Scientific Session I

This session will present cutting-edge hand and upper extremity therapy research you do not want to miss!
 

TEST-RETEST RELIABILITY AND PRECISION OF THE INTERMETACARPAL DISTANCE METHOD IN PERSONS WITH THUMB OSTEOARTHRITIS

Purpose: Restoring the thumb webspace is often a priority in hand therapy for persons with thumb carpometacarpal (CMC1) osteoarthritis (OA). Various measures of palmar abduction are available to assess the resolution of this adduction contracture. Goniometry is reported to be the most commonly used measure of CMC1 palmar abduction yet has been shown to have low reliability in healthy adults and persons with CMC1 OA. The intermetacarpal distance (IMD) method involves assessing the distance (in mm) between the 1st and 2nd metacarpal head. It is the most reliable measure of CMC1 palmar abduction in individuals with healthy hands and has excellent inter-rater reliability in persons with CMC1 OA. However, its test-retest reliability has not yet been established in this clinical population. Therefore, the purpose of this study was to determine the test-retest reliability and precision of the IMD method for measuring palmar abduction in persons with CMC1 OA.

Methods: Two raters, one being a CHT with 24 years of experience and the second being an entry-level occupational therapist with less than 1 year of hand therapy experience, utilized the IMD method to measure palmar abduction in the affected hands of 27 subjects (39 thumbs) with radiographically confirmed CMC1 OA on two separate occasions approximately 2 weeks apart. The decision to use two IMD raters with differing experience levels is supported by recently published literature on the IMD method’s inter-rater reliability. To characterize the sample, information on participants’ demographics, hand dominance, pain (numerical rating scale), and self-reported disability (Thumb Disability Exam) were collected. Descriptive statistics were employed to summarize the sample’s characteristics. Finally, the Intraclass correlation coefficient (ICC) was used to assess test-retest reliability, and the standard error of measurement (SEM), minimal detectable change (MDC), and MDC percent were used to assess precision.

Results: Participants were predominantly female, white, non-Hispanic, and right-hand dominant (Table 1). ICC values for palmar abduction all exceeded .90 indicating excellent reliability. SEM values were less than .7 mm, MDC values were 1.6 mm or less and MDC percent values were 4.4% or less indicating excellent precision (Table 2).

Conclusion: The IMD has excellent test-retest reliability and precision when used to measure palmar abduction in persons with CMC1 OA. For therapists to be highly confident that palmar abduction has improved in response to hand therapy, it should exceed 1.24 mm. Our results further support using the IMD for quantifying CMC1 palmar abduction in persons with CMC1 OA. 

Authors: Karl Dischinger | Corey McGee:

GRIP STRENGTH MEASUREMENTS TAKEN IN OUTPATIENT PHYSICAL THERAPY PRACTICE COMPARED TO ESTABLISHED NORMS: A RETROSPECTIVE OBSERVATIONAL STUDY

Purpose: In 2018, Wang et al. established normative grip strength values using US National Institutes of Health Toolbox handgrip data. As a recommendation for future research, Wang et al. reported that future studies should endeavor to validate normative equations using new independent samples. Operational variability may impact comparability of grip strength measurements obtained in clinical practice to the established norms. The objective of this study is to validate measurements taken in an outpatient physical therapy practice to the norms published by Wang et al.

Methods: The Institutional Review Board approved the data collection for this retrospective observational study. Participants To allow for norm comparison with the study of Wang et al, the following subjects were included: (1) subjects within age 18 to 85; (2) subjects with <30% between-side difference in grip strength; (3) subjects with grip strength values within the 1.5 interquartile range of the mean for participants of same sex and age-group. The data for the study was collected during the usual care of patients within one outpatient rehabilitation facility of a large non-profit health organization. Records were collected for the timeframe of January 1, 2018, to August 31, 2019. During that time, physical therapists treated 5039 individual patients for a total of 5866 treatment episodes. After taking out the multiple treatment episodes patients, missing or unclear data were removed and final 976 data were included in the study. The data were coded and none of the included patients and providers could be identified during further analyses. A calibrated Jamar dynamometer was used. Participants were instructed to squeeze the dynamometer as hard as they could while seated in an upright posture, with arms by their sides, elbows flexed to 90°, and forearms in a neutral position. The force associated with the maximal trial was documented in kilograms. Statistical Analysis Statistical analysis was performed using the statistical program for the social sciences version 28 for windows (SPSS, IBM Corporation., Armonk, NY). Descriptive statistics were calculated to illustrate the participant’s characteristics. Categorical data is presented in frequencies and percentages. Continuous data is presented in mean, standard deviation (SD). Grip strength data is presented in mean, SD, 95% confidence intervals (CI95) and percentiles (P25-P50-P75). First, the strongest and weakest side of our study were compared to the dominant and non-dominant side, respectively, using the reference tables from Wang et al. Patients were stratified by sex and 13 age groups. Secondly, the strongest grip strength from our sample compared to the predicted dominant grip strength using the equations for dominant predicted grip strength from Wang et al. Male: –29.959 – 3.095E–05 × (age3) + 38.719 × (height) + 0.113 × (weight) Female: –22.717 – 1.920E–05 × (age3) + 30.360 × (height) + 0.048 × (weight) The coefficient of determination (adjusted r2) was used for calculations. Absolute agreement between observed and predicted grip strength was assessed using interclass correlation coefficient (ICC). In addition, the agreement was visually assessed with Bland–Altman (B&A) plots including reference lines superimposed on the 1plots. The reference lines represent the mean difference of the 2 measurements and the width of the 95% limits of agreements (mean difference +/- 1.96 SD). T-tests and F-tests were used to compare means. The level of significance was set at α=0.05 for all statistical tests. Prior to analysis, data was visually inspected for assumptions of normality and linearity.

Results: Strength was assessed by 14 different providers using 5 different instruments. 976 patients had grip strength measurements taken at the initial evaluation of which 558 (57%) were females and 418 (43%) were males. The mean grip strength in 47 of 52 group comparisons showed no significant difference from Wang et al. Significant individual differences were noted between the observed grip strength and the predicted grip strength calculated using Wang et al.’s reference regression equations.

Conclusion: Despite operational variability, grip strength measurements obtained in daily clinical practice compare with the grip strength normative values obtained in more stringent clinical research. Providers can use the strongest grip strength values obtained in clinical practice to compare with reported dominant hand grip strength values. Significant individual differences were noted between the observed grip strength and the predicted grip strength calculated using Wang et al.’s reference regression equations. The authors recommend standardizing testing procedures, but providers should not be discouraged by operational variability when taking grip strength measurements. 

Authors: Becky Alwood | Frank Aerts | Bhupinder Singh

IS THE SQUEGG™ DIGITAL GRIP DEVICE MORE RELIABLE THAN THE ADAPTED SPHYGMOMANOMETER? A CLINICAL MEASUREMENT STUDY.

Purpose: Grip strength is an important outcome measurement in pediatric rheumatology settings. In our children’s hospital outpatient service, therapists have chosen to use an adapted sphygmomanometer for testing instead of the ‘gold standard’ hydraulic dynamometer because of concerns with the size, weight, and resulting comfort for using this equipment. However, the adapted sphygmomanometer has been criticized for potentially low reliability and difficulties in obtaining the analog equipment with the proliferation of digital blood pressure measurement devices. The Squegg™ digital grip device represents a new option for measurement that may address these concerns, but it has not been tested with this clinical population. We are undertaking testing of grip strength in children attending a pediatric outpatient rheumatology service to compare the reliability the adapted sphygmomanometer (AdSphyg) and Squegg™ across a spectrum of ages and hand sizes. Our primary research question is what is the test-retest reliability of the Squegg™ and how does it compare to the adapted sphygmomanometer in children with musculoskeletal health concerns? Secondary questions will explore the influence of age, hand size and dominance on average grip strength values, and any differences in comfort using the two devices.

Methods: We are recruiting children attending an outpatient pediatric rheumatology clinic, where grip strength would be tested as part of routine care. After giving informed assent or [parental] consent, participants meeting our inclusion criteria of no active disease in the hands or wrists are asked to perform maximal grip strength testing. We follow a standardized testing protocol for positioning and 3 trials; and random selection of the start device ( a new AdSphyg or new Squegg™). Both hands are tested, with rest periods in between trials. Participants also provide ratings of comfort for performing maximum gripping, and state if they prefer being able to see the score in real time (only possible with the Squegg™). The sphygmomanometer was adapted using published instructions, with the included nylon carry-case fabric used to create the pouch, allowing easy cleaning between participants. Descriptive statistics, t-tests, Pearson’s correlations and intraclass correlations (ICCs) were calculated to address our research questions. We hypothesized that results from both tools would have similar moderate positive correlations (0.6 -0.8) to age and hand size.

Results: This is an interim analysis of 33 participants of a planned sample size of 50; we will update analyses to share the final results. Average age was 11.6 years (range 5-17) and female predominance (64%); the majority were right-handed (88%) and had a diagnosis of juvenile idiopathic arthritis (55%). Ceiling effects were seen on 12 participants, where their strength exceeded the measurement capacity of the AdSphyg. Test-retest reliability across the 3 trials for both hands was excellent for any individual measure with ICC(2,1) evaluating absolute agreement = 0.96 [95%CI 0.94-0.97] for the Squegg™ and 0.98 [95%CI 0.97-0.99] for the AdSphyg, based on 198 discrete measurements. However, if only measures without a ceiling effect were included (n=115) then ICC(2,1) for the AdSphyg = 0.95 [95%CI 0.91-0.97] for any individual measure. Standard error of measurement was 4.68 kgs for the Squegg™ and 15.8 mmHg for the AdSphyg (excluding ceiling values). Average pain ratings (comfort) during grip testing were 2.1/10 for Squegg™ and 2.3/10 for AdSphyg but did not differ statistically (p=0.75). 97% of participants preferred to see their performance, with one child reporting no preference. Age and hand size were moderately correlated to strength across both tools (e.g. r=0.68 for age & mean grip on Squegg™ vs. r=0.63 for age & mean grip on AdSphyg).

Conclusion: Grip strength measures taken with both Squegg™ and an adapted sphygmomanometer demonstrate excellent test-retest reliability in a single session using new equipment in children with musculoskeletal diagnoses. However, the extent of ceiling effects seen illustrate an important limitation of the AdSphyg. More research is needed before using either of these tools in multi-centre research as there is a gap in comparing the reliability of different tools, and the responsiveness of grip strength as an outcome measure. The impact of loss of calibration over time on reliability is also understudied. Importantly, children with musculoskeletal conditions generally did not find it more painful to exert maximum effort using Squegg™ than using the AdSphyg. While our correlation analyses reflected our predictions, they may be unstable estimates given the small sample size. 

Authors: Tara Packham | Michelle Roque | Julie Herrington | Degen Southmayd | Michelle Batthish | Emily Xiao 

BIOPSYCHOSOCIAL EDUCATION FOR INDIVIDUALS WITH SUBACUTE AND CHRONIC PAIN IN THE HAND, WRIST, OR ELBOW: A TELEHEALTH PILOT STUDY

Purpose: Despite best practices in treating hand, wrist, or elbow injuries, some individuals continue to have pain beyond the expected recovery period. Rehabilitation professionals have successfully treated individuals with lingering pain from musculoskeletal injuries using pain neuroscience education (PNE). However, literature involving the use of PNE for individuals with distal upper extremity pain is lacking. This study investigated whether a PNE program with solution-focused counseling techniques would reduce pain and improve outcomes in individuals following elbow, wrist, and hand injuries.

Methods: Ten individuals aged 18 years and older (M= 46.6, SD=13.83) living in the United States with subacute or chronic pain in the distal upper extremities and receiving hand therapy services were recruited using a snowball sampling technique with assistance from American Society of Hand Therapists and Michigan Occupational Therapy Association members. A power analysis using G*Power 3.1 predicted that ten participants would achieve 80% power with a 95% confidence interval. Multiple modifications occurred in this study, expanding the population and reducing the number of variables studied due to issues with recruitment during the COVID-19 pandemic. Participants completed four weekly telehealth sessions lasting 30 to 60 minutes. This PNE program was a pre-experimental design in which all individuals received the intervention. A one-way repeated measures multivariate analysis of variance (MANOVA) was selected to determine the effects of the pain neuroscience educational program. Six dependent variables were studied: perceived pain using the Pain Numeric Rating Scale (NRS), pain catastrophizing using the Pain Catastrophizing Scale (PCS), kinesiophobia using the Tampa Scale for Kinesiophobia –11 (TSK-11), and function and social participation using the Quick Disabilities of the Arm, Shoulder, and Hand Outcome Measure (QuickDASH) and the Canadian Occupational Performance Measure (COPM). Participants improved from pretest to posttest in all variables in the primary analysis except for QuickDASH. Data on the difference between participants from pretest to posttest on the combined variables using the one-way repeated measures MANOVA were not reported because all assumptions were not met during post-hoc analysis. Therefore, univariate analyses with a Bonferroni correction assessed differences from pretest to posttest on the individual variables.

Results: Three of the six variables were statistically and clinically significant with large effect sizes. These variables include pain (F (1, 9) = 13.048, p = .006; np2 = .592); kinesiophobia (F (1, 9) = 14.188, p = .004; np2 = .612) as well as satisfaction with occupational performance (F (1, 9) = 14.656, p = .004; np2 = .620). Pain catastrophizing (F (1, 9) = 1.858, p = .206; np2 = 0.171) and occupational performance (F (1, 9) = 4.279, p= .069; np2 = 0.322) achieved large effect sizes but were underpowered to achieve statistical significance at the 95% confidence interval. Function and social participation measured by the QuickDASH were neither statistically significant nor clinically significant (F (1, 9) =.005, p = .943; = np2 0.001). Exploratory analyses indicated additional positive outcomes. Participants achieved a statistically significant improvement in mood from pretest to posttest with a large effect size (F (1,9) = 5.335, p =.046; np2 = .372). A strong working alliance between the researcher and participants was also achieved (goals, M = 18.5, 95% CI [17.14, 19.86]; tasks, M = 17.2, 95% CI [15.45, 18.95]; and bond, M = 18.7, 95% CI [17.69, 19.71]). Furthermore, participants reported that the brief PNE program with solution-focused counseling techniques was at least moderately to extremely effective at reducing their pain, and they were at least moderately to extremely satisfied with the intervention. Finally, participants also reported reduced usage of medication to treat pain from pretest to posttest.

Conclusion: This study's findings are significant, demonstrating that a brief PNE program with solution-focused counseling techniques in a telehealth format can lead to meaningful changes in pain and related outcomes for individuals with subacute and chronic pain in the distal upper extremities. Moreover, this pilot study provides effect sizes for assessment tools to study pain using PNE in the distal upper extremity population, which can significantly enhance the design and power of future randomized controlled trials. 

Authors: Amy De Maagd | Gloria Lee

ESTABLISHING INTERRATER AND INTRARATER RELIABILITY FOR THE COMPLETE MINNESOTA DEXTERITY TEST

Purpose: The purpose of this study was to establish interrater and intrarater reliability for all five subtests of the Complete Minnesota Dexterity Test (CMDT). The current psychometric properties of the CMDT are outdated. It was anticipated that this study would establish a test procedure with sound inter and intrarater reliability that may be used in a future study to renorm the CMDT.

Methods: After obtaining Institutional Review Board approval at Jacksonville University, participants were recruited using paper flyers posted in the Health Sciences Building. Participants were also recruited verbally as they walked past the evaluation tables in a main hallway. Inclusion criteria were anyone over the age of 18 who was able to read and understand English. Individuals with a current upper extremity injury or back pain were excluded due to the fact that the test was administered in standing position. After written consent was obtained, two teams of three evaluators assessed participants. In an attempt to control for confounding factors such as practice and fatigue, the sequence of the subtests was varied (for example, participant 1 completed subtests 1-2-3-4-5, participant 2 completed subtests 2-3-4-5-1, etc.). This randomized, non-blinded cross-sectional study used an intraclass correlation coefficient (ICC) via two-way mixed effects model using the absolute agreement definition for interrater reliability and consistency definition for intrarater reliability. ICC values were used to establish reliabiilty with 95% confidence intervals.

Results: Forty-seven (47) individuals participated in the study with participants ranging from 18-53 years old. Overall, 42 (89.4%) of participants were right-handed and 5 (10.6%) of participants were left-handed. The sample size threshold for intrarater reliability was 46 and was exceeded. The sample size threshold of 33 participants per 3 raters (Group A = 25, Group B = 22) was not met for interrater reliability. There was very little variance in the ICC of interrater reliability which ranged from 0.994 to 1.000, and all ICC values were found to be significantly higher than 0.80, with 5% significance level. The ICC of the intrarater reliability was between 0.824 (two hand turn and place) and 0.912 (placing test). All ICC vlues were significantly higher than 0.80 with the exception of the two hand turn and place test.

Conclusion: The test procedures resulted in strong reliability metrics for interrater and intrarater reliability highlighted by significant findings within a 95% confidence interval. Despite the threshold being met for intrarater reliability, the participant threshold for interrater reliability was not, yet still had little variance. Establishing psychometric principles such as reliability is an essential step when evaluating a standardized tool such as the CMDT. The variation used when sequencing the subtest administration appeared to successfully control for potentially confounding factors such as practice and fatigue. It is anticipated that the test procedure established in this study will be used for in a future normative study. In the future, research regarding the usage of the test in clinical (for example, administered in sitting vs standing) and professional settings would prove valuable to determine testing criteria when performing the assessment. 

Authors: Jacqueline Walter | Kevin Bandt | Kayleigh Hahn | Eden Hawes | Camryn Landis | Alyssa McDermott | Raymond Shockely | Dillon Arthur

RETHINKING REPORTING ON RETURN TO WORK FOR UPPER EXTREMITY PATIENTS: DISCREPENCIES IN RATING WORK DEMAND

Purpose: Return to work (RTW) after injury is a key goal. Stratified estimates for RTW by job type/exertion levels can be helpful in shaping patient expectations. However, job categories described in the literature are either broad (ie blue collar/white collar or light/medium/heavy) and/or describe overall force needed rather than consider only the upper extremity force needed. Ability to report on upper extremity-specific job categories is a precursor to analyzing which factors contribute to RTW for each job category. This study explores two patient rated metrics to describe upper extremity force required on a typical work day.

Methods: A survey questionnaire was developed integrating categories from the United States Department of Labor, categories used in existing peer-reviewed studies, and feedback from hand surgeons and hand therapists. This convenience sample included all patients that were sent to a hospital-based, outpatient, hand therapy walk-in service, ages 18 and older, employed at the time of injury to a hand/wrist/elbow, and English speaking. Participants were excluded if they had a polytrauma. Participants were emailed a recruitment letter with a link to a questionnaire posing questions about return to work, injury information, and demographic information. This study was IRB approved and data were collected via REDCap. Participants were asked to state their occupation. Participants were then asked to describe the arm or hand strength typically needed to perform their job using one of five categories: (sedentary work- up to 10 lbs. occasionally; light work- up to 20 lbs. occasionally, or 10 lbs. frequently; medium work- 20-50 lbs. occasionally, 10-25 lbs. frequently, or up to 10 lbs. constantly; heavy work- 50-100 lbs. occasionally, 25-50 lbs. frequently, or 10-20 lbs. constantly; very heavy work- over 100 lbs. occasionally, over 50 lbs. frequently, or over 20 lbs. constantly) as well as using a scale from 0 (light desk work) to 10 (heavy physical work). Categories were grouped into sedentary/light and medium/heavy/very heavy. Means were calculated for the categories and the 0-10 scale and then compared to determine whether participants scored the work-related upper extremity demand consistently.

Results: Fifty-two participants with a range of upper extremity injuries responded to the survey questionnaire. T-test analysis found a significant difference (2.69 vs. 6.00, P<0.001) between the mean sedentary/light (36 participants) versus medium/heavy/very heavy categories (16 participants) and the 0-10 rating scale. While many participants responded similarly on both scales, there were several in each category that were discordant. Nearly 70% of participants in the sedentary/light group rated their job as a 3 or less on a 0-10 scale, yet 11/36 participants selected 4, 5, 6, 7, or 10 level of force needed. Conversely, the medium/heavy/very heavy workers showed a more evenly distributed group, with over 80% of participants rating a 4/10 or higher and a mean centering around 6. Yet, like the sedentary/light worker group, there was inconsistency between the scales where one participant indicated the arm/hand demand on an average day was a 3/10 and another 0/10. Occupations that were scored inconsistently (i.e. more exertive category yet lower number on 0-10 scale or vice versa) included: teacher, fashion stylist, relationship manager for a tech company, scientist, office manager, and crossing guard. Crosstab calculation demonstrated a significant difference in percentages of scores across the work categories (P=0.020). There was a significant difference in the breakdown between sedentary/light versus medium/heavy/very heavy workers. For the score of 1, the sedentary/light group was a higher percentage for that score. For the 5 and 8 score, the medium/heavy worker was higher.

Conclusion: Categorizing typical upper extremity exertion in the context of injury at one’s job appears to be more complex than anticipated. While a 5-point scale and the 0-10 scale show some consistency in how participants assessed their work type, there was still a wide distribution of scores that would improve the discriminatory attributes of both scales. By taking into account the actual occupation and understanding the potential differences of the duties of that occupation, health care professionals can better understand why these scores may act in discordant ways. These preliminary findings indicate that categorizing the strength and force typically needed at a patient’s job for RTW research requires a nuanced approach. One dimensional ratings or groupings likely will fall short in conveying the range of tasks required in light or heavy work, even within the same occupation. 

Authors: Joseph Nguyen | Gwen Weinstock-Zlotnick

COMPREHENSIVE PSYCHOSOCIAL EVALUATION IN HAND THERAPY – IT'S MORE THAN DEPRESSION!

Purpose: Over the last 40 years, researchers have continuously documented the dominant role psychosocial factors play in physical healing and disability perceptions of adults with upper extremity (UE) conditions. This population is at particular risk for experiencing psychosocial barriers to physical healing given the sheer number of daily tasks requiring UE function. Difficulty or inability to complete typical daily activities often cause feelings of dependence on others, loss of roles, uncertainty about the future, and involuntary inactivity which may lead to psychosocial sequelae. Although this problem is well documented in the literature, there are minimal resources available that specifically guide hand therapy rehabilitation specialists in best-practice psychosocial evaluation procedures for this population. Practitioners cannot predict a person will experience negative psychosocial factors based solely on objective information about the injury such as severity or experience of trauma; therefore, intentional evaluation is warranted. There are numerous assessment instruments measuring a multitude of psychosocial constructs; however, it is unrealistic to measure every construct in the context of hand therapy. Rather, it is important to identify the psychosocial constructs that most often limit performance of daily tasks in this population to inform the creation of a brief psychosocial evaluation method appropriate for the hand therapy context. Therefore, the purpose of this scoping review was to map the psychosocial constructs assessed and their effect on functional outcomes in adults with UE conditions.

Methods: This scoping review was developed following the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Relevant literature published after 1984 was collected from: Academic Search Ultimate, CINAHL, Embase, Medline, PsycInfo, PubMed, and SocINDEX. Empirical studies that utilized a published psychosocial assessment instrument to determine effects on functional outcomes in adults experiencing UE impairment were included. Following the collection of literature from these databases, a manual search of the references of all included studies was also completed. Data from each study was collected using a customized data extraction instrument.

Results: A total of 94 studies met this scoping review’s inclusion criteria. Within the included studies 85 unique psychosocial assessment instruments were administered measuring 21 different psychosocial constructs. Depression, anxiety, and the catastrophizing coping style were the most commonly measured constructs. The 21 identified psychosocial constructs were further categorized into three broad clusters representing psychosocial assessments that measured: psychological symptoms, personal characteristics and coping styles, and psychosocial resiliency factors. Psychological symptoms were by far the most assessed psychosocial construct cluster as there were 150 assessments integrated throughout the 94 included studies. Meanwhile, there were 61 assessments of personal characteristics and coping styles and only 29 assessments of psychosocial resiliency factors. Findings from the included studies were synthesized through the lens of each of the three psychosocial construct clusters to identify relationships to outcomes relevant to hand therapy practice. The literature indicates that adults with UE conditions who employ negative coping strategies, such as fear and avoidance, tend to experience greater psychological symptoms. The presence and extent of psychological symptoms is positively correlated with pain intensity and perceived disability. Meanwhile, those who embody psychosocial resiliency factors, such as high self-efficacy and internal locus of control, tend to experience less pain and perceptions of disability. However, it should be noted that the evidence relevant to psychosocial resiliency factors was much more limited than the data on psychological symptoms.

Conclusion: Given that a person’s propensity to experience psychosocial barriers to functional performance cannot be predicted based on the severity of their UE condition, objective physical measurements, or a particular personality profile, intentional psychosocial evaluation is imperative for every person experiencing a UE condition. Although the available literature is highly skewed towards measurement of negative psychosocial factors, such as psychological symptoms and negative coping styles, it is also important to measure psychosocial resiliency given its promising association with improved functional outcomes in the population. A balanced evaluation of both positive and negative psychosocial constructs is recommended. Based on the results of this review, a preliminary psychosocial evaluation model was developed to guide hand therapy specialists. 

Author: Karrianna Iseminger

HAND THERAPY LEVEL II FIELDWORK EDUCATORS' PERCEPTIONS OF OCCUPATIONAL THERAPY STUDENTS’ NEED FOR ADDITIONAL EDUCATION

Purpose: This study was designed to gather the perceptions of hand therapy fieldwork educators in occupational therapy’s perceptions regarding their level II fieldwork students' need for additional hand therapy education before beginning their fieldwork experience. The results are intended to design curriculum and learning modules focused on increasing foundational hand therapy knowledge and skills to better prepare incoming level II fieldwork students and improve student success.

Methods: This study consisted of non-experimental, descriptive research utilizing a survey method. The survey, which was distributed via email by the American Society of Hand Therapists, contained questions to gather qualitative and quantitative data to describe the fieldwork educators’ perceptions of student preparedness, data regarding student interviews and placements, additional education sought by fieldwork students before beginning their placement, and fieldwork educators' opinions on which materials should be included in curricula and education modules related to hand therapy.

Results: Figure 1 demonstrates that most respondents felt that students’ didactic and experiential education did not prepare them with adequate hand therapy-specific knowledge of upper extremity evaluation and providing appropriate intervention and modification as needed. However, respondents did feel that students were adequately prepared to incorporate client-centered, occupation-based activities into their treatment sessions When asked about students’ understanding of how evaluation results affect the performance of activities of daily living, responses were comparable. As shown in Figure 2, 96% respondents reported that students would probably benefit or definitely benefit from a specialized course or education module to prepare them for their level II placement in hand therapy. Figure 3 demonstrates the basic didactic material those respondents indicated a specialized hand therapy course or education module should include. Qualitative data includes assessment, special testing, differential diagnosis and grading of exercise based on patient response to intervention. Figure 4 demonstrates the basic clinical skills that respondents would include. Qualitative themes include manual therapy, provocative testing, and clinical reasoning. Fifty-seven percent of respondents feel that a specialized hand therapy course or education module should include advanced practice information and skills. Qualitative responses agreed with including all advanced information listed. Figure 5 details respondent selections.

Conclusion: Occupational therapy students entering a level II fieldwork in hand therapy must be prepared for the rigor of the setting to be successful. FWEs feel that their students’ didactic and experiential education has not adequately prepared them with evaluation and intervention knowledge and skills. This study supports both hypotheses; that FWEs feel their students are underprepared for level II fieldwork in this setting and would benefit from a specialized education course or module relevant to hand therapy. Responses indicate that both basic and advanced information would be beneficial, with themes focused on assessment, clinical reasoning, manual therapies, differential diagnosis, special testing, and grading of exercises based on patient response to intervention. The data gathered in this study will lead to developing specialized hand therapy education materials to prepare occupational therapy level II fieldwork students for this advanced practice setting. 

Author: Sarah Donley

EFFECTIVENESS OF A WORK CONDITIONING-WORK HARDENING PROGRAM ON PATIENTS RECEIVING HAND THERAPY

Purpose: Skilled rehabilitation is often required following routine workplace injuries, such as tendinopathies, crush injuries, and lacerations, which may necessitate outpatient rehabilitation services with or without surgery. Certified Hand Therapists (CHTs) are skilled rehabilitation experts that guide injured workers through care plans that emphasize returning to full function, leveraging Worker’s Compensation (WC) benefits. While Acute WC rehabilitation (physical or occupational therapy services received acutely post-injury or surgery) is often sufficient for a patient to return to work safely and efficiently, patients sometimes require greater intensity and duration of care in the form of Work Conditioning-Work Hardening (WCWH), to build the necessary capacities and confidence to fulfill their job duties. The purpose of this study was to compare patient reported outcomes (PROs), CHT visit utilization, and Physical Demand Level (PDL) changes over time between Acute WC and Acute+WCWH care delivery modes among patients with a Medium or higher PDL (i.e., exerts 20-50 pounds of force occasionally, 20-25 pounds of force frequently, or 10 pounds of force constantly) that received WC services. Patients with lower PDL levels were excluded from this study.

Methods: Patient data, including initial and final PRO, initial and final PDL, job PDL classification, visit utilization, and demographic information, were obtained for patients that required CHT services utilizing WC benefits between February 2021 and March 2024. Cohorts were developed based on care delivery classification—Acute WC and Acute+WCWH. Episodes included in the Acute+WCWH cohort were blended such that all visits were combined and the earliest recorded PRO and PDL information was input as ‘initial’ values and terminal WCWH measurements were used for the ‘final’ values. The PRO required for inclusion in this study was the Quick Disabilities of the Arm, Shoulder, and Hand (qDASH), a disability scale that ranges from 0 (normal, pain free function) to 100 (total disability). Patient’s estimated PDL values were assigned numbers by rank: 1=Sedentary, 2=Light, 3=Medium, 4=Heavy, and 5=Very Heavy. Numeric change from initial to final estimated PDL was calculated for each episode. Analyses of Variance (ANOVAs) compared total visits per episode, change from initial to final PRO, and change from initial to final PDL; controlling for general health (Veterans RAND 12-Item Health Survey [VR12] Mental & Physical Component Scores), chronicity (condition > 90 days: yes/no), and related surgery (<=120 days of 1st visit). Significance was set a priori at α=0.05 and Tukey’s post-hoc analyses were performed for all significant results.

Results: After carefully combining episodes among patients in the Acute+WCWH cohort, a total of 2,724 patient episodes were identified, including 25 in the Acute+WCWH cohort. While all patients were appropriate for comparisons of CHT visit utilization and PDL change, 938 patient episodes were available for a comparison of qDASH change. Of the 25 patient episodes in the Acute+WCWH cohort, 11 patient episodes had initial and final qDASH available for the PRO analysis. Controlling for chronicity, related surgery, and initial VR12, the Acute+WCWH cohort (mean visits 39.1 [95% CI 33.5,44.7]; mean PDL change 1.2 [1.1,1.2]; mean qDASH change 31.7 [23.3,40.1]) attended 22.7 more visits (p<0.001), achieved 1.2 more PDL change (p<0.001), and achieved 12.9 points more qDASH change (p<0.001) than the Acute WC cohort (16.4 [15.9,17.0]; 0.0 [0.0,0.0]; 18.8 [17.9,19.7]).

Conclusion: The study identified nearly 23 more visits in the Acute+WCWH cohort than the Acute WC cohort. While this represents a significant utilization expense, the Acute+WCWH cohort achieved nearly 13 points more change in qDASH and over 1 PDL categorical improvement more than the Acute WC cohort. Limitations in this study are the size of the WCWH cohort—particularly in the PRO analysis—and the integrity of documentation early in the study window. Operational efficiencies and improvements to the electronic medical record have improved the consistency of the estimated PDL classification significantly between 2021 and 2024; however, there has been notable variability in reporting accuracy that time. Episodes with qDASH were limited because therapists could choose between several PRO options. For this study, we opted to use the sample of patients with initial and final qDASH instead of attempting to combine disparate PROs. Notably, while more visits were utilized in the Acute+WCWH cohort, these patients represented ~1% of the sample—indicating reserved use for those with the greatest need and potential benefit, resulting in differentiated outcomes. 

Authors: Michele Auch | Patrick Furgason | Lucas Myers | Thomas Denninger | Kari Melby | Adam Lutz:

PAVING THE WAY FOR LARGE-SCALE HAND THERAPY RESEARCH: A RESEARCHER NETWORK ANALYSIS

Purpose: A growing community of hand therapy researchers is working toward improving care quality by facilitating inquiry into factors impacting daily practice. Importantly, exploring relationships among patient biopsychosocial factors, real-world practice variations, and outcomes across the profession can inform initiatives to optimize practice efficiency and address diverse patient needs. Conducting research that explores these complex relationships will require large-scale, coordinated efforts among hand therapy researchers. Therefore, our study aimed to characterize and evaluate the current network of hand therapy researchers to (1) gain insight into the feasibility of large-scale collaborative research efforts and (2) identify avenues for knowledge diffusion and development.

Methods: Using published literature, we completed a social network analysis of hand therapy researchers. Individuals in the network were identified via author lists for research articles published in the top field-specific journals (Journal of Hand Therapy and Hand Therapy) from 1/2014 to 12/2023. To focus on individuals conducting active, well-developed hand therapy-relevant research, 546 articles were selected for inclusion from 753 full-length research articles based on the criteria of being data-driven (i.e., not reviews or commentaries) and involving live subjects. The final network was constructed from bidirectional connections between pairs of researchers co-authoring the included articles. These connections were weighted by the total number of collaborations. The network was plotted and evaluated for structural characteristics and to identify influential individuals. At the network level, we assessed network size (total individuals, distance between individuals), density (number of observed connections vs. possible connections), degree centralization (how focused connections are on a small number of people), and components (isolated groups of collaborators). At the individual level, we assessed measures of centrality (influence), including degree (number of connections), betweenness (how often an individual lies on the shortest path between 2 other individuals), and closeness (the number of steps needed to reach other individuals). All network plots and analyses were performed using the igraph network analysis package for R statistical software.

Results: We identified 1,938 unique researchers from the included articles, with the number of researchers authoring individual articles ranging from 1 to 13. Most researchers (N=1,664; 86%) had only 1 publication; the most prolific researcher had 36 publications. Nine isolates, that is, individuals who only published single-author papers, were excluded. A total of 5,378 connections were identified between the remaining 1,929 researchers. Graphically, the resulting network plot (FIGURE 1a) exhibits a decentralized and highly modular structure, though containing at least one densely and repeatedly connected core of researchers. The network density of 0.003 and degree centralization of 0.043 confirm this relatively sparse, decentralized structure. The mean direct path length between researchers traverses 3.8 inter-researcher connections (longest direct path: 9). The network is comprised of 263 components, including a range of 2 to 266 researchers (median: 5). The 2 largest components contain 340 (18%) of the network’s researchers and appear to feature more highly weighted connections and centralized structures (FIGURE 1b). The 5 emergent components in a second tier each include 20 to 29 researchers (116 total; FIGURE 1c). Individual researcher centrality measures are highly skewed (TABLE 1). Three individuals fall in the top 5 for both degree and betweenness, indicating they excel at both establishing and facilitating connections, and carry strong influence within the network. The two largest network components contain 5/5 of the top researchers for unweighted degree, 4/5 for weighted degree, and 5/5 for betweenness. The second tier of components contains 1/5 for weighted degree. Clearly, most of the power and brokering ability within the network is consolidated within a few individuals and groups. Interestingly, none of the top 5 researchers for closeness are within these 7 components, which may indicate a lack of efficiency among the networks most prominent groups.

Conclusion: Outside of a few core groups, hand therapy research is decentralized and primarily conducted at a low volume via small, siloed collaborations. While engaging the most prominent researchers will be essential to the success of future large-scale research efforts, targeting emerging second-tier and other moderately-sized groups may help spark greater collaboration across the network. Fostering connections between isolated groups is critical to promote efficient diffusion of knowledge and initiatives. These findings provide the foundation for expanded research exploring how researcher attributes (e.g., professional background) relate to network features. 

Authors: Katherine Loomis | Tanmay Khese | Evonne Lin | Shawn Roll