Scientific Session II

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

RELIABILITY & VALIDITY OF THE MEASURES USED IN THE SOMATOSENSORY REHABILITATION METHOD WITH INDUCED SENSORY CHANGES: A PSYCHOMETRIC STUDY

Purpose: Allodynography, the rainbow pain scale (RPS), and esthesiography are core sensory evaluations used in the somatosensory rehabilitation method (SRM). Preliminary work in patients suggest good reliability of allodynography and the RPS but more research in larger samples is needed to expand our understanding of the range of measurement properties. We undertook testing of evoked sensory changes to enact a reference standard (known area where sensation-altering creams were applied), creating an opportunity to robustly examine discriminative (diagnostic) validity between sensory phenomena as well as inter-rater reliability. Our primary research question was what is the inter-rater reliability and discriminative validity of allodynography, the rainbow pain scale and esthesiography?

Methods: We recruited healthy volunteers from students and faculty at McMaster University to attend a laboratory testing session for a cross sectional measurement study. After giving informed consent, participants were randomly assigned to have an active topical cream applied to one forearm, and a control to the other. Active creams (Zostrix™ 0.075% capsaicin or EMLA™ 2.5% lidocaine and 2.5% prilocaine) were applied to a 2cm x 2cm square on the volar forearm. IcyHot™ (16% menthol and 11% camphor) was applied to the contralateral forearm as a control condition, to elicit a cooling sensation without altering the light touch threshold. Participants were blinded to which active cream was applied, and to what arm (right or left). Two blinded raters independently tested participants, starting with screening for allodynia using a 15g (#5.18)monofilament and asking if the pressure elicited at least 3/10 on a numeric rating scale for pain, following standardized evaluation procedures. If no allodynia was elicited, then the rater proceeded to screen for sensory loss using a 0.2g (#3.22) monofilament, conducting esthesiography if loss was identified. If allodynia was identified on screening, then allodynography was conducted on that forearm. The area of sensory alteration was measured using a clear plastic ruler (length x width in cm). Descriptive statistics, contingency tables, weighted correlations (kappa) and intraclass correlations (ICCs) were calculated to address our research questions.

Results: 96 healthy volunteers participated in our study with an average age of 23.7 years (range 19-58) and female predominance (78%). Interim analysis after testing 61 participants confirmed seemingly random but widespread model failure (i.e. where participants did not report the sensory alteration intended), therefore we partially unblinded participants by informing them of their active group allocation before testing, while retaining blinding of which arm had the active cream. Combining all screening results, the SRM methods had a sensitivity of 62.5% and specificity of 53.1% however, these were influenced by model failures as only 33% of tests had active findings when there should have been 50% findings if sensory changes were consistently elicited. If we considered the examinations only those who were partially unblinded, sensitivity was similar at 63.6% but specificity dropped to 41.7%. Splitting apart screening for allodynia and hypoesthesia in all cases, sensitivity to identify allodynia was 53.3% (specificity 56.3%) and sensitivity to identify hypoesthesia was 36.4%, with a specificity of 48.6%. Across all tests by both raters (n=384 tests on 192 arms), we saw discordance between the expected and observed conditions 52% of the time. Estimates of inter-rater reliability were generally moderate when the rating type was concordant with the expected condition (See Table 1).

Conclusion: Despite our aspirations to conduct a robust psychometric study using induced sensory alterations, perception and anticipation and lack of elicitation of clear sensory alterations appeared to add important variability to our findings. Healthy voluteers reported struggling to discriminate between induced sensory loss and pain. The lack of a consistent response to evoked alterations also reduced statistical power for evaluating reliability. The resulting estimates for reliability and discriminative validity should be used with caution to judge the measurement properties of the SRM evaluations of allodynography, the rainbow pain scale and esthesiography as they are likely imprecise and unstable. 

Authors: Michelle Li | Emily Zheng | Cloris Su | Hannah Nguyen | Isabelle Quintal | Tara Packham

RELIABILITY OF THE CORBETT TARGETED COIN TEST

Purpose: Manual dexterity is important for performing many daily functional activities.The CTCT measures aspects of dexterity that are not currently measured by most other assessments including palm-to-finger translation and proprioceptive target placement important to many occupations (examples: eating a handful of popcorn or picking up a pen and moving it into position for writing).The purpose of this study was to determine inter-rater reliability, intra-rater reliability, and test-retest reliability of the Corbett Targeted Coin Test (CTCT).

Methods: Adult participants were recruited and those meeting the inclusion criteria provided consent. The inclusion criteria consisted of participants who were over 18 years of age, non-institutionalized, community-dwelling, able to complete active fist closure, and able to perform finger-to-palm translation of 20 coins. Subjects (n=27) were tested by the same two trained researchers (one researcher for intra-rater reliability and two researchers for inter-rater reliability) with a five-minute break between tests, following CTCT standardized testing procedures. A second group of subjects (n=16) completed the test with one researcher and returned one week later for test-retest reliability to limit practice effects. Both the dominant (D) and nondominant (ND) hands were tested.

Results: Intraclass Correlation Coefficients (ICC) results demonstrated good intra-rater reliability (r= .81 and r=.82 D, and r=.78 ND), good inter-rater reliability (r= .99 and r=1.00 D, and r= .99 and r=1.00 ND), and moderate test-retest reliability (r= .54 D and r= .50 ND). When compared to other standardized dexterity assessments, the CTCT demonstrated comparable inter-rater reliability (r =0.98 to 0.995) intra-rater reliability (0.68 to 0.99) and test/retest reliability (r= 0.37 to 0.99).

Conclusion: Therapists can be confident in the reliability of using the CTCT when evaluating and monitoring patient dexterity with palm-to-finger translation and proprioceptive target placement. 

Authors:Jeanine Beasley | Lydia Stout | Spencer Jackson | Allison Range | Alayna Kagande | Carla Floyd-Slabaugh | Kirk Anderson | Sarah Corder

A MIXED METHODS ANALYSIS OF HEALTH LITERACY AMONG ADULTS WITH BRACHIAL PLEXUS BIRTH INJURY

Purpose: Brachial Plexus Birth Injury (BPBI) can cause permanent neuromusculoskeletal sequelae and functional impairments that persist into adulthood. Information to guide healthcare providers in delivering care for affected individuals in adulthood is limited. In this sequential mixed methods study we sought to understand the healthcare experience of BPBI-affected adults drawing upon the World Health Organization’s (WHO) broad definition of health literacy: a person’s ability to access health information and act to improve their health.

Methods: This analysis is part of a larger sequential mixed methods study focused on understanding health-related quality of life (HRQoL) and the health literacy of BPBI-affected adults. First, BPBI-affected adults were recruited from two online support groups to participate in a survey designed to obtain the breadth of their HRQoL and healthcare experiences. Next, a purposively diverse sample of 12 respondents participated in individual semi-structured interviews to explore HRQoL and health-care experiences in depth. Then the qualitative responses from the surveys and interviews were systematically pooled and linked to numeric codes in the International Classification of Functioning, Disability and Health (ICF) taxonomy to identify a subset of patient reported outcome measures (PROMs) that aligned with measuring the respondents reported HRQoL and health literacy experiences. Qualitative data pertaining to participants’ experiences with healthcare linked to 5/9 scales of the Health Literacy Questionnaire (HLQ). We returned to both online support groups to administer a survey of all PROMs, including the five HLQ scales: HLQ1: Feeling understood and supported by healthcare providers (HCPs); HLQ2: Having sufficient information to manage my health; HLQ3: Actively managing my health; HLQ6: Ability to actively engage with HCPs; HLQ7: Navigating the healthcare system. Each HLQ scale consists of 4-6 questions with a 4-5 level Likert response scale with higher numbers representing more positive ratings. Mean responses on each subscale were compared to 95% confidence intervals for HLQ published scores for 5 other adult chronic health conditions: heart disease, kidney disease, kidney transplant, prostate cancer, psoriasis. The relevant pooled qualitative data from the first survey and the interviews were qualitatively analyzed to determine themes of the health-literacy experience.

Results: Results of the first survey were obtained from 183 respondents, 21 to 87 years of age, including 152 females. In the interview portion of the study, there were 12 interview participants, 26 to 81 years of age, 7 female. In our second survey, we received complete HLQ forms from 147 participants, 22 to 88 years of age, including 119 females. Means (±SDs) for each HLQ scale were as follows: HLQ1: 2.67±0.88 (4-level Likert scale); HLQ2: 2.83±0.73 (4-level scale); HLQ3: 2.75±0.64 (4-level scale); HLQ6: 3.47±0.88 (5-level scale); HLQ7: 3.25±1.07 (5-level scale). When these 5 HLQ scale mean scores were compared to the 95% confidence intervals for published means of corresponding HLQ scale scores from the 5 other chronic conditions (Figure 1), BPBI-affected adults’ scores were lower scores in 17 of these 25 comparisons (i.e., 5 scales across all 5 comparison conditions), higher in 6/25, and no difference in 2/25. BPBI-affected adults scored lower than those with all other conditions, except for psoriasis, on HLQ3, HLQ6 and HLQ7. Findings from the qualitative portion of the analysis revealed a range of health literacy experiences for BPBI-affected adults, including: 1) A spectrum of experiences, skewed towards feelings of being dismissed and distrust, although when affected adults felt their HCPs sought to understand them, the quality of care was perceived more positively. 2) Varied knowledge of BPBI among affected adults and an expressed desire to know more about the progression of BPBI and expected HRQoL outcomes. 3) A range in the amount and types of healthcare services utilized throughout the lifespan among affected adults. 4) Diverse communication experiences, from BPBI-affected persons receiving conflicting or inadequate information to experiencing communication that facilitated positive healthcare experiences and access to care. 5) Varied levels of difficulty with accessing healthcare providers with knowledge of BPBI in adults and resources pertaining to BPBI affected adults.

Conclusion: The health-literacy of BPBI-affected adults falls below that measured in populations of adults with other chronic medical conditions. Opportunities exist for improving the health literacy experience, including 1) access care for the BPBI affected extremity, 2) communication and supportive relationships with HCPs, 3) accessible information about BPBI prognosis, treatment, and long-term outcomes, and 4) availability of healthcare providers knowledgeable of BPBI care for affected adults. 

Authors: Jenny Dorich | Jordyn Whiting | Richard Ittenbach | Vicki Plano Clark | Jennifer Marks | Roger Cornwall

INTER-RATER RELIABILITY OF VIDEO BASED RANGE OF MOTION ASSESSMENTS IN POST-RECONSTRUCTION BRACHIAL PLEXUS PATIENTS

Purpose: Brachial plexus injuries (BPI) are among the most devastating neurological pathologies faced by patients today. Post-reconstruction assessments of patient progression are reliant on in-person goniometric measurements, which can be time consuming and require both the patient and physician to be present. Furthermore, due to the complexity of these injuries, many patients are faced with long commutes to be evaluated by BPI experts. In an attempt to remove barriers to patient care, the purpose of this study was to evaluate the reliability of video-based upper extremity range of motion (ROM) assessments. Furthermore, the purpose of this study was to determine the feasibility of remote physician assessments of post-reconstruction BPI patients to improve patient access to care.

Methods: Eight post-reconstruction BPI patients were filmed in-office following their clinical visit using a 3-camera system of two laterally fixed cameras and one fixed front-facing camera. Patients performed 3 range of motion exercises: elbow flexion, forward shoulder flexion, and shoulder abduction. Patient footage was then evaluated by 8 brachial plexus reconstruction experts. Patient range of motion was first assessed visually, and then digitally using the ImageJ angle measurement tool. Data analysis was conducted using Shrout-Fleiss Intraclass 3 fixed set correlations to determine inter-rater reliability

.Results: Inter-rater reliability for elbow flexion was 80.1% for visual assessments and 96.0% for digital assessments. Forward shoulder flexion inter-rater reliability was 95.4% for visual assessments and 98.5% for digital assessments. Finally, visual assessments of shoulder abduction had an inter-rater reliability of 91.2% for visual assessments and 96.2% for digital assessments (Fig. 1).

Conclusion: Visual and digital evaluations of patient elbow flexion, shoulder flexion, and shoulder abduction were both highly reliable among brachial plexus experts. Shoulder ROM assessments on average had greater inter-rater reliability than elbow ROM assessments. Visual evaluations of patient ROM were less reliable than digital assessments with ImageJ for all 3 exercises. These results support the utilization of 2D video-based assessments of post-reconstruction BPI patients’ ROM, potentially reducing the need for in-office visits to monitor patient progression. These results also create the opportunity for patient evaluations to occur more frequently at the convenience of both patient and provider. 

Authors: Stephen DeMartini | Eshan Sane | David Brogan | Christopher Dy

WHAT DO PATIENTS WITH TRAUMATIC BRACHIAL PLEXUS INJURIES NEED FOR SOCIAL AND EMOTIONAL SUPPORT? A QUALITATIVE ANALYSIS.

Purpose: Patients with brachial plexus injuries face clinical outcomes that are complex and life altering. This project aims to qualify potential areas of improvement in post-surgical care of brachial plexus injury patients, specifically from a social and emotional perspective. We also investigate patient perspectives and the potential utility of a new patient-facing role called a Navigator who can facilitate these improvements.

Methods: We conducted semi-structured interviews with 25 brachial plexus patients after reconstruction. The interview guide was primarily focused on interactions with members of the care team throughout their recovery. Both inductive and deductive thematic analysis were used to identify recurring topics and ideas across patient experiences.

Results: Our study revealed four primary themes. 1) Patient perception of family and household responsibilities influences the desire for additional support from the care team. 2) The navigator role would include a variety of tasks that address recurring challenges reported by BPI patients, including family education and coordination of appointments, transportation, and insurance. Patients also expressed that it would be beneficial for the navigator to have experience with a BPI themselves. 3) Patient and family education should emphasize the understanding of neuropathic pain, timeline of healing, and expected new roles. 4) A potential solution to patient isolation may involve shared experiences with current BPI patients.

Conclusion: Patients with brachial plexus injuries have unique needs for support from both their care team and family. There are variations in desired level of support, as some patients expressed adequate levels of support from their care team and family while some desired more. Accurately identifying patients who would benefit from additional support would be an effective use of healthcare resources rather than a standardized approach where all patients receive the same level of additional supportive services. These services include appointment coordination, navigating insurance, disability programs, family education, and accessing resources such as mental health services and physical or occupational therapy. For patients with family support, formal education on understanding neuropathic pain, realistic expectations, timelines for recovery, and lifestyle modifications may facilitate the learning process after a BPI, enabling patients to feel more understood by their family and friends. Building a strong and reliable community of BPI patients could improve social well-being in many patients, as some patients expressed a desire to guide other patients through their journey (and that they wish someone had done this for them). 

Authors: Amanda Faust | Eshan Sane | Macy Stonner | David Brogan | Christopher Dy

PEDIATRIC UPPER LIMB SURGICAL EXPERIENCES WITH HEMIPLEGIA: A QUALITATIVE STUDY OF CHILD AND PARENT PERSPECTIVES

Purpose: Various surgical procedures have been reported as beneficial interventions for addressing the impaired manual function caused by spasticity and muscle imbalances in children with upper extremity hemiplegia; however, the effect of surgery on this patient population’s quality of life is not well understood. Furthermore, the child and family’s surgical decision making experience has not been explored. Yet, prior studies have identified the need to explore shared decision making among children with neurodevelopmental disorders. The study aim is to better understand patients’ and parents’ experiences with surgical decision making, the recovery process, and their perceptions of surgical outcomes qualitatively to inform patient-centered care practices for children with upper extremity hemiplegia.

Methods: Patients who underwent reconstructive surgery on their hemiplegic upper extremity between December 2019 and March 2022 and their parents were recruited to participate in one-on-one semi-structured interviews. Data collection and analysis were performed iteratively with separate analysis of patient and parent data. Two researchers independently performed qualitative coding. Then they met with the senior author to bring consensus to all coded data. All three researchers performed independent theming of the separate patient and parent data and then met to compare findings and perform thematic analysis of merged patient and parent data. The research team also derived models reflecting the children’s and parents’ experiences with upper extremity surgery.

Results: Seven patients (5 female, mean age 14.3+/-3.1 years) and parent dyads (n = 14) participated in interviews. All patients were classified as MACS (Manual Ability Classification System) level III or higher. The patients’ etiology was related to cerebral palsy (n = 3) and brain surgery (n = 4). Patients underwent a variety of surgical procedures, including one isolated wrist extension tendon transfer (WETT), two with WETT and wrist flexor tendon lengthening, two with WETT and hyperselective neurectomy, and two with wrist arthrodesis and flexor tendon lengthening. One overarching theme arose in the merged data: The experience of upper extremity surgical decision-making and recovery is a journey. Additionally, we found four subthemes: 1. Knowledge and desired outcomes are foundational to the patient and family’s surgical decision making, 2. Pediatric patients value participating in surgical decision making, 3. Recovery is a process resulting in positive outcomes for the child and family, and 4. Emotional complexity is present and relationships/communication with the medical team are valued throughout the journey. Models of the parents’ (Figures 1a) and child’s (Figures 1b) experiences of upper extremity surgery display the relationship of the subthemes within the overarching theme and illustrate differences and similarities between the parents and children’s experiences. While parents and children have similar experiences, parents seek knowledge for a longer period and in more ways than the children leading up to surgical decision making. Also, parents consider a potential need for further surgical interventions that may be beneficial for their child whereas children do not. Additionally, emotional complexity is a larger aspect of the journey for the children than for their parents.

Conclusion: The journey of deciding to undergo upper extremity surgery and recovery is complex, emotional, and lengthy for pediatric patients and their parents, yet outcomes are perceived favorably. Study findings reveal aspects of the experience which hand specialists may consider for facilitating patient-centered care practices for shared surgical decision making and maximizing the child and family’s quality of life during the recovery experience. 

Authors: Angelica Rodriguez | Kevin Little | Jenny Dorich

OUTCOMES OF GLENOHUMERAL DYSPLASIA FOLLOWING BRACHIAL PLEXUS BIRTH INJURY USING THE SUP-ER ORTHOSIS

Purpose: This study investigates the efficacy of the Supination-External Rotation (Sup-ER) orthosis in addressing the progression of glenohumeral dysplasia (GHD) in patients with brachial plexus birth injuries (BPBIs). Although previous research studies have examined the success of the Sup-ER orthosis based on Active Movement Scale (AMS) scores, it was speculated whether the Sup-ER orthosis would have the same success as published studies if the outcome variables were increased to also include serial, objective ultrasound measurements.

Methods: The Sup-ER orthosis was fabricated for 20 infants diagnosed with GHD subsequent to BPBIs. AMS scores of shoulder abduction (SA), forward flexion (FF), Sup and ER, as well as alpha angle measurements from ultrasound findings were collected prior to and at each follow-up visit following the fabrication of the Sup-ER orthosis. The success of the Sup-ER orthosis in correcting GHD was confirmed through ultrasound findings and improving AMS scores, leading to the discharge of patients from care. Failure to rectify GHD necessitated a transition to operative management for the patient. Analysis of the outcome measurements were conducted using a two-tailed paired sample t-test. The level of significance was set at p < 0.05.

Results: Fourteen out of the twenty patients (70%) fabricated with the Sup-ER orthosis successfully demonstrated resolution of GHD on ultrasound and improvement of AMS scores. The average time of fabrication of the Sup-ER orthosis to the time of discharge from the orthosis was 17.4 (SD 8.3) weeks. In these patients, average SA was 6.6 (SD 0.8) (p < 0.05), SF was 6.6 (SD 0.8) (p < 0.05), ER was 6.7 (SD 0.6) (p < 0.05), and Sup was 6.8 (SD 0.8) (p = 0.078) following discontinuation of the orthosis. Additionally, in these patients the average alpha angle following treatment with the Sup-ER orthosis was reduced to 14.43 (SD 4.86) (p < 0.05). Of the remaining patients (30%), the implementation of the Sup-ER orthosis failed to resolve GHD as evidenced by either ultrasound findings or AMS scores. These patients had to undergo further microsurgical intervention.

Conclusion: In contrast to previous studies demonstrating the success of the Sup-ER orthosis, the results in this study indicate that there is a failure of the intervention warranting microsurgical intervention. Nevertheless, the Sup-ER orthosis has been shown effective in resolving glenohumeral dysplasia, as evidenced by improving AMS scores and serial, objective ultrasound measurements, and should be advocated for in the routine care for brachial plexus birth injury patients. 

Authors: Ann Marie Feretti | Nathan Khabyeh-Hasbani | Victoria Ferrante | Manisha Joshi | Megan Horowitz | Steven Koehler

ENHANCING HAND FUNCTION RECOVERY AFTER EXTENDED RADIAL FOREARM FREE FLAP: A CASE SERIES AND REVIEW OF AN INNOVATIVE THERAPY PROTOCOL

Purpose: The Extended Radial Forearm Free Flap (E-RFFF) presents distinct rehabilitation challenges compared to traditional flaps due to its larger size and the increased risk of donor site morbidity. Traditional rehabilitation often relies on prolonged immobilization to minimize graft loss, potentially leading to complications such as joint stiffness and swelling. Our novel hand therapy protocol addresses these issues by emphasizing early active motion, thereby safeguarding the donor site while also aiming to reduce complications. The study aims to report and evaluate a novel hand therapy protocol for enhancing recovery in E-RFFF patients by prioritizing early active motion and minimizing complications, aiming to improve overall functional outcomes compared to traditional rehabilitation methods.

Methods: We conducted a retrospective study at Vanderbilt University Medical Center on patients who underwent E-RFFF from 2022 to 2024. Our sample included eight patients for whom we tracked demographic characteristics, range of motion, strength, and sensation. Developed in collaboration with occupational therapy experts, our protocol promotes early active motion in stages tailored to each phase of postoperative recovery. The protocol starts with digit and thumb active range of motion (AROM), advancing to complex movements like the "Dart Thrower's Motion" for wrist articulation to enhance mid-carpal articulation while minimizing donor site tension. Therapy protocols adapted to the graft cover wound care, functional use, and exercises for flexibility, strength, and proprioception, aiming to preserve graft integrity and support hand and wrist functional recovery.

Results: The study included eight patients, all of whom underwent E-RFFF for phalloplasty. Initial post-operative assessments (within 7 days) showed an average pain level of 3.37. Specific challenges included limited thumb opposition in 12.5% of patients, reduced range of motion in composite digital flexion and extension (25% of patients for each), as well as decreased wrist and forearm mobility and grip strength (37.5% scored ≤3 on the MMT scale). However, by 30 days post-operation, notable improvements were observed. Pain levels decreased to an average of 2.28, with all patients achieving recovery within normal functional limits for thumb opposition, digital flexion and extension, wrist and forearm mobility, grip strength, and sensation to light touch. Importantly, we observed effective preservation of sensory function, and despite the early mobilization protocol, there was no increase in edema, further highlighting the protocol's safety and efficacy. Additionally, no increase in edema was observed between the first and second follow-ups despite an early mobilization protocol. All skin grafts and acellular dermal matrix (ADM) were successfully integrated.

Conclusion: The innovative hand therapy protocol suggests a promising approach to managing the unique recovery needs of E-RFFF patients. Facilitating early ROM not only preserves graft integrity but also addresses the risk of edema, enhancing overall functional outcomes. This protocol may serve as a benchmark for postoperative care in similar surgical contexts, advocating for integrating early mobilization into standard practice. 

Authors: Patrick Assi | Justin Stehr | Ricardo Torres-Guzman | Virginia Bailey | Andrew James

A SURVEY STUDY OF PRACTICE PATTERNS WITH PEDIATRIC HAND THERAPY PATIENTS

Purpose: Upper extremity impairment is common in children. Various acute and chronic upper extremity conditions lead to functional limitations warranting referral to hand therapy. Hand therapists’ experiences treating pediatric patients remain unexplored. Thus, our study aims to gain preliminary insights into hand therapists’ practice patterns treating pediatric patients.

Methods: A survey was designed to assess hand therapists’ practice patterns treating pediatric patients. The following Likert scale was used for all questions: routinely (76% - 100%), often (51% - 75%), occasionally (26% - 50%), rarely (1% - 25%), and never (0%). The survey was distributed using an electronic REDCap link in an email invitation to all American Society of Hand Therapists members. Responses were analyzed with descriptive statistics. All data analysis was performed by one researcher who received routine oversight from a research mentor.

Results: The survey received 157 responses (5% response rate) with 135 records meeting inclusion criteria. Respondents were 26 to over 65 years old; 94% female (n = 125), 6% male (n = 8); 95% Occupational Therapists (n = 128) and 5% Physical Therapists (n = 7). All respondents (n = 135) indicated they primarily work in an outpatient facility, with 10% (n = 13) practicing in a pediatric specific facility. Overall, years of practice and years of experience treating pediatric patients varied (Figure 1) with more participants having fewer years of pediatric experience than overall years of experience practicing hand therapy. Fourteen percent of respondents (n = 19) reported treating pediatric patients (0 months - 17 years old) routinely/often, 77% (n = 104) reported treating pediatric patients occasionally/rarely, and 9% (n = 12) reported never treating pediatric patients. Among all respondents, 74% (n = 91) indicated the most comfort treating school-aged patients (6 - 17 years old), and 78% (n = 95) indicated the least comfort treating infants and toddlers (birth - 2 years old). Respondents reported routinely/often treating the following types of diagnoses: traumatic injuries, 82% (n = 111); overuse injuries, 81% (n = 110); systemic conditions, 60% (n = 81); neurological/neuromuscular conditions,15% (n = 20); and congenital anomalies, 9% (n = 12) (Figure 2a). Respondents who indicated they do treat pediatric patients (91%, n = 123), referred to hereafter as pediatric-practicing respondents, received additional questions about their pediatric practice. Pediatric-practicing respondents indicated routinely/often having comfort treating pediatric patients with the following types of diagnoses: traumatic injuries, 71% (n = 87); overuse injuries, 61% (n = 75); systemic conditions, 33% (n = 40); congenital anomalies, 25% (n = 31); neurological/neuromuscular conditions, 20% (n = 25) (Figure 2b). Regarding patient referrals, 16% (n = 20) of pediatric-practicing respondents routinely/often receive referrals to treat pediatric patients. Furthermore, among pediatric-practicing respondents, 54% (n = 67) routinely/often communicate with the referring provider and 63% (n = 77) have access to pediatric patients’ medical records. Regarding clinical environment and resources, 34% (n = 42) of pediatric-practicing respondents routinely/often have a conducive environment for treating pediatric patients and 36% (n = 44) have access to adequate equipment for pediatric care. Regarding resources for providing pediatric hand therapy intervention, pediatric-practicing respondents are routinely/often able to: use tools for assessing body functions, 68% (n = 82); identify patient/family treatment priorities, 68% (n = 81); schedule appointments for the recommended frequency, 64% (n = 77); deliver child-focused intervention, 45% (n = 54); use patient/family education materials that align with pediatric patients, 26% (n = 31); and access standardized assessments for pediatric patients, 22% (n = 26). Finally, pediatric-practicing respondents routinely/often have access to the following types of resources to guide care of pediatric patients: research articles and evidence-based practice tools, 30% (n = 36); continuing education, 28%, (n = 34); reference books, 28% (n = 33); and mentorship, 18% (n = 21).

Conclusion: Among this sample of hand therapists, pediatric referrals are low. However, most therapists provide care to pediatric patients, reporting the greatest comfort with treating school-aged children with traumatic and overuse injuries. The current study reveals several opportunities for enhancing pediatric hand therapy care in the following areas: connections with referral sources, clinical environments, intervention resources, and professional development tools. Additionally, study findings highlight further research exploring therapists’ experiences treating pediatric patients in greater depth is necessary to inform practice enhancements. 

Authors: McKenzie Osborne | Jenny Dorich

A QUALITATIVE ANALYSIS OF PATIENT/FAMILY TREATMENT GOALS FOR CHILDREN WITH BRACHIAL PLEXUS BIRTH INJURY

Purpose: Brachial Plexus Birth Injury (BPBI) is characterized by upper extremity paralysis resulting from birth trauma. Often, recovery is incomplete resulting in chronic functional impairments impacting many aspects of quality of life across the lifespan. Ideally, care is initiated in the neonatal period, requiring long-term collaborative coordination of therapeutic and surgical interventions. Recovery patterns are variable and current interventions are not curative. Therefore, understanding of patient/family treatment goals is needed to guide BPBI care; however, evidence of patient/family treatment priorities is currently unavailable. This qualitative analysis was undertaken to achieve two aims. First, to elucidate the breadth of patient/family treatment goals at the onset of care and determine how these goals vary by patient age, sex, and injury severity. Second, to evaluate patient/family goals set sequentially during a course of care to explore how such goals may evolve throughout long-term BPBI care.

Methods: At a tertiary BPBI clinic, patients/families are asked in writing what treatment goals they have at each visit, and their written goals are recorded verbatim. The present study retrospectively retrieved from the medical record such goals set at the first clinic visit for 120 patients (63 females/57 males, 88 upper/32 global injuries) seen between 2006 and 2022, distributed evenly across 3 age groups (0-2yrs, 3-9yrs, 10-17yrs) according to age at first visit. For the first aim, two researchers performed independent qualitative coding of all treatment goals set at the patients’ start of care, meeting iteratively with the senior author to bring consensus to all coding. All three researchers collaboratively reflected on the coded data to derive themes respective to overall goal patterns. Coded goal data were then compared across age groups, sex, and injury severity (upper vs. global). For the second aim, a subset of patients (n = 106) were identified that had sequential goals set at multiple visits during the course of their care. The same researchers qualitatively analyzed sequential goals for each patient to determine if and how they changed during the course of care. These changes were then pooled for all 106 patients, and patterns of goal changes were noted in order to derive themes.

Results: In our first aim analyzing the goals at the onset of treatment, two themes arose in the data, each with respective subthemes. Theme 1: Patients/families want improvement predominantly focused on, but not limited to, participation and physiological function of the arm. Theme 1 has two subthemes: a) Regarding participation, sports/play dominate over schoolwork and b) Among physiologic functions of the arm, range of mobility predominates over strength, with no specific joint or motion focus, and rare references to sensation. Theme 2: Age drives differences more than sex or injury severity. Theme 2 has four subthemes: a) Goal focus is predominately on arm function and mobility in the early ages shifting to a focus more on activity participation with age, b) Heterogeneity and specificity of goals increase with age, aligning with children becoming individualized with maturation, c) Appearance and pain concerns arise in the middle and upper age groups respectively, and d) Goal differences based on sex or injury severity are few. In our second aim analyzing sequential goals, one theme with two subthemes arose from the data. Theme: During a course of care, goals often vary over time and among patients. Subthemes include: a) Variability exists in the number of goals, goal content, goal specificity and range of goals, b) Variability exists among patients regarding if, when, and how goals change during a course of care.

Conclusion: Patient/family treatment goals for children with BPBI at the onset of care are broad in scope, focusing on more than just the involved arm, with goals varying more by age than by sex or injury severity. Additionally, patient goals vary over time and among patients throughout a course of care. The finding that patient treatment goals are broad, diverse, and fluid over time, underscores the need for individualized goal-based treatment planning that adapts as patients age and as care progresses. 

Authors: Jenny Dorich | Allison Allgier | Tamara Al-Muhtaseb | Vicki Plano Clark | Roger Cornwall