTR, MPH

Purpose of presentation: Arthritis isthe leading cause of disability in theUnited States. One in three adultAmericans or 70 million people havephysician-diagnosed arthritis or re-port having chronic joint symptoms,according to the Centers for DiseaseControl and Prevention (CDC). Thisclinical paper presents an overviewof the medical and socioeconomicimpacts of arthritis on the U.S. pop-ulation. Descriptions of evidence-based arthritis education programsand clinical arthritis self-manage-ment programs are presented fortherapists to enhance the scope oftreatment and education they pro-vide to persons with arthritis.

Method and rationale: The CDC ispartnering with allied health organ-izations, including the AmericanOccupational Therapy Association(AOTA) and the American Societyof Hand Therapists (ASHT) statehealth departments, and the ArthritisFoundation, to implement its Na-tional Arthritis Plan to reduce theeffects of arthritis on the U.S. pop-ulation. The Oklahoma Arthritis Net-work was developed with fundingfrom the CDC to the Oklahoma StateDepartment of Health (OSDH) toincrease public awareness about ar-thritis. Involvement of occupationaland physical therapists was soughtfor becoming instructors of the Ar-thritis Self-Help Course, a standard-ized educational program designedto teach people with arthritis how totake a more active part in theirarthritis care. The course, which wasdeveloped by the Stanford ArthritisCenter in 1979, has been rigorouslyevaluated for effectiveness, was up-dated and revised in 2003, and hasbeen presented to over 300,000 peo-ple since 1981. Arthritis Self-HelpCourses are currently being offeredthroughout the state of Oklahoma bycounty health departments and otherhealth care facilities. Our hand ther-apy private practice offers both theArthritis Self-Help Course as a groupintervention and arthritis self-helpprograms for individual patients.Outcomes from two of our Self-Help

Courses were compared with na-tional outcomes. Outcomes of groupinterventions in 2002 were measuredby comparisons of pre-and post-course questionnaires completed byparticipants and by telephone follow-up at five months after class. Out-comes in 2003 were measured usinga new ‘‘Survey of Health and Func-tion,’’ developed for this project bythe Oklahoma State Department ofHealth and the University of Okla-homa Health Sciences Center. Self-help interventions of conditioningexercise, problem-solving, and painmanagement techniques have beenutilized in addition to biomechanicaltreatment methods for the past twoyears in our clinic to enhanceindividual patients’ occupationalperformance.

Observations: CDC reports indicatethere are significant variations inrates of reported arthritis betweenstates, with Hawaii having the lowestrate at 17.8% and West Virginia thehighest rate at 42.6%. Oklahomareports 36.3%, or 936,000 persons,with chronic joint symptoms. Preva-lence is greater in females and Cau-casians. In 1992, $65 billion was spenton arthritis care and lost productivity,and costs are projected at over $100billion in 2020. There is a lack ofphysician and patient awareness ofthe value of self-help interventions inimproving and maintaining health ofarthritis patients, as evidenced bypatient remarks and difficultiestherapists encountered in marketingself-help programs to physicians.Physicians typically refer patients totherapy for splinting or postopera-tive care but rarely request self-management instruction.Outcomes of group interventions

in 2002 indicated that 54% of partic-ipants perceived a decrease in painlevel to a pain scale less than 5 out of10, and 25% perceived a decrease inlevel of fatigue and joint stiffness toa scale of less than 5 out of 10 afterclass instruction. 30% of participantsperceived their ability to implementhealth habits increased to a compe-tence scale of greater than 5 out of 10.Follow-up five months later indi-cated 83% of respondents continuedto utilize exercise, problem solving,and pain management, and contin-ued to report enhanced ability tomanage pain, fatigue, and stiffness.

January–March 2004 81

radius fracture were identified attheir initial visit to hand clinic. Thefollowing variables were determinedfor all patients: age, sex, educationallevel, smoking status, injury compen-sation status, occupational use ofhand, energy of injury, dominanceof injury and baseline self-reporteddisability (Patient Rated Wrist Eval-uation [PRWE], Disabilities ArmShoulder Hand [DASH], and ShortForm [SF]-36). Radiographic injuryseverity (pre-reduction radial short-ening, dorsal angulation, and AOfracture type was obtained for 85patients. Patients were followed upat regular intervals (two, three, six,and 12 months) to determine theirwork status. Physical impairment ofgrip, motion, and dexterity at threemonths was measured. The averagenumber of weeks lost from work was9.4 (SD = 9.3; range = 0–44, median= 6). Significant correlates withlost time from work included:occupational demand, self-reporteddisability, workers’ compensationstatus, radiographic displacement,and grip/motion at three months. Astepwise multiple linear regressionindicated that 28% of the variation inlosttime could be explained at base-line on the basis of the DASH score,occupational demand, and SF-36score. When radiographic variableswere included (n = 85 patients) inmodeling, 44% of the variation inlosttime was explained by PRWE,workers’ compensation status, radialinclination, occupational demand,energy of injury, sex, and age. Pre-diction from three-month clinicaldata (self-report better than impair-ment) was more accurate than frombaseline data. Time lost from workafter a distal radius fracture is highlyvariable. Patients who use their handmore at work, or are on workers’compensation, report higher initialpain and functional problems and,with more severe displacement, canbe expect to have the highest lost-time.

makes clinically appropriate re-quests. But when this is not thescenario, the patient–therapist rela-tionship may degenerate. This clini-cal paper identifies characteristicsassociated with hand therapy pa-tients whose behavior may causethem to be labeled as ‘‘difficult,’’and provides strategies and recom-mendations for handling such situa-tions. Literature on the ‘‘difficult’’patient is reviewed. Models ofpatient relationships (paternalistic,informative, interpretive, and delib-erative) are described. Hand therapycase examples are offered, illus-trating ways to promote effectivepatient–therapist relationships in sit-uations that could otherwise be chal-lenging and unrewarding.

Use of the Functional Dexterity Test

for Outcomes with Thumb Aplasia.

Kimberly Goldie Staines, OTR, CHT,David Netscher, MD, Ramsey Majzoub,MD, John Thornby, PhD

Purpose: Outcomes for childrenwith congenital hand deficienciesare difficult to conclude due tolimited available research on handfunctional dexterity, strength, andperceived deficits in children. Ourpurpose in this study was to use theFunctional Dexterity Test (FDT), ob-jective evaluation, and evaluation ofperceived deficits to establish func-tional outcomes post index polliciza-tion.

Methods: We used several objectiveevaluations of strength and handdexterity to evaluate outcomes on12 hands (10 children with indexfinger pollicization) as comparedwith normally developing childrenbased on recently published results,including the FDT. Evaluated chil-dren were 3 to 12 years of age, were 1to 10 years post pollicization, anddemonstrate no upper extremity de-ficiency with exception of the hand.Study evaluation included grip andpinch strength, total active range ofmotion (TAM), and dexterity [includ-ing FDT and Jebson Hand Function

In 2003, 40% of participants in-dicated severe arthritis pain pre-instruction, compared with 11%post-instruction. Perceived confi-dence in utilizing pain management,activity modifications, and stressmanagement increased by 19.8%after completing class. Participants,perceived abilities to communicatetheir health needs to their doctorincreased 21.9% following class.

Individualized arthritis servicesare provided in our hand therapyclinic upon physician referral, incor-porating splinting, home programs,and activity modifications in addi-tion to self-management instruction.Although outcome studies have notbeen utilized in individual cases,patients’ response to a combinationof biomechanical and self-manage-ment interventions has been positive.

Conclusions: Occupational andphysical therapists will increasinglytreat patients with arthritis as fre-quency of occurrence increases in theU.S. population. Evidence-based ar-thritis education can be effectivelyutilized in both group and individualsettings to broaden therapists’ ap-proach to arthritis treatment. Ourlocal outcomes compared favorablywith national studies conducted bythe Stanford Arthritis Center, indi-cating decline in perceived pain andincreased self-efficacy, which per-sisted over time.

Relevance to hand therapy: Handtherapists already possess the knowl-edge base to be arthritis educators forgroup and individual programs. 36states in addition to Oklahoma areparticipating in the National ArthritisPlan, so public health resources areavailable to therapists seeking train-ing as arthritis educators. Our mar-keting efforts to educate physiciansabout our special arthritis serviceshave increased our patient referralsfrom primary care physicians andrheumatologists, in addition to af-fording us media exposure throughnewspaper articles and televisionappearances.

Predictors of Time Lost from Work

Following a Distal Radius Fracture.

Joy C. MacDermid, PT, PhD, Robert S.Richards, MD, FRCSC, James H. Roth,MD, FRCSC, Robert McMurty

A cohort of 145 patients who wereemployed and experienced a distal

Handling ‘‘Difficult’’ Hand Therapy

Patients. Cynthia Cooper, MFA, MA,OTR/L, CHT

Ideally, the hand therapy patientand the hand therapist have similargoals. Also ideally, the patient at-tends therapy as scheduled, partic-ipates in the care, is compliant, and

Test (JHFT). In addition, parentswere asked to complete a quantitativeinterview related to their child’shand appearance, perceived func-tion, and social perceptions. TheFDT was easily administered in chil-dren 3 and older. The JHFT had to bemodified by excluding two subtests

82 JOURNAL OF HAND THERAPY