Effectiveness of "Patient-oriented"Hand Rehabilitation Program for Work-related Upper Extremity Disorders

Iris Luanne De La Calzada, OTR/LBoston UniversityMay 2009

Overview

PurposeIntroductionThe “patient-oriented” approachWhat is the difference?Current practice trendsRecent changes around the worldThe questionSearch methodsMajor findings

Other Major FindingsConsistenciesInconsistenciesLimitations of researchImplications for practice/policiesMy practice scenarioReferences

PurposeTo look at evidence-based information on the superiority of a patient-oriented hand rehabilitation program over conventional methods

To determine the significance of the role of occupational therapists in such programs

To determine the various ways of improving service delivery in an out-patient hand clinic

Introduction

Work-related upper extremity injuries affect :- THE SHOULDER- THE ELBOW- THE WRIST- THE FINGERS OF THE HAND

Injuries occur during work activity and within the work environment

IntroductionWORK-RELATED UPPER EXTREMITY

INJURIES result in:1. Loss of productivity2. Increased medical costs for injured

workers3. Increased disability payments for

employers

MOST COMMON CAUSES:SPRAINS & STRAINS POOR BODY MECHANICS & POSITION FALLS

United States Bureau of Labor Statistics Fact Sheet. (November 20, 2008). Nonfatal occupational injuries and illnesses requiring days away from work, 2007. Retrieved on March 24, 2009 from website: http://www.bls.gov/news.release/pdf/osh2.pdf

The Patient-oriented ApproachWHAT IS IT?

a concept that uses an ongoing investigation of factors

that increase quality of care delivered based on :

1. Functional outcomes2. Client satisfaction3. Overall reduced worker’s

compensation cost- uses a client-centered toolkit-patient is an active participant

Harth, A., Germann, G., Jester, A. (2008). Evaluating the effectiveness of a patient-oriented hand rehabilitation programme. The Journal of Hand Surgery (European Volume), 33E(6). 772-778. *

What is the difference?

Mossberg, K. and McFarland, C. (2001). A patient-oriented health status measure for outpatient rehabilitation. American Journal of Physical Medicine & Rehabilitation, 80(12). 896-902.

Current practice trendsRecent changes around the world

The QUESTION

For adults with work-related upper extremity injuries, does a patient-oriented hand rehabilitation result in earlier return to work and improved functional outcomes than conventional occupational therapy intervention?

Search Methods 6 full-text articles in English were chosen

Major FindingsConsistently good results in 3 studies in terms of functional outcomes using the patient-oriented approach compared to traditional approach

Major Findings

Case-Smith, J. (2003). Outcomes in hand rehabilitation using occupational therapy services. American Journal of Occupational Therapy, 57. 499-506. *Harth, A., Germann, G., Jester, A. (2008). Evaluating the effectiveness of a patient-oriented hand rehabilitation programme. The Journal of Hand Surgery (EuropeanVolume), 33E(6). 772-778. *Tschernetzki-Nielson, P., Brintnell, E., Haws, C., Graham, K. (2007). Changing to an outcome-focused program improves return to work outcomes. Journal of Occupational Rehabilitation, 17. 473-486. *

Other Major FindingsGood predictors for return-to-work:

1. Patient beliefs and perceptions

2. More efficient services

3. Absences from the program (Tschernetzki-Nielson, 2007)

Strongest predictors of NO return to work:

1. More time off work2. Male gender

(Matheson, et al., 2002)

Poor predictors for return to work:

1. Age2. Grip force (Matheson,

et al., 2002)3. Stakeholder

involvement (Tschernetzki-Nielson, et al., 2007)

Consistencies

Adults: 16-64 yearsRacial, ethnic, or socioeconomic groups not consideredVarious orthopedic /non-orthopedic injuries and disordersNo mention of training for professional providersNo RCTs – all 6 studies with different non-RCT designs

InconsistenciesOnly 1 study (Case-Smith, 2005) with exclusive occupational therapy servicesMore male participants in 4 out of 6 studies4 measured work as outcome with good resultsAttitudes toward return to work and actual return to work after discharge not explored

DASH found a useful toolCIQ scores with poor correlation

Limitations of ResearchWeak, AOTA levels I-IVOTs as contributorsNo RCTs done within last 5-10 yearsSample sizes >20Lack of uniformity on research methodologyLack of practice standards in quality assuranceStrongest evidence from studies completed abroad

Patient-oriented approach is NEW!US healthcare is not government controlledOccupational therapy contribution in hand rehabilitation in isolation not measured in all studies

Implications to OT PracticeComplete more RCTs in the United StatesPromote OTs as primary researchers or team leaders or consultantsResearch payment and reimbursement systemAdvocate patient-oriented hand rehabilitation and RTW programs as added employee benefits

Emphasize OTs ‘ responsibility on the psychosocial componentsFocus on role of OTs in the transition from medical model to patient-oriented service delivery

My Practice Scenario

Advocate the creation of RTW and hand rehabilitation programsAdapt the patient-oriented service deliveryUse evidence-based data as guide for practiceUse standardized evaluation tools such as the DASH Outcome Measure, the PDI, and the SF-36 as part of occupational therapy assessment

Prepare and take the certification examination for hand therapists

"Everything can be improved." – C.W. Barron

Thank you!

ReferencesCase-Smith, J. (2003). Outcomes in hand rehabilitation using

occupational therapy services. American Journal of Occupational Therapy, 57. 499-506. *

European Federation Societies for Hand Therapy (EFSHT) Education Committee (2008). European Certified Hand Therapist Profile. Retrieved on January 27, 2009 fromwebsite: http://www.eurohandtherapy.org/documents/EFSHT_Hand_Therapist_Profile.pdf

Hand Therapy Certification Commission (2001). Who is a hand therapist? Retrieved on March 19, 2009 from website: http://www.htcc.org/about/index.cfm

Harth, A., Germann, G., Jester, A. (2008). Evaluating the effectiveness of a patient-oriented hand rehabilitation programme. The Journal of Hand Surgery (EuropeanVolume), 33E(6). 772-778. *

Goodman, G., Browning, M., Campbell, S., Hudak, H. (2005). Evaluation of an occupational rehabilitation program. Work Journal, 24. 33-40. *

Lieberman, D., & Scheer, J., (2002). AOTA’s evidence-based literature review project: An overview. American Journal of Occupational Therapy, 56 (3). 344-349.

Matheson, L., Isernhagen, S., Hart, D. (2002). Relationships among lifting ability, grip force, and return to work. Journal of the American Physical Therapy Association,82(3). 249-256. *

Mossberg, K. and McFarland, C. (2001). A patient-oriented health status measure for outpatient rehabilitation. American Journal of Physical Medicine & Rehabilitation, 80(12). 896-902.

Pomerance, J. (2009). Return to work in the setting of upper extremity illness. Journal of Hand Surgery, 34A.137-141.

Rempel, D., Harrison, R., and Barnhart, S. (1992). Work-related cumulative trauma disorders of the upper extremity. Journal of the American Medical Association, 267(6). 838-842.

The German Federal Ministry of Education and Research. (2006). Patient-oriented research. Retrieved on January 27, 2009 from website: http://www.bmbf.de/en/6647.php#top

Tschernetzki-Nielson, P., Brintnell, E., Haws, C., Graham, K. (2007). Changing to an outcome-focused program improves return to work outcomes. Journal of Occupational Rehabilitation, 17. 473-486. *

United States Bureau of Labor Statistics (2007, May). Occupational Employment and Wages: Occupational Therapists. Retrieved on April 14, 2009 from website: http://www.bls.gov/oes/2007/may/oes291122.htm

United States Bureau of Labor Statistics Fact Sheet. (November 20, 2008). Nonfatal occupational injuries and illnesses requiring days away from work, 2007. Retrieved on March 24, 2009 from website: http://www.bls.gov/news.release/pdf/osh2.pdf

Wong, J., Fung, B., Chu, M., Chan, R. (2007). The use of disabilities of the arm, shoulder, and hand questionnaire in rehabilitation after acute traumatic hand injuries. Journal of Hand Therapy, 20. 49-56. *

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