Scientific Posters

Scientific posters summarize hand therapy-related research in an electronic format. The author provides an overview of the study background, purpose, results and conclusions in the e-poster format. In addition, a subset of e-posters present critically appraised papers and critically appraised topics. In these e-posters, the authors highlight their structured approach to addressing clinical questions and assessing research evidence. All scientific posters can be viewed on site on the kiosks in the Exhibit Hall or through the ASHT on-demand platform.

CONCEPTUALIZING COLD INTOLERANCE: A CONCEPT ANALYSIS

Purpose: Cold intolerance is a common sequela after hand injury. The experience of cold intolerance may include colour changes, pain, sensory changes, stiffness, and difficulty in rewarming after cold exposure. Despite being a common experience, there is variability in the presentation and no explicit diagnostic criteria. In practice, it may be difficult to distinguish from vasospastic disorders and cold allodynia as a feature of persistent pain. We hypothesize mapping the construct of cold intolerance in the context of hand surgery and rehabilitation can inform assessment and treatment recommendations and assist in identifying research gaps. Our guiding questions are a) how is the concept of cold intolerance described and operationalized in the hand therapy and hand surgery literature? b) What are the characteristics, features and gaps of the literature describing cold intolerance after hand injury or surgery?

Methods: We are conducting a concept analysis of cold intolerance after hand injury. In conjunction with a health librarian, we developed a search strategy based on the keywords of cold intolerance, cold sensitivity, and cold hypersensitivity and limited it to the anatomic region of the fingers and hand. We ran this search in Medline/PubMed, Embase, and CINAHL. We included papers using any study design, with an English abstract, from any time period, with a focus on human subjects with an upper extremity injury experiencing post-traumatic symptoms in their hand or digits. We excluded papers where there is a single use of one of the key terms without any description. Abstracts and full text were reviewed by 2 independent reviewers for inclusion and reported using a PRISMA diagram. Eighty-seven articles were selected to undergo data extraction using a standardized form informed by Rodger’s evolutionary concept analysis process. We are extracting concept [cold intolerance] attributes, consequences, mechanisms, antecedents, temporal factors, surrogate terms, measures, and interventions; as well as study characteristics and author disciplines. We will synthesize the data using qualitative content description to formulate a clear conceptualization of cold intolerance, contrasting the term in surgical and rehabilitation contexts.

Results: We will describe the current state of the literature and how it delineates the concept of cold intolerance, identifying gaps, discrepancies and uncertainties. During ongoing data extraction, there are common themes currently emerging. It is apparent that the conceptualization of cold intolerance has largely been influenced by the field of hand surgery. A large proportion of literature contributing to the advancement of the concept of cold intolerance is based in colder geographical origins, and study populations with greater male to female ratios. Additionally, several early definitions and attributes of the concept appear to be widely accepted and continue to be referenced in current literature. Further synthesis aims to develop additional thematic strands describing cold intolerance, including accepted/understood physiological mechanisms, temporal factors, measurement tools, consequences, and treatment recommendations. We will discuss the implications of these findings for assessment, education and intervention in hand therapy and hand surgery research and practice.

Conclusion: Clarifying the concept of cold intolerance can assist in advancing research and care of persons after hand injury. Without a clear understanding of this phenomenon, the burden of this sequelae of traumatic injury can not be ascertained to justify resources to address research and service gaps, limiting innovation and supports.

Authors: Avery Jones | Leah Bissonette | Tara Packham

ESTABLISHING POPULATION NORMS FOR THE MACHAND PERFORMANCE ASSESSMENT 2.0: A CLINICAL MEASUREMENT STUDY

Purpose: The MacHAND Performance Assessment (MPA) is an outcome measure evaluating an individual’s ability to complete fine and gross motor upper limb tasks. These tasks focus on different grasp and pinching patterns with a combination of timed and untimed activities. While this outcome measure has been in use for many years, there is a lack of evidence on its validity for specific clinical populations and normative data has not been established. Recent work at McGill University updated the MPA (now MPA 2.0) and conduct psychometric testing of a short, French form of the MPA 2.0 (MPA-SF) for adults who have sustained hand burns. To complement the work being done at McGill, this study aimed to obtain normative data in healthy adults completing the MPA 2.0. The creators of the MPA assumed that a score of 100 on the MPA indicated that a participant had no difficulty with any of the 20 tasks, thus has “normal” hand function. Therefore, this research will test this assumption of whether a score of 100 is typical in a healthy adult population. Our research questions were: what is the mean score and standard deviation of healthy participants on the MPA 2.0? What is the relationship between MPA 2.0 scores and PROMIS Upper Limb Item Bank tranformed scores or grip strength? How do these differ for MPA-SF scores?

Methods: We recruited healthy adult volunteers, defined as persons who do not report any recent hand or arm injuries, and/or who do not report persistent pain or disability in their upper limbs due to past injuries or chronic conditions, to participate in a cross-sectional study. After giving informed consent, participants were evaluated using the MPA 2.0, following standardized instructions for administration of each task. Because data collection sometimes had time constraints, some participants only performed the assessment with their right hand. Items were administered in a randomized order, to permit comparison with the short form by controlling for any order effect. We also asked participants to complete the full PROMIS upper limb item bank (20 items), transforming the score to a percentage metric and measured grip strength following standardized recommendations for clinical assessment. Descriptive statistics, and Pearson’s correlations were calculated to address our research questions. We hypothesized that the MPA 2.0 would demonstrate strong positive correlation (r>0.8) to PROMIS transformed scores and moderate positive correlations (0.6 -0.8) to grip strength.

Results: To date, we have tested 101 unique participants and 134 hands. Participants are largely female (73%) with an average age of 25 years (range 16-68). Scores on the PROMIS item bank ranged from 88.75 to 100%, with 73% of persons scoring themselves at 100%. A past history of injury was not associated with a score of less than 100 (p=0.67 for Fisher’s exact test). Scores on the MPA 2.0 ranged from 93 to 100 with a mean score of 97.6: only 4.5% of participants achieved a perfect score of 100/100. Items with the lowest mean scores were fastening a nut onto a bolt, the 6-hole peg test (both of which were timed), and the buttoning task (see Figure 1). Observations related to this were the interference of long artificial fingernails, and an apparent lack of familiarity with the nut & bolt assembly. All participants received perfect scores on the tasks of hammering [power grip], opening a jar [spherical grasp], inserting and removing a plug [lateral pinch], lifting a full can of soda to simulate drinking [cylindrical grasp], and lifting a weighted plate [lumbrical grasp]. PROMIS scores demonstrated low positive correlation to MPA 2.0 total scores (r=0.19). Grip strength demonstrated a slight negative correlation to MPA 2.0 total scores for the same hand (r=-0.20).

Conclusion: The results from this study will provide health professionals with preliminary estimates for comparing MPA 2.0 results between healthy and patient populations. Moving forward, targeted recruitment of adults between the ages of 30 and 80 and equal numbers of males and females is necessary to provide robust estimates for these age groups. The failure to see the hypothesized relationships in this preliminary work will also inform future studies of validity.

MEDIAN NERVE PRESSURE WITH DIFFERENT GLOVES IN CYCLING: A COMPARATIVE STUDY

Purpose: The purpose of this study is to evaluate the effectiveness of various cycling glove designs in reducing median nerve pressure during cycling, as compared to a control group without gloves. The study aims to identify the glove features that contribute the most to pressure reduction.

Methods: This pilot study involved thirteen participants that provided consent. Participants were given three conditions (bare hand, off the shelf biking glove, and the ShockTekTM glove) for testing on a stationary bike in a random order. The novel pliance® pressure sensor measured the pressure over palm and median nerve area when attached securely to the right side of the handlebar. The center of pressure calculated by the pliance-x software served as a reference for identifying the central palm region. This alignment was further corroborated through the manual recording of the center of the palm during testing. The average pressure over the median nerve region was calculated over ten pedal strokes at a speed of approximately 60 rpms.

Results: Analysis revealed that for bare-handed conditions, the peak pressure was typically observed where the median nerve traverses through the palm of the hand. The average pressure on the median nerve area across all subjects was 51.96 kPa (range: 30.02 – 70.12 kPa). While typical gloves showed no significant impact on the pressure over the median nerve, median nerve relief sport gloves (ShockTekTM) demonstrated a notable reduction in pressure, with an average of 20.23 kPa (range: 7.26 – 36.83 kPa), corresponding to a 61% decrease in median nerve pressure during cycling.

Conclusion: While cycling offers numerous health benefits, it also presents potential risk factors for the development or exacerbation of Carpal Tunnel Syndrome. This condition is usually associated with the ulnar nerve, but symptoms related to the median nerve have also been reported. Cyclists frequently mitigate these risks with specialized cycling gloves to provide protection and comfort by minimizing friction, vibrations, and pressure on the hands during rides. The findings with this study underscore the potential efficacy of median nerve relief sport gloves (ShockTekTM) in alleviating pressure on the median nerve during cycling activities. This reduction should be considered when therapists suggest gloves for individuals reporting CTS symptoms during biking and possibly other activities that place pressure on the median nerve at the carpal tunnel.

Authors: Jeanine Beasley | Genevieve Wisby | Wendy Reffeor | Yunju Lee

GONIOMETRIC BIOFEEDBACK DEVICE DEVELOPMENT

Purpose: Biofeedback during hand rehabilitation is effective, engaging, and may lead to improved outcomes. We believe that real-time range of motion feedback has the potential to motivate patients and increase exercise compliance, thus maximizing the benefit of rehabilitation and improving functional outcomes. To this end, our team developed a wearable, wireless, smartphone app-linked goniometer that continuously tracks proximal interphalangeal joint (PIPJ) angle (Figure 1). Our primary purpose was to evaluate the accuracy of the wearable goniometer device when measuring PIPJ motion compared to gold standard fluoroscopy and clinical standard handheld goniometry. Our secondary purpose was to assess feasibility of device use during hand therapy exercises.

Methods: To assess the accuracy of the device compared to fluoroscopic measurements, subjects were fitted with the wearable device on their right index finger PIPJ. The PIPJ was then actively flexed and extended through its complete range of motion under live fluoroscopy (lateral projection). Paired angular measurements were derived from both the wearable device and fluoroscopic images. This process was then repeated for the left index finger PIPJ. To assess the accuracy of the device compared to handheld goniometry, subjects donned the device and performed four to five positions of progressive flexion while wearing the device. Paired angular measurements were derived from the wearable device and a handheld goniometer operated by a certified hand therapist (CHT). The bilateral index, middle, and small fingers were evaluated in each subject. To assess the feasibility of device use during therapy exercises, a CHT guided subjects through a simulated home exercise program (HEP) consisting of composite fist, PIP blocking, blocked extension while the device measured PIPJ angle in real time. Bland-Altman plots were used to visualize correspondence between the device measurement and the fluoroscopic or handheld goniometer measurements. Means were compared using a paired t-test.

Results: Six subjects (12 fingers, 259 paired data points) were included in the fluoroscopy portion of the study. Mean difference between device and fluoroscopic measurement was 0.9o (SD = 2.2o, 95% CI = 0.7o – 1.2o), with errors ranging from -4.7o to +5.6o (Figure 2A). Nine subjects (27 fingers, 212 paired data-points) were included in the handheld goniometer portion of the study. Mean difference between device and handheld goniometer measurement was 0.6o (SD = 5.2o, 95% CI = -0.1o – 1.3o), with errors ranging from -13.1o to 12.9o (Figure 2B). The device successfully tracked PIPJ angle in real time during a simulated HEP for all fingers evaluated.

Conclusion: The wearable goniometer device demonstrates acceptable accuracy as the mean of measurements generated by the wearable goniometer device was fewer than 1o greater than the mean derived from fluoroscopy and handheld goniometry. All measurements generated by the device were within 6o of fluoroscopy-derived gold-standard measurements indicating that the device is acceptably precise. The wearable goniometer device successfully tracks PIPJ angle during hand therapy exercises and is a feasible method of providing real-time biofeedback. This wearable goniometer device may be used to maximize the overall benefit of rehabilitation including increasing patient motivation, improving compliance with HEP, and setting and monitoring motion goals.

THE SHORT-TERM BENEFITS OF FORMAL HAND THERAPY IN PATIENTS STATUS-POST RADIAL FOREARM FREE FLAP: A RETROSPECTIVE CASE SERIES

Purpose: The purpose of this case series is to determine the short-term outcomes in patients status-post a radial forearm free flap (RFFF) procedure who have undergone a formal hand therapy program.

Methods: A retrospective analysis of eight patients was conducted at a hospital-based outpatient clinic. All patients were status-post RFFF for gender affirming phalloplasty procedures. With this approach, a free flap is taken from the forearm, including nerves and vascular structures, to create a neophallus. A non-meshed split thickness graft is then taken from the thigh to cover the forearm donor site. Patients began formal hand therapy with a certified hand therapist between 2-3 weeks post-op. The QuickDASH was used as the patient-reported outcome measure. The QuickDASH creates a symptom score of 0-100%. A higher score indicates a greater level of symptom severity, whereas lower scores indicate a lower level of symptoms. Objective measures taken included wrist and forearm active range of motion (AROM) with a goniometer, edema of the hand via tape measure using the figure-8 method, and grip strength with a Jamar dynamometer. Measurements were taken at initial evaluation and discharge. All patients received the same standard of care including wound care, scar management, edema management, range of motion exercises, and strengthening.

Results: On average, patients received 16 hand therapy visits over a course of 13 weeks. At initial evaluation, an average QuickDASH symptom score of 68.18% was reported. Patients had on average a 48° extension and 38° flexion discrepancy compared to the non-operative wrist. They had on average a 46° of supination and 25° of pronation discrepancy compared to non-operative forearm. Primary strength measurements were delayed until approximately 6 weeks post-op secondary to surgical precautions. They had on average 58.77% grip strength compared to the non-operative limb. On average, patients presented with an extra 3.9 cm of edema in the surgical hand compared to the non-operative side. At discharge, only 5 of the 8 patients completed the QuickDASH. The average reported QuickDASH symptom score was 9.55%. Patients had on average a 11° extension and 6° flexion discrepancy compared to the non-operative wrist. They had on average a +1° of supination and equal pronation compared to non-operative forearm. They had on average 85.87% of their grip strength of the non-operative limb. Patients continued to maintain on average an extra 2.2 cm of edema in the operative hand compared to the non-operative side.

Conclusion: After approximately 3 months post-op and formal hand therapy, patients status-post a RFFF can expect near normal AROM in the operative wrist and forearm. At time of discharge, patients had on average 85.87% of their grip strength when compared to the non-operative limb. As most surgeries are performed on the non-dominant hand, this is near normal when using the 10% rule for grip strength norms. After completing their course of hand therapy, patients report minimal functional deficits in the upper extremity via the QuickDASH. One lingering presentation appears to be dorsal hand edema as patients continue to have on average an extra 2.2 cm of edema when compared to the non-operative hand. Further studies are necessary to determine the duration of post-operative edema. In general, further long-term studies are needed to determine the overall functional outcomes of the upper extremity after this procedure.

Author: Jamie Nguyen

IMPACT OF A MUSCULOSKELETAL HEALTH FOR MUSICIANS (MHM) PROGRAM FOR PROFESSIONAL AND MUSICIAN STUDENTS

Purpose: This study is a follow-up on the treatment arm of our randomized control trial which examined the efficacy of a formal musculoskeletal health for musicians (MHM). In this arm we added targeted hand and wrist intrinsic isometric exercises. The MHM combines education with exercise instruction for pain and injury prevention in professional and student musicians. In this study, our aim was to implement an improved MHM and formally assess the overall adherence, and changes in performance related pain scores. We hypothesized that high MHM adherence would lead to improvements in patient reported pain.

Methods: Musicians were administered a questionnaire prior to and after the implementation of the MHM. The questionnaire collected data on practice habits, type of instrument, number of years of playing, and instrument playing level. The validated, Musculoskeletal Pain Interference and Impact Questionnaire for Musicians (MPIIQM) was used to collect data at baseline and ≥ 1 month after implementation of the MHM. It included categories related to frequency, intensity, duration and location of pain, and impact of pain on playing habits. A customized survey (rated 1-5) captured adherence across 5 categories. The two-part intervention included a 30-minute lecture on overuse injuries, musculoskeletal pain conditions, and anatomy related to performance mechanics. The second, 60-minute component included a workshop covering five domains: warm up exercises, pacing/breaks, posture/playing positions, “smart” practice habits, and specific pre-performance stretches and exercises plus the hand specific program.

Results: 48 patients were recruited for the study. Of these patients only17 responded to the follow-up survey and included in the final analysis. The mean age was 24.5 ± 7.14 years 71% female, and 29% male. Participants played their instrument for an average of 15.68 ± years and practiced an average of 14.1 ± 9.5 hours per week. At baseline, worst pain level was 4.5/10 and did not change at follow up (4.5/10). Our preliminary results demonstrated low adherence to the MHM in 3/5 domains (smart practice, posture, pacing) and high adherence in physical warm-up and stretching.

Conclusion: - Patients who consistently reported pain, reported pain in the hands, wrists, and forearms - Compared to our pilot study, we had a lower response rate and overall adherence likely due to less follow-up time points, and absence of weekly reminders - High adherence to pacing guidelines, posture recommendations, and smart practice habits were related to pain reduction in our previous study. The low adherence numbers here may reflect the poor outcome

Authors: Benjamin Basseri | Stone Streeter | Jose Gutierrez Naranjo | Aviva Wolff

PERSPECTIVES AND PRACTICES REGARDING NERVE AND TENDON TRANSFER SURGERIES FOR TETRAPLEGIA: AN INTERNATIONAL SURVEY

Purpose: Spinal cord injury (SCI) causes substantial disability and has an estimated worldwide prevalence of 20.6 million. Surgery can improve upper limb movement in people with cervical SCI, and includes traditional tendon and newer nerve transfers, The purpose of this study was to gain an updated international expert perspective on upper limb reconstruction in the context of these expanded treatment opportunities.

Methods: IRB approval was obtained. A 34-item survey was developed by a multidisciplinary group of clinicians and researchers in the United States and Canada. Questions were asked about demographics, experience, practice patterns, barriers to care and recommendations to improve access. Participants were recruited at the 2023 Tetrahand World Congress in Atlanta, GA, USA, and included experts across diverse fields including hand therapists, occupational therapists, physical therapists, surgeons and non-surgeon physicians and researchers.

Results: A total of 50 participants completed the survey. The participants self-identified primarily as surgeons (50%) and rehabilitative therapists (44%). The largest portion of respondents (48%) were from the United States, 14% were Canadian, and the remainder were from countries that included Australia, France, The Netherlands, New Zealand, Norway, Sweden and Switzerland. 50% of total respondents were surgeons and 44% of respondents were rehabilitative therapists. Nearly half (48%) of the respondents had more than 10 years of clinical experience, and 52% reported their clinical practice was comprised of caring for “a moderate amount”, “a lot”, or “all or almost all” individuals with spinal cord injury. The majority (90%) of participants reported that both nerve and tendon transfer surgeries were performed at their institutions. Surveyed clinician experts recommended early surgery in order to both 1) better coordinate rehabilitation and 2) avoid the loss of opportunity for time-sensitive nerve transfer. However, some disadvantages to performing early upper limb surgery were also identified and included interruptions to 1) natural recovery and 2) rehabilitation. The majority of respondents (64%) reported that nerve or tendon transfer surgeries to improve upper limb movement in people with SCI were usually being performed within 12 months after the initial injury at their institutions. Many respondents (47%) felt these surgeries should be performed sooner, and 84% of noted that timing should be different for nerve compared to tendon transfer surgery. Participants emphasized the importance of postoperative rehabilitation. Rehabilitation was more commonly delivered in an outpatient setting for nerve transfers. By contrast, rehabilitation for tendon transfers was more commonly delivered in the inpatient setting. A long duration of formal postoperative rehabilitation was recommended for both nerve and tendon transfer surgery. Multiple factors impacting access to upper limb surgery were reported across study participants. Access to therapy (65%) and a lack of external support (70%) were substantially more likely than insurance, cost, or distance to impact access to surgery. Only the American and Canadian participants reported insurance and ability to pay as factors impacting access to surgery. Participants reported additional factors that impacted access to postoperative rehabilitation. These factors included: logistics and insurance status. The impact of cost on access to rehabilitation therapy after surgery was reported only by the American and Canadian participants. Participants were also asked how to improve access to these surgeries. Specific factors included: 1) expanding knowledge of upper limb treatments in SCI (both for providers, and people with SCI), 2) improving facilities that specialize in this care and 3) training more clinicians who have synthesized knowledge of both upper limb treatment and SCI.

Conclusion: There are many factors that influence access to specialized upper limb reconstruction in a unique population such as those living with cervical SCI. Coordination of care, access to therapy that transcends disciplines and improved education may help lead to progress, despite substantial barriers such as lack of external support, cost, and logistical obstacles.

THUMB PAIN EXPERIENCED IN HAND THERAPISTS

Purpose: Certified hand therapists (CHTs) utilize their thumbs daily to perform interventions with their patients. As a result, repetitive and/or forceful movements of the thumb may cause cumulative trauma disorders and potentially increase the risk of developing thumb arthritis. Thumb pain is commonly reported in certified hand therapists, but there is limited research available to support this. The purpose of this study was to examine thumb pain experienced in CHTs practicing in the United States and Canada along with potential risks associated with it.

Methods: A cross-sectional survey of 31 questions was created utilizing information from two studies and the American Society of Hand Therapists’ (ASHT) core demographic questions. ASHT emailed the Qualtrics survey to its members on January 9th, 2024. Descriptive statistics and qualitative analysis were used to interpret the results.

Results: A total of 249 certified hand therapists responded to the survey yielding a response rate of 9.6% of ASHT members. 197 certified hand therapists in total were included in the study (92% occupational therapists, 8% physical therapists). Daily occurrence of thumb pain was experienced in over one third of certified hand therapists in this study. The majority of thumb pain was located in bilateral CMC joints. Manual massage was the most commonly reported work activity that contributed to participants' thumb pain. The most common effective interventions to treat their own thumb pain were joint protection, orthoses, and taping. Nearly half of participants (49%) reported that they had difficulty performing ADLs and IADLs due to thumb pain.

Conclusion: Thumb pain experienced in CHTs not only impacts their work life, but also their personal everyday lives. Factors that were identified as contributing to thumb pain at work were related to manual therapy techniques and orthotic fabrication. Of concern is the number of certified hand therapists who continue to work while in pain despite receiving treatment for it.

Authors: Jenna Lemon | Jeanine Beasley | Dianna Lunsford | Christine Zmyslo

MEASURING ACTIVITY FOLLOWING FREE-FUNCTIONING MUSCLE TRANSFER FOR PAN-BRACHIAL PLEXUS INJURY: A CASE SERIES

Purpose: Pan-brachial plexus injuries (pan-BPIs) result in severe upper limb impairment and permanent dysfunction. Little is understood about how reconstructive surgeries to restore arm movement impact arm use in day-to-day life. This study aims to report the outcomes of two activity measures to better understand how the restored arm is used in day-to-day life following pan-BPI. The current study aims to (i) report activity outcomes for individuals following FFMT reconstructive surgery for management of a pan-BPI using two different patient-report outcome measures, and, (ii) to better understand how patients use the affected arm following reconstructive surgery.

Methods: A case series of individuals with a diagnosis of traumatic pan-BPI and underwent a first free-functioning muscle transfer surgery. Scores of the Brachial Assessment Tool (BrAT) and the Disability of the Arm, Shoulder and Hand (DASH) are compared using one-sample t-tests and descriptive analysis.

Results: This study consisted of eight males with a mean age of 43.5 (SD 11.67) years. Participants scored a mean of 44.17 (SD 16.29) on the DASH and 14.25 (SD 6.2) on the BrAT. When attributing responses to the affected limb using the BrAT, 75% of responses were ‘cannot’ perform an activity while 59% of the DASH responses indicated ‘no’ or ‘mild’ difficulty in performing an activity.

Conclusion: Further research needs to be conducted to fully understand what these measures assess in order to for health professionals to employ the most appropriate outcome measure and to better appreciate its relevance to patient recovery.

Authors: Sara Brito | Bridget Hill | Nikos Thomacos

EVALUATING NON-SURGEON CLINICIAN KNOWLEDGE ON UPPER LIMB RECONSTRUCTION FOR CERVICAL SPINAL CORD INJURY UTILIZING AN INFORMATIONAL DECISION AID

Purpose: Traditional tendon transfer and novel nerve transfer surgeries can be used to improve upper limb movement for individuals with cervical spinal cord injury (SCI). These procedures are not commonly performed, despite having proven to be an effective treatment option. Increasing SCI provider knowledge may improve utilization of these procedures in this population. The purpose of this study was to assess non-surgeon clinician knowledge about upper limb reconstruction in cervical SCI before and after using an informational Decision Aid (DA) about nerve and tendon transfer surgery.

Methods: An online DA about surgical options to improve upper limb function in cervical SCI was previously created by a multidisciplinary team consisting of cervical SCI experts, decision aid developers, clinicians, SCI lived-experience consultants and researchers with expertise in patient-centered care (Moritz et. al., MDM Policy & Practice, 2023). This tool was further revised prior to use in this project to expand the information and include content regarding the time-sensitive nature of nerve transfer surgery. A pre/post knowledge test about nerve and tendon transfers was developed and tested by a multi-disciplinary, international group based on clinical evidence and Continuing Medical Education best practices. The assessment consisted of 10 questions evaluating knowledge about recovery after SCI, nerve and tendon transfer surgery, and perioperative considerations. Non-surgeon clinician participants (occupational therapists, OT; physical therapists PT, physical medicine and rehabilitation specialists, PM+R; critical and acute care specialists, CAC; SCI patient advocates and community members and dissemination and implementations experts, ADV) that had been recruited to take part in a related focus group study were asked to complete the pre/post knowledge survey before and after interacting with the DA. Participants were identified by direct recommendation by research team members or members of the advisory board, which included people living with cervical SCI, a multidisciplinary group of clinicians, and medical information and dissemination researchers. Data were collected via REDCap, a secure HIPAA-compliant online survey tool. The provided link first directed participants to the pre test, then to the DA after the completion of the pre test. Participants were able to read over the DA without further direction until they returned to the REDCap website to complete the post test. Test scores and correct answers were only provided after completion of both the pre and post tests. Participants were also asked to rate the acceptability, appropriateness, and feasibility of using the DA in clinical practice. Incomplete data were excluded.

Results: Thirty-five participants were included in the study, including eleven people in the OT+PT group, ten people in the PM+R group, seven people each in the CAC and ADV groups. In total, 40% of participants were physicians, and 37% were occupational or physical therapists, and the remainder were researchers, SCI community members, or other experts. Participants found the DA to be highly acceptable, appropriate, and feasible, with mean ratings of 4.380.58, 4.290.60, and 4.130.84 on a scale of one to five, respectively. Participant knowledge scores improved from 72% prior to reviewing the DA to 93% after reviewing the DA. The CAC group showed the largest improvement in pre/post knowledge (34%). Each of the four groups showed an increased post test score after viewing the DA, with the CAC group showing the largest improvement (34.29%). Additionally, rates of correct answers for nine of the ten questions improved following review of the DA. Only one question had no change in the rate of correct answers (94.29% of participants answering correctly for both the pre test and the post test), and no questions had decreased rates of correct answers after participants viewed the DA.

Conclusion: The DA increased provider knowledge of nerve and tendon transfer surgery for cervical SCI, and was found to be acceptable, appropriate, and feasible. Future work will focus on dissemination and implementation of this DA into clinical practice.

PREOPERATIVE EDEMA MANAGEMENT OF THE BURNED HAND

Purpose: The purpose of this study is to identify the benefits for preoperative edema management of the burned hand. Current practices for preoperative edema management have led to unsatisfactory edema management, prolonged immobilization and range of motion restrictions.

Methods: Upon admission a comprehensive hand assessment is completed with preoperative edema management beginning within 24 hours of admission. Elevation is managed with the hand consistently above the bedrail. A self adhesive compression dressing is applied to the burned hand and changed every other day. Figure of 8 measurements are taken during dressing changes. Once edema has stabilized, a maintenance compression glove is applied until surgery.

Results: 10 patients (9 males, 1 female) were included in this study. 18 total hands were studied with 16 hands requiring skin grafting. All subjects were right hand dominant. Ages arranged from 17-74 years. Burn size ranged from 1-24% total body surface (TBSA) area with 6 patients having less than 10% TBSA. No hand infections were noted. Use of self adhesive compression dressing both preoperatively and postoperatively yielded decreased edema of the hand allowing for optimal hand results. By discharge, 12 hands (67%) were able to make a full fist, 4 hands (22%) were unable and 2 hands (11%) had range of motion limitations due to early discharge with follow up care in outpatient clinic.

Conclusion: Application of a self adhesive compression dressing in combination with consistent hand elevation within 24 hours of admission improves edema and may expedite return of full composite range of motion in adults with hand burns requiring surgery.

Author: Jose Lucio

ARE WE MISSING THE MARK? PATIENT-REPORTED EFFICACY AND UTILIZATION OF NON-PHARMACOLOGICAL TREATMENT FOR PHANTOM LIMB PAIN

Purpose: Phantom limb pain (PLP) is a debilitating condition affecting many individuals with amputations. Despite available treatments, inadequate pain relief and functional limitations persist. This study aimed to characterize phantom limb experiences, treatment utilization, and perceived efficacy, with a focus on non-surgical and non-pharmacological approaches.

Methods: A cross-sectional survey was conducted among 86 individuals with major extremity amputations in the United States. The survey assessed phantom limb sensation characteristics, pain intensity and frequency, postural changes, telescoping, treatment utilization, and perceived efficacy.

Results: Nearly all participants (98.84%, n=85) reported phantom limb sensations, with tingling, pain, and throbbing being the most common. Among non-pharmacological treatments, graded motor imagery (GMI) and virtual reality/augmented reality (VR/AR) demonstrated promising perceived efficacy (median 5, IQR 3-7.5 and median 5, IQR 4-6, respectively) despite lower utilization rates (24%, n=16 and 3%, n=2, respectively). Other non-pharmacological approaches, such as mirror therapy (31% utilization, n=21; median efficacy 3, IQR 1-5), rest/distraction (50%, n=34; median efficacy 3.5, IQR 2-6), and heat (43%, n=29; median efficacy 4, IQR 2-7), were more commonly used but had lower perceived efficacy. On average, participants tried 4.1 (SD=3.2) non-pharmacological treatments.

Conclusion: This study highlights the potential of non-pharmacological interventions, particularly GMI and VR/AR, in the management of PLP. The low utilization rates of these promising approaches present an opportunity for occupational therapists to increase access and incorporate these techniques into comprehensive, patient-centered treatment plans. By staying informed about the latest advancements in PLP management and collaborating with other healthcare professionals, occupational therapists can play a crucial role in improving outcomes and quality of life for individuals with major extremity amputations.

Authors: Marcie Siebert | Ryan Serbin | James Frix | Bryan Loeffler | Glenn Gaston

GRADED MOTOR IMAGERY IN COMPEX HAND REHABILITATION

Purpose: Complex hand injuries result in trauma to many integral anatomic structures including tendons, nerves, arteries, and associated musculature. The potential loss of function and quality of life associated with such injuries is substantial. Effective rehabilitation of these injuries is imperative to the restoration of function and return to optimal quality of life. Although multiple research investigations have been conducted using graded motor imagery with mirror box therapy, no identifiable evidence was identified to determine the efficacy of this approach for complex hand injuries. The purpose of this retrospective case study was to examine the efficacy of graded motor imagery using mirror box therapy to promote fine motor and prehensile function in the reconstructed hand of a 28 year-old male patient who had suffered near amputation at the Zone IV level while using a skill saw.

Methods: Procedure Functional measures were assessed using the Upper Extremity Functional Index (UEFI) and Grip Strength with a Jamar grip dynamometer The mirror box was fabricated by the investigator using components from a local home improvement store The subject performed fine motor manipulation with pegs and pinching activities using a clothes pin in the uninvolved hand and a small Nerf ball in the involved hand for enhanced tactile input. Gripping activities were later incorporated using resistive sponge balls and particle manipulation was used simultaneously with both hands for tactile input.

Results: The subject responded positively with an improvement in perceived functional participation using the Upper Extremity Functional Index questionnaire from 0% initially to 24% (based on reported score on an 80 point scale) Grip improved from 0 psi to 10 psi. The subject also exhibited a highly positive perspective regarding both hand function and his attitude toward his involved limb which he had previously chosen to deny as evidenced in his qualitative outcomes and quantitative interview responses.

Conclusion: The implementation of graded motor imagery rehabilitation in the care of patients who have suffered traumatic hand injuries and have undergone extensive surgical reconstruction is a valuable intervention in restoring fine motor and light gross motor function. Prior to this Case Study, no investigations had been conducted to examine the efficacy of graded motor imagery in complex hand injuries requiring reconstruction. The outcomes of this Case Study support the implementation of mirror box therapy for this patient population. Further investigation in regard to this treatment approach would benefit this population.

Author: Christine Eddow

ENHANCING PEDIATRIC GRIP STRENGTH ASSESSMENT: THE DEVELOPMENT AND PRELIMINARY EVALUATION OF A CHILD-FRIENDLY DYNAMOMETER

Purpose: Pediatric grip strength assessment poses challenges to healthcare professionals due to the lack of validated tools for young clients, hindering their engagement in the assessment and impacting the accuracy of measurements. Current market offerings, such as industry-standard hydraulic dynamometers, are unsuitable for children due to their size, weight and lack of feedback, leading to skewed measurements and floor effects. We hypothesized that a right-sized measurement instrument with toy-like features and providing visual and auditory feedback would support maximum grip efforts in young children and older children who might otherwise have difficulty following instructions. this ongoing development study aims to address the challenge of assessing grip strength in pediatric populations through a comprehensive design-thinking approach.

Methods: Our core team of engineering students purposefully sampled multidisciplinary stakeholders who regularly take and use grip strength measurements to inform clinical decision-making . We sought to include pediatric health and musculoskeletal care professionals and researchers from a wide range of backgrounds including, but not limited to, occupational therapists, physiotherapists, physicians, researchers, and other rehabilitation specialists. Stakeholders were invited to participate in 30-minute virtual interviews using a semi-structured interview guide based on a priori assumptions regarding the problem validity, value proposition, and potential customer segments. If more time was needed to explore emerging ideas, a follow-up interview was requested and scheduled. The interviews, in turn, validated or invalidated the assumptions based on feedback that was provided to inform and refine the 3D-printed preliminary prototype of the device (figure 1).

Results: To date, we have interviewed 30 stakeholders. Fifteen were occupational therapists, 2 of which founded their own clinics, and 3 of which were assistant professors and clinician scientists. Five of the stakeholders were physiotherapists, 2 of which owned their own physiotherapy practice. The remaining 10 stakeholders came from medicine and child development disciplines, holding a variety of relevant positions such as Associate Professor in Pediatrics, Research Director in the Division of Plastic and Reconstructive Surgery, Rehabilitation Specialist, and Neuromuscular Specialist. Interviewing these professionals informed the device development process through co-design by using the stakeholders’ feedback to guide iterative design. Through the interviews, a large number of stakeholders expressed enthusiasm for the prototype concept. They reported the device could address key challenges in grip strength assessment and endorsed its engaging, child-friendly design and intuitive use.

Conclusion: The prototype addresses the challenges of measuring grip strength in young children by providing a child-friendly, light weight, and engaging grip strength measurement tool. Shaped as a dinosaur, the device is seen as a toy or a friend by the child, ultimately encouraging active participation and understanding from the child. Drawing on design-thinking processes from engineering, we have leveraged interdisciplinary collaboration and co-design processes to develop a working prototype. Further refinement of the physical features and feedback elements, as well as demonstrating consistency and accuracy in measurement will support the uptake of this innovation in clinical practice.

Authors: Rooaa Shanshal | Deena Al-Sammak | Tara Packham

DRY NEEDLING FOR LATERAL ELBOW TENDINOPATHY IN OCCUPATIONAL THERAPY: A RETROSPECTIVE PILOT STUDY AND REVIEW OF STATE LEGISLATION

Purpose: Dry needling (DN) is an emerging modality used to manage pain, restore musculoskeletal function, and improve participation (American Physical Therapy Association, 2013), with emerging evidence of effictiveness in plantar fascitis (Dunning et al., 2018) and chronic neck pain (Martín-Sacristán et al., 2022). The complexity of the pathogenesis and pathophysiology of lateral elbow tendinopathy (LET) make it challenging to treat (Challoumas et al., 2020). A variety of interventions are recommended for the management of LET, but there remains no universally accepted modalities (Ma & Wang, 2020). According to JOSPT guidelines, DN treatment for LET has “B” level of evidence suggesting moderate success with symptom treatment (Lucado, et al., 2022). However, only three studies met the inclusion criteria. State licensing boards, vary in their position on the practice of DN by occupational therapists with majority, staying silent on the statute. The purpose of this study was to determine the effectiveness of DN in LET. The secondary aim of the study was to provide a review of current state legislation across the United States on DN for Occupational Therapists (OT).

Methods: A pilot study with retrospective design examined existing medical records of a practicing OT certified in DN in Indiana. Medical charts that had a diagnosis of LET were included. Control group (traditional therapy) charts were collected from July 2019 to May of 2021, prior to OT receiving certification in DN. Experimental group (DN & traditional therapy) charts were collected from January 2022 to June 2023. Outcome measures included Numerical Pain Rating Scale (NPRS) and QuickDASH collected at time of evaluation and discharge. Charts that did not contain outcome measures were excluded. A review of state-specific legislation of occupational therapy’s practice of DN, updated position statements of the American Occupational Therapy Association (AOTA), American Society of Hand Therapy (ASHT), was conducted through internet searches, phone calls, and emails.

Results: 27 charts met inclusion criteria, however, only eight charts (6 experimental and 2 control) were selected for final data analysis due to missing data. Both groups had a reduction in pain from evaluation to discharge with number of visit ranging from 2 to 12. The experimental group had a statistically significant improvement (p=.02) while the control did not (p=.08). The unpaired t-test for comparison of pain levels between groups was not significantly different at evaluation (p=.32) or at discharge (p=.13). QuickDASH scores were missing at either evaluation or discharge and comparisons could not be made. AOTA recently updated their policy “E.18: Interventions to Support Occupations” in 2023, which approved the use of dry needling and other emerging techniques that are used to support occupational function (AOTA Policy E.18, 2023). The American Society of Hand Therapists (ASHT) has no formal position on DN for practicing occupational therapists due to insufficient evidence to support or refute its efficacy (ASHT, 2016). As of February 2024, state legislation allows OTs to use DN in 10 states, while 24 states have no stance, and 16 states do not allow DN.

Conclusion: Results indicate that the addition of DN to traditional therapy had similar outcomes to traditional therapy alone. Both groups (traditional therapy and traditional therapy with DN) improved in pain intensity by discharge, but the DN group had a statistically significant change. Similarly, Uygur et al. (2021) compared outcomes of patients with lateral epicondylitis receiving standard care to dry needling and found that both groups improved in the Patient-Rated Tennis Elbow Evaluation (PRTEE). The dry needling group had statistically significant improvement compared to the standard of care group at the end of 3 months. However, given the small sample size, retrospective design and missing data, results of our study need to be interpreted with caution. Dry needling in lateral elbow tendinopathy shows promise, but ambiguity in state legislation limits inclusion of this intervention by OT in their daily practice. AOTA’s policy update (2023) is an opportunity to renew legislation efforts for the inclusion of DN in state licensure for OTs.

MUSCOLOSKELETAL LOAD, AND ERGONOMIC RISKFACTORS AMOMG SURGEONS, A COMPERISON BETWEEN LAPROSCOPIC AND ROBOTIC SURGERIES

Purpose: Aim: This study aimed to document and compare General chirurgic surgeons' muscle activity load, musculoskeletal pain, and ergonomic risk factors in real-time while performing laparoscopic and robotic surgery.

Methods: Methods: This study is a multiple-dimensional subjective and objective assessment documenting the muscle activity load, pain, and ergonomic risk factors. Two senior surgeons, specialists in minimally invasive surgery, performed 22 laparoscopic and 22 robotic Hernia surgeries, using the Da Vinci robotic system. The surgeon filled out a demographic questionnaire, visual analog scale (VAS) for pain rate before and after each surgery. The surgery process was divided into three main stages to document the load and the ergonomic risk factors of each stage of the surgery. Twelve Surface electromyography (SEMG) Trigno wireless sensors produced by Delsys Inc. were attached bilaterally to the Upper trapezius, Deltoid posterior and Anterior, Biceps and Wrist extensors and the Spinus Erectus. Maximal Voluntary (MVC) contraction was measured for each muscle before the surgery and served as a reference to compare the muscle load. The sensors document the muscle load during surgery without disturbing the surgeon's work. In addition, during his work, the surgeon was videotaped from 3600, one minute for each surgical stage. The researcher analyzed the videotape using the Rapid Entire Body Assessment (REBA) and assessed the level of ergonomic risk factors.

Results: Results: There are differences in muscle load measured, between the laparoscopic and the robotic-assisted surgery methods at the various stages of Hernia surgery. The REBA score for the robotic surgery was higher, requiring further investigation and ergonomic change implementation. The muscle activity (%of MVC) was significantly lower in the robotic-assisted method in the middle deltoid, biceps, and wrist but higher in the upper trapezius and anterior deltoid. The muscle fatigue of the laparoscopic method was significantly higher in the Deltoid, Biceps, and Erectus spinatus. The Erectus spinatus fatigue was higher in the last stage of the robotic methods.

Conclusion: Conclusion: Muscle load was lower in the laparoscopic method of surgery, but further ergonomic changes implementation will be beneficial for the robotic methods. Implementing ergonomic changes may be beneficial for surgeons using both methods of surgery.

THE EFFICACY OF A VERSATILE CUSTOM ORTHOSIS DESIGNED FOR THE STIFF HAND: A CLINICAL CASE STUDY

Purpose: Stiffness and loss of motion of the entire hand, regardless of involved joint, is a common sequela of hand pathologies, injuries, and surgical interventions due the associated trauma and immobilization of the region. Many techniques have been developed to address stiffness of larger joints including dynamic and static progressive methods Because of the complexity of the hand, protocols addressing individual joints are impractical. Because the hand has multiple joints, regional stiffness and loss of motion are a common sequlae in hand pathologies and injuries regardless of of the structures involved due to widespread edema, inflammation, and fibroplasia. Treating individual joints with either dynamic or static-progressive strategies is not practical when treating the multiple joints of the hand. The purpose of this clinical case study was to design a versatile static-progressive orthosis that could address multiple joint restrictions in the stiff hand to promote functional range of motion and the ability to perform a functional grasp following traumatic metacarpal injury and ray resection. The research question is: Will a multifunctional custom orthosis be an effective and efficient method for addressing hand stiffness?

Methods: The purpose of this retrospective case study was to examine the efficacy of a versatile custom orthosis designed by the investigator* to address multiple joint stiffness in the hand of a 61 year-old patient who had suffered trauma to her left ring finger and undergone surgical intervention including 4th ray resection. The patient presented with marked stiffness of all joints of the involved hand resulting in significant functional impairments. A traditional dynamic splint was prescribed and found to be impractical to address the multiple contractures. *Design patent pending Procedure A multi-component thermoplastic shell was fabricated that was able to differentially isolate the DIP's, PIP's and MCP's with concurrent static-progressive finger straps applied sequentially to each of the joints based on the patient's tolerance. The patient was to apply the orthosis 3 times daily isolating the DIP's, PIP's, and MCP's by changing a block component isolating each segment. Measurements were taken weekly over a period of 6 weeks.

Results: The results of the study were significant for a composite improvement in finger motion allowing the subject to form a functional grasp. Primary remaining impairment was power gripping due to inability to fully close the hand.

Conclusion: The outcomes of this study provide an efficient and cost-effective alternative for therapists treating hand patients with multiple joint involvement. Results suggest investigations with larger populations of patients with hand injuries be conducted to further assess the value of this intervention.

Author: Christine Eddow

COMPARISON BETWEEN THE INTRINSIC GLOVE AND SURGEON PLASTER SPLINT APPLICATION FOR THE POSITION OF IMMOBILIZATION OF THE METACARPOPHALANGEAL JOINTS

Purpose: Initial splinting of traumatized hands in protected positioning protects injured structures and promote optimal biomechanics of the hand. Plaster is often utilized to achieve and maintain consistent metacarpophalangeal joint positioning but can be inconsistent in application and result in inaccurate positioning. Poor outcomes can result from prolonged improper positioning. Our novel standardized "Intrinsic Glove" allows immediate, full range, active motion while providing elastic and semi-rigid properties that allow the patient to return to the desired position at rest. The purpose of the study is to evaluate the effectiveness and practicality of the Intrinsic Glove in achieving standardized safe positioning as compared to traditional plaster splinting in preparation for a clinical trial using the Intrinsic Glove to manage metacarpal fractures.

Methods: Our study compares at least 8 applications by hand surgeons of the Intrinsic Glove to 8 applications of a plaster splint for safe immobilization, aiming to establish a mid-range position of safety with approximately 60 degrees of index metacarpophalangeal joint flexion. There will be two groups: one which utilized the Intrinsic Glove and a control group which utilized the traditional forearm based, volar, plaster splint. The applications will be timed, and goniometric measurements obtained at initial application and again after 10 minutes in each respective group.

Results: Preliminary results indicate significant benefit in using the glove. Hypothesizing less than one minuate application time of the glove compared to approximately 6 minutes application time of the forearm based plaster splint with equitable positioning of the metacarpophalangeal joints. The study will be completed with full reporting and presenting potential before the annual meeting.

Conclusion: The Intrinsic Glove proved a potential alternative to traditional plaster splinting for reliably achieving acceptable ranges of standardized safe positioning of the metacarpophalangeal joints in statistically significant faster time.

REHABILITATION PROTOCOL FOLLOWING ADOLESCENT SHOULDER REANIMATION

Purpose: This study proposes a postoperative rehabilitation protocol following adolescent shoulder reanimation procedures in patients who did not receive timely or effective care for brachial plexus birth injuries. Preliminary findings from a series of eight patients who underwent postoperative implementation of this rehabilitation protocol is included.

Methods: Through collaborative communication between the operating surgeon and occupational therapists, a four-phase rehabilitation protocol and a modified orthosis, based on the external rotation abduction thermoplastic shoulder orthosis (ERATSO) described by Buchanan et al., were developed. The focus of Phase 1 (0-6 weeks) of the rehabilitation protocol is immobilization using the custom fabricated orthosis to support the healing structures and help the patient and family manage functional activities in the position of immobilization. In Phase 2 (7-12 weeks), protected active and passive movement is initiated, with an emphasis on activating transferred muscles and cortical remapping. In Phase 3 (12-18 weeks), full active movement and initiation of functional activities is conducted. In Phase 4 (19 weeks onward), repetition of motion against gravity and reinforcing the recruitment of donor muscles for the new, established movement, is encouraged. Demographic data, rehabilitation summary reports, and outcome measurements were extracted from those who underwent implementation of this protocol at the time of data collection. Data was analyzed descriptively.

Results: Eight patients (average 13.8 years-old) with an average follow-up time of 35 weeks were included in the rehabilitation protocol. Prior to undergoing reanimation procedures, patients had 0° external rotation (ER) from neutral and in maximum abduction, 0-20° of abduction and 0-20° of forward flexion (FF) that were mediated through scapulothoracic motion. At latest therapy appointment patients achieved an average of 71° (30-90°) ER from neutral and an average of 82° (65-90°) ER in maximum abduction, an average of 115° (90-180°) of abduction, and an average of 91° (20-170°) FF.

Conclusion: When searching for postoperative therapeutic management options following shoulder reanimation surgeries for patients in this population, there were severe shortcomings and limitations in the literature. Our multidisciplinary team consisting of hand therapists and an orthopaedic surgeon specializing in correcting brachial plexus injuries, considered the available evidence and developed the four-phase rehabilitation protocol based on the stages of healing and feasibility for patient implementation. This study provides a comprehensive, four-phase rehabilitation protocol with a step-by-step guide of constructing a two-piece orthosis tailored for adolescent patients that underwent shoulder reanimation procedures following undertreated/untreated brachial plexus birth injury.

CONSERVATIVE MULTI-MODAL TREATMENT OF CHRONIC LATERAL ELBOW PAIN: A CASE SERIES

Purpose: This retrospective case series investigated the effectiveness of an occupational therapist’s (OT) multi-modal treatment approach in decreasing pain in patients with chronic lateral elbow pain.

Methods: Data was collected by retrospectively reviewing charts of patients who were primarily treated by a single OT for lateral epicondylitis, lateral elbow pain, or radial tunnel syndrome between 2018 and 2023. Pain ratings were gathered from the initial and last visit of 84 patients, with long-term follow-up pain ratings obtained from 37 of these patients. Initial visit pain ratings were then compared to the last visit and long-term pain ratings to analyze the effectiveness of multi-modal conservative treatment.Results: Most commonly utilized treatments included gua sha, cupping, dry needling, nerve glides, microcurrent, and postural correction.

Results indicated statistical significance regarding decreased pain with p-value <0.001. Conservative treatment was effective in significantly decreasing pain for 94% of patients. 6% of patients resulted in surgery. The median number of visits to discharge was 4.5 and the median duration of treatment was 39 days.

Conclusion: Chronic lateral elbow pain is a multi-faceted condition, which requires a combination of interventions to appropriately treat. Multi-modal conservative treatment was effective in significantly decreasing short-term and long-term pain ratings of chronic lateral elbow pain. Continued research is needed to evaluate the effectiveness of multi-modal approaches.

Authors: Matthew Lott | Madeline Jeffries

A NOVEL, COMPREHENSIVE EVALUATION FOR PERIPHERAL NERVE DYSFUNCTION AS A CONSEQUENCE OF ELBOW AND FOREARM TRAUMA

Purpose: To investigate the effectiveness of the newly-developed Upper Extremity Peripheral Nerve Screen (UEPNS) in identifying and responding to early peripheral nerve injury in patients with complex elbow and forearm trauma.

Methods: This study is a prospective case series of 3 patients with complex elbow or forearm trauma screened with the UEPNS in conjunction with a standard orthopedic upper extremity evaluation, re-evaluation and discharge.

Results: With the use of the UEPNS, signs of a peripheral nerve injury were identified that led to treatment modificaitons to avoid further damage. All patients demonstrated improvements in range of motion, activities and participation in activities of daily living.

Conclusion: The effectiveness and practicality of the UEPNS to identify peripheral nerve injuries with elbow and forearm trauma is described. Treatment results for the 3 patients with elbow and forearm injuries screened with the UEPNS demonstrated benefit of early identification.

Authors: Laurie C Rogers |Susan Smith | Margaret Finley | Sarah Doerrer

CRITICALLY APPRAISED TOPIC: CONTRALATERAL TRAINING IN DISTAL RADIUS FRACTURES: CRITICAL ANALYSIS OF CLINICAL IMPLICATIONS

Purpose: Distal radius fractures (DRF) are the most common type of fracture (Bergh et al., 2020) and can result in decreased grip strength (Chung et al., 2019), leading to deficits in activity of daily living (ADL) participation (Meskers et al., 2019; McGrath et al., 2020). Contralateral training (CLT), or the training of the unaffected limb, has been shown to increase strength and decrease atrophy in an immobilized extremity (Andrushko et al., 2023). Cross education (CE), which was considered a form of CLT for this study, seeks to impact the central nervous system by leveraging the neural pathways and promote symmetry and bilateral improvements despite only training the affected extremity. Studies have shown that CLT can be effective in the distal radius population (Magnus et al., 2013), however the state of DRF rehabilitation is evolving to include more accelerated approaches that emphasize early mobility, therefore it is warranted that this evidence is revisited. The purpose of this critically appraised topic was to explore the literature and clinical impact of CLT on patients who have had a DRF. CAT question: What is the effectiveness of CLT on wrist motion and grip strength in patients who have a DRF?

Methods: Articles published within the last 15 years were searched in CINAHL, PubMed, and Google Scholar. Search terms: (contralateral training OR cross education OR cross training) AND (distal radius fracture OR distal radius fracture with open reduction internal fixation OR post-operative distal radius fracture OR drf OR drf with orif) AND (grip strength OR hand function OR upper extremity function OR strength OR mmt). Articles were included in the study if they explored CLT or CE for a patient with a DRF, and measured strength and/or a functional outcome pre- and post-intervention. 22 articles were reviewed and 3 met the inclusion criteria. All three studies were level 2b, 1 double blind randomized control trial (RCT) and 2 single blinded RCTs. Study design, participant characteristics, intervention details, outcomes measured, and key findings were reviewed.

Results: Magnus et al. (2013) found that CLT using a strength training approach, yielded increased strength (17.3 vs. 11.8 kg) and wrist AROM (100.5 vs. 80.2) of the impacted limb at 12 weeks post-fracture, but the groups showed no difference at 26 weeks. Korbus and Schott (2019) found that CE, using either a mirror therapy (MT) or mental practice (MP) approach, yielded improved scores on subjective function, AROM, and grip strength over the control group over a six week training period. Bayon-Calatayud et al. (2016) found no difference in pain, function, or AROM between the MT and control group, however they followed patients for a total of 3 weeks and had samples that included both conservative and post-operative management.

Conclusion: This CAT on CLT for DRF provides valuable implications for hand therapists and patients. CLT can improve patient outcomes for strength, AROM, and subjective measures while the affected limb is immobilized. A variety of approaches including strength training, mirror therapy, and mental practice show the potential for benefit. The benefit for CLT appears to peak within the first 12 weeks following distal radius fracture, and when the affected limb is immobilized. Hand therapists should consider integrating CLT into rehabilitation plans during periods of immobilization, however may not see a benefit when the affected limb is released to perform AROM. Limitations include the small sample sizes, limited generalization, and two studies described an immobilization period of ~6 weeks which limits generalization to modern post-operative protocols. Further research is warranted to explore the impact of CLT on distal radius fractures with open reduction internal fixation, which generally allows for earlier mobilization.

Authors: Ricky Altahif | Kathryn Milbert

CRITICALLY APPRAISED TOPIC: WHAT IS THE PREVALENCE OF POST-TRAUMATIC STRESS DISORDER (PTSD) IN OLDER ADULTS AFTER A FALLS-RELATED INJURY

Purpose: Background: Every year, over 800,000 older adults are hospitalized due to fall-related injuries. Falls are associated with upper extremity fractures, particularly wrist fractures. Unfortunately, as the population of older adults grows, the number of falls and fall injuries is also expected to increase. Among the older population, stressors such as loss of physical integrity or serious illness can lead to the development of PTSD. It is well-documented that functional outcomes and health-related quality of life following a traumatic injury are strongly influenced by PTSD, even after adjustment for baseline status and injury severity. Although not always conceptualized as a traumatic event, emerging evidence suggests falls may lead to the development of PTSD in older adults. CAT Question: What is the prevalence of PTSD among older adults who experience a fall-related injury?

Methods: Search Strategy: A literature search was conducted using the PubMed database. A search strategy was initially generated using the combined MeSH terms: “Post-Traumatic Stress Disorder” and “Accidental Falls.” Nine articles were initially retrieved. The search strategy was expanded using the MeSH term “Post-Traumatic Stress Disorder” and the keyword “Falls.” The reference lists of selected papers were manually screened to identify other citations. Articles were considered for inclusion if they described originally designed studies with 1) subjects over the age of 65 for part or all the population; 2) falls as a mechanism of injury; and 3) assessment of psychological consequences of said fall. Only English-language articles were included. The search was not restricted by date or publication status. Data extracted included study characteristics, patient characteristics, and risk factors/outcomes generated.

Results: The search strategy generated 195 citations. 189 from the database search, and 6 from a manual review of references. 9 relevant publications were retained for review. Adamczewska & Nyman found probable PTSD in 32% of 119 older adults (ages 60+) hospitalized due to a falls-related injury. (2021). Bloch et al. found probable PTSD in 26% of 36 older adults (ages 75+) admitted to the ED because of a fall, 2 months after ED admission (2014). Chung et al. found that 7% of 196 older adults (65+) hospitalized due to a fall met the criteria for full acute PTSD (2009). Eckert et al. found tht 49% of 115 older adults with hip/pelvic fracture because of a fall reported post-traumatic stress symptoms in avoidant and re-experiencing clusters (2020). Eman Abdulle & van der Naalt found that among 162 older adults (ages 60+) with mild traumatic brain injury (MBTI), 75% of which resulted from a fall, 38% of patients met criteria established for PTSD (2020) Jayasinghe et al. found that among 100 older adults admitted to the hospital for a fall, 27% demonstrated severe post-traumatic stress symptoms (2014). Kornfield et al. followed 456 older adults undergoing surgical repair of a hip fracture resulting from a fall. They found no patients in this sample qualified for the full diagnosis of PTSD (2017). Schindelar et al. found that among patients who underwent surgery for distal radius fracture because of a fall (median age 63 years), 1 patient (2.3%) met criteria for probable PTSD 0-2 weeks post-surgery, 2 (4.8%) met criteria 3-6 months post and 3 (7.3%) met criteria 12-15 months post (2009). The findings are detailed in Table 1 (see below).

Conclusion: Conclusion: A minority of older adults may develop persistent PTSD after a fall, with estimates of prevalence ranging from 0% to 38% depending on assessment method and timing. Limitations: The assessment methods and timing varied widely between studies. Additionally, several studies reported PTSD symptom severity as an outcome separate from PTSD diagnosis, using the total score of the PTSD assessment instrument as a proxy measure for overall symptom severity. Most reviewed studies used the diagnostic criteria in the DSM-IV. Early research suggests that changes from DSM-IV to DSM-V may alter the number of individuals who screened positive for probable PTSD. As a significant portion of this research is cross-sectional and there are likely to be notable differences in the demographic characteristics of the samples, the generalizability of the findings may be limited. Clinical Implications: Hand therapists treating older adults for falls-related wrist fractures should be aware of the potential for post-traumatic stress disorder (PTSD) post-injury. Future research should focus on predicting and identifying PTSD in older adults with falls-related injuries, as well as developing a screening process for at-risk patients.

Author: Case Peters

CRITICALLY APPRAISED TOPIC: PREFABRICATED ORTHOSES FOR THE CONSERVATIVE MANAGEMENT OF TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES: A LITERATURE REVIEW

Purpose: Clients with ulnar-sided wrist pain from TFCC injuries are often referred to a hand therapist, with care provided by an occupational or physical therapist. Orthotic fabrication is frequently used to address pain, ROM, and functional use of the upper extremity. The purpose of this literature review is to examine literature related to prefabricated orthotic fabrication for the conservative management of TFCC injuries for the preparation of a survey study. The purpose of the survey study will be to determine which orthoses hand therapists most commonly recommend for the conservative management of TFCC injuries and determine therapists' perception on their effectiveness for pain, ROM, function and weightbearing status. The research question "What is the effectiveness of prefabricated orthoses for the conservative management of TFCC injuries?" was used to guide this literature review.

Methods: A comprehensive literature search was conducted to identify studies examining conservative treatment for TFCC lesions, focused on prefabricated orthoses. This search utilized many electronic databases including PubMed, MEDLINE, CINAHL, Cochrane Library, and Scopus. Various search terms such as "TFCC", "TFCC injury", "wrist pain," "conservative treatment," and "orthotic devices" were used within the literature review. This literature review was utilized to design a survey-based study that will be conducted in fall 2024. Studies were included in this literature review 1. Study examined conservative treatment options for TFCC injuries. 2. Included prefabricated orthoses for TFCC injuries. Studies were examined using the American Occupational Therapy Association's Levels of evidence and included studies at levels 1-4.

Results: A total of three studies met the inclusion criteria to be included in this literature review, Kim et al. (2023), Asmus et al. (2022), and Barlow (2016). Studies included in this literature review include one Level IIb prospective cohort study, one Level III retrospective cross-sectional case series study, and one Level IV single-subject case report. Kim et al. (2023), a Level IIb study, focused on individuals with TFCC lesions both traumatic and degenerative using the WristWidget to determine if the weight-bearing capacity can be used as a diagnositic tool to differentiate stable vs unstable TFCC injuries. Results of this study found an increased ability for weight-bearing capacity by an average of 4kgs in all participants. Asmus et al. (2022), a level III study, focused on using the WristWidget for patients with TFCC lesions with outcomes measures focusing on weight-bearing capacity. Results of this study found approximately a 60% increase in weight-bearing capacity using the WristWidget compared to without. Barlow (2016), a level IV single-subject casre report, utilized the WristWidget to examine weight-bearing tolerance and found an 80% increase in weight-bearing tolerance using with the WristWidget compared to without.

Conclusion: The findings from this literature review suggest evidence to support the use of prefabricated orthoses for conservative management of TFCC injuries is limited, but suppportive for improving weightbearing capacity. Studies primarily focused on weightbearing capacity with a limited focus on comparisons of function pre and post use of the prefabricated orthosis. The WristWidget was the only prefabricated orthosis used in these three studies, but favorable results were found for the use of this prefabricated orthosis for weightbearing capacity compared to not using the WristWidget. Practitioners should consider utilizing this prefabricated orthosis for clients with pain or limited ability to weightbear on their upper extremity following a TFCC injury. Further studies are needed to support the use of prefabricated orthoses for functional outcomes.

Authors: David Plutschack | Tucker Aeschliman | Jonah Lewis | Megan Plantikow | John Levis

CRITICALLY APPRAISED TOPIC: THE USE OF FOREARM BASED ORTHOSES TO LIMIT AND / OR PREVENT FOREARM ROTATION

Purpose: a. After forearm and/ or elbow and/ or wrist trauma it is often necessary to prevent and/ or limit forearm rotation. Clinicians commonly fabricate either the Sugar Tong orthosis or the Muenster orthosis for this purpose. This poster examines the current evidence for forearm- based orthoses that limit and / or prevent forearm rotation and reveals some overlooked details in the literature. b. What is the current evidence that supports the use of the Sugar tong orthosis and/ or the Muenster orthosis for prevention and/ or limitation of forearm rotation following trauma and/ or surgery?

Methods: c.A literature search was conducted using the following databases and search terms: Databases Searched Medline CINAHL (EBSCO) Pubmed Google Scholar Search Terms Splints/ orthoses to limit forearm rotation Muenster orthosis Sugar tong orthosis Forearm immobilization Limits Used Full text articles Studies in English Years 2007-2024 Slaughter et al (2010) compared the effectiveness of the Muenster orthosis, Sugar tong orthosis, anti-pronation orthosis, and a standard wrist orthosis on prevention of forearm rotation in 5 volunteers who had not experienced any trauma (Slaughter et al 2010). Rahman et al (2018) examined the degree of forearm rotation allowed with a Sugar Tong cast, a short arm cast, a Muenster cast, and a long arm cast. All of these immobilization devices were fabricated with fiberglass and this study was performed on 7 cadavers. Trocchia et al (Trocchia et al 2012) defined the arc of motion from pronation to supination in 15 volunteers wearing different immobilization orthoses. Average arc of motion from pronation to supination for unrestricted elbow - 189°, for a long arm cast -11°, a Muenster cast -35°, a “removable splint set to 90° elbow flexion” -124° and a splint set to the extension flexion arc of elbow motion allowed in a Muenster cast- 139°. Kim and Kim (Kim and Kim, 2012) conducted a study to compare the degree of active pronation and supination allowed by a short arm orthosis, a short arm cast, a sugar tong orthosis, a long arm orthosis, and a long arm cast fabricated on forty healthy volunteers. Lawton et al (Lawton et al 2007) looked at Scaphoid fractures immobilized in long arm thumb spica casts versus Muenster style thumb spica casts. The Muenster cast allowed for elbow flexion and extension while still limiting forearm rotation. This study was conducted on ten healthy volunteers, and it appears that both cast designs were fabricated using Delta cast material. McCarron et al (McCarron et al, 2023) found that current clinical practice following repair of the triangular fibrocartilage complex included on average 6 weeks of immobilization. The most commonly fabricated orthosis was the Sugar Tong orthosis followed by the Muenster orthosis, both of which include the wrist and forearm.

Results: e. The above cited studies attempt to demonstrate the effectiveness of different immobilization designs on prevention of forearm rotation. The studies include a variety of different types of immobilization designs including long and short arm casts, Sugar Tong orthosis, Muenster orthosis, long arm orthosis, and short arm orthosis.. f.The immobilization materials used in the above-mentioned designs included fiberglass and plaster, but not thermoplastic materials. In addition, the studies have all been conducted with healthy volunteers or on cadavers, and some indicated using mock restiction set -ups to imitate an immobilization orthosis.

Conclusion: g. Limitations of the studies include the healthy population of volunteers that were included, the use of plaster and or fiberglass as the main material and the idea that the volunteers used maximum force to test the strength of the immobilization. h. It appears that the most restrictive cast (or orthosis) is one in which the elbow and wrist are both included as in a long-arm cast. However, the elbow is at risk of becoming stiff if the immobilization period is prolonged. This type of cast can be uncomfortable for the patient. It should be noted that a long arm orthosis has the advantage of being removable and can be fabricated on the anterior or posterior surfaces of the forearm or both. i. Clinicians should be aware of the fact that neither the Muenster orthosis nor the Sugar Tong orthosis completely prevent forearm rotation. The elbow would need to be included for the full prevention of forearm rotation. It is recommended that clinicians be familiar with both options and practice orthotic fabrication of each type to become comfortable and efficient.

Author: Deborah A Schwartz

CRITICALLY APPRAISED TOPIC: THE EFFECTIVENESS OF MINDFULNESS ON REDUCING PAIN AND STRESS IN PATIENTS EXPERIENCING AN UPPER EXTREMITY AILMENT

Purpose: Hand therapy often takes on a biomechanical approach to reducing pain through the use of modalities, soft-tissue massage, and adaptive equipment. The psychological aspect of pain is often neglected thus a patient's perception of pain can be a triggering factor in the healing process. Mindfulness is a type of meditation that focuses on bringing awareness to the present moment by taking in all emotions and sensations without jugding or critizing one self . Having a better understanding of and incorporation of the mind-body component in hand therapy can help patients better cope with chronic pain and decrease anxieties associated with the injury.

Methods: To break down my format into a PICO question: The patient group are individuals who are experiencing an upper extremity pain and stress. The intervention is mindfulness. I did not include a comparison group. The outcome is pain/stress reduction. The Inclusion Certieria I utilized included the following: Individuals experiencing pain; Individuals practicing mindfulness-based interventions; Adults ages 18≤; articles that were peer-reviewed and publisjed within the last 15years The certieria that I excluded: Individuals not experiencing pain; interventions not related to mindfulness-based practice Data bases utilized included ASHT, PubMed, University of Michigan Library, Google scholar Search Terms used for Population included Upper extremity pain, injury; Intervention: Mindfulness, Meditation; Outcome: Pain and stress reduction

Results: A total of 13 studies were located and reviewed. 3 articles were selected from the review process. The best evidence found on this topic included two randomized controlled trials (RCTs) and one systematic review. These articles looked at the effectiveness of mindfulness in reducing pain/stress. Results provide evidence that mindfulness-based interventions can decrease pain and stress in patients experiencing an upper extremity ailment. The first article included was Mindful Body Scans and Sonographic Biofeedback as Preparatory Activities to Address Patient Psychological States in Hand Therapy: A Pilot Study. This article was a randomized cross over designed that investigated how mind-body interventions used as a preparatory activity affected the patient’s pain, stress, and anxiety. It aimed to determine potential benefits of including a mindful body scan or sonographic biofeedback within hand therapy and to explore the positive effects of pairing hand therapy with preparatory mind-body interventions. This study was selected because it was a recent study that measured pain, anxiety, and stress from 21 hand therapy patients at different periods of a treatement session to assess the impact of the mindfulness techniques. The second article included: Mindfulness-based interventions for chronic pain: Evidence and applications. This systematic review analyzed the effectiveness of mindfulness-based interventions (MBIs) in reducing chronic pain. This article was selected because it was a recent systematic review that supported the use of mindfulness-based interventions in reducing chronic pain. This was the highest level of evidence, and it provided information on the use of mindfulness interventions in the treatment of a variety of chronic pain conditions. The third article included was Does a Brief Mindfulness Exercise Improve Outcomes In Upper Extremity Patients? A Randomized Controlled Trial. This randomized control trial assess effects of mindfulness in patients with upper-extremity conditions. This article was selected because it was a recent RTC that found Mindfulness to be positively associated with less pain (though below the minimal clinically important difference), increased mood, and better function.

Conclusion: Findings related to mindfulness interventions appeared to have promising results in the treatment of pain and stress among patients who are experiencing and upper extremity ailment. Future research should assess how mindfulness relates to improving functional outcomes and its effects over long term practice. Future studies are warranted to enhance understanding of how mindfulness therapies improve pain and mental health in different settings and among patients with various upper extremity diagnosis. Additional evidence is also needed to support mindfulness interventions to increase availability for patients.

Author: Brittney Hall

CRITICALLY APPRAISED PAPER: "MANAGEMENT OF STABLE PROXIMAL INTERPHALANGEAL JOINT VOLAR PLATE INJURIES WITH FIGURE-OF-8 ORTHOSES: A PARALLEL-GROUP RANDOMIZED CONTROLLED TRIAL"

Purpose: The objective is to compare the effects of range of motion, pain, function, and amount of hand therapy appointments made between patients with figure-of-8 orthoses or dorsal blocking orthoses to manage volar plate injuries.This is a Level 1B, Parallel-group Randomized Controlled Trial. Measurable outcomes found no significant differences in finding one orthosis better than the other, showing efficient evidence for using both. Earlier extension, improved function scores, and fewer appointments scheduled were some benefits of using the figure-of-8 orthosis. Further research should be conducted to explore different types of orthoses. While there are some limitations, this study tells clinicians they have an option in choices for orthoses.

Methods: Participants were recruited from a major regional Australian hospital in an outpatient clinic. Inclusion criteria included 1) have a stable volar plate injury to the PIP joint of the finger, 2) were between the ages of 13-65 years, and 3) have completed assessments with an OT or physiotherapist who has experience managing volar plate injuries within 2 weeks of the injury. No exclusion criteria are listed. Group 1: For 12 weeks, 20 participants (n=20) were allocated to a therapist using typical referral processes at a hand clinic in Australia. Participants in the intervention group received a customized thermoplastic figure-of-8 orthosis placed in 30 degrees. They were placed in 15-20 degrees up until the 4-week appointment while being instructed not to remove the orthosis at all times. Participants were instructed to do daily active and passive range of motion exercises for each joint in the finger and received education on their injuries. Group 2: For 12 weeks, 22 participants (n=22) were allocated to a therapist using typical referral processes at a hand clinic in Australia. The control group received a customized dorsal blocking orthosis. This orthosis started at 30 degrees PIP flexion and was progressively adjusted by 10 degrees until a neutral position was reached. They were instructed not to remove the orthosis. Participants were instructed to do daily active and passive range of motion exercises for each joint in the finger and received education on their injuries.

Results: All outcome measures were assessed at baseline, and 4, 7, and 12 weeks after the initial assessment. A goniometer measured the finger’s range of motion with a Roylan goniometer on the dorsal side of the affected finger. Pain measurements were taken subjectively utilizing a visual analog scale (VAS), with 1 as the lowest pain and 10 as the highest pain reported. The Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) measured function. This outcome measure is reported to be valid and reliable. Repeated Measures ANOVA found no significant effects for group-by-time interactions concerning PIP flexion, distal interphalangeal (DIP) flexion, DIP extension, pain, and QuickDASH scores in either group. The group-by-time interaction for PIP extension was found to be significant at p = 0.03 in the intervention group. When examining effects between time points, there was a significant change in QuickDASH scores between time points 3 and 4 in the intervention group. There were no between-group differences found at the end time point. Time had significant effects on PIP flexion, DIP flexion, pain, and QuickDASH scores which shows a change from baseline to follow-up in both groups. The number of appointments scheduled between groups was found to be significantly different (p< 0.001). The intervention group scheduled an average of 4 (±1.5) and the control group scheduled an average of 6 (±1.5) over 12 weeks.

Conclusion: A small sample size of 42 from one clinic caused effects to be insufficiently powered and lower generalizability. The study does not mention how compliance was measured with wearing the orthoses or daily exercises. Measurement bias is possible as therapists were not blinded to which group the participant was allocated to. Treating therapists also collected the measurements, influencing evaluation and favorment. There was a short follow-up period as no further assessments were done past 12 weeks. Co-interventions possibly occurred, such as taking anti-inflammatories or modalities that would affect outcome measures. This study has internal threats (maturation, instrumentation) and external threats (history – COVID-19, sampling bias, and setting influence). The authors concluded that there were similar outcomes after 12 weeks between a dorsal block and figure-of-8 orthoses regarding range of movement, pain, and function. The use of these orthoses in maximal comfortable extension could lower the number of appointments scheduled while increasing convenience for patients as well. To examine the outcomes of other types of orthoses and initial PIP positioning, further research on a larger scale is required.

Authors: Rachel Metts | Sarah Doerrer

CRITICALLY APPRAISED PAPER: “ROBOT- ASSISTED TRAINING AS SELF- TRAINING FOR UPPER LIMB HEMIPLEGIA IN CHRONIC STROKE: A RANDOMIZED CONTROLLED TRIAL”

Purpose: The research objective of this RCT is to examine whether robotic-assisted training (RT) could improve UE function and the use of the paretic UE during daily activities, as compared to conventional self-training methods in mild to moderate impairment hemiplegic chronic stroke patients. Level of evidence IB. This study highlights that an intensive approach to rehabilitation in UE paralysis after stroke is less effective in the chronic phase (6 months post stroke), but that motor improvements can still occur. When focusing on improving motor impairmant, CIMT and standard occupational therapy can be considered equally effective approaches and can be combined with robotic self-training with no additional harm. Movement Therapy (MT) which included RT and constraint Induced Movement Therapy (CIMT) training was found to be more influential than the control regarding the frequency of UE use and was the only group to reach a minimally clinically important difference with the MAL-14 . These results can guide OTP’s by implementing CIMT for learned nonuse and opting not to use robotic therapy on a stand-alone basis due to lack of evidence and substantial cost.

Methods: Participants were selected from 25 outpatient clinics in Japan. Inclusion criteria was between 20-80 years old, upper limb hemiparesis due to a stroke occurring at least 6 months ago, and undergoing rehabilitation to treat the UE. Also must have had a Fugl Meyer Assessment (FMA-UE) score greater than 44, upper limb function of 1b or higher on the Stroke Impairment Assessment Set, and a score of 2 or below on the Modified Ashworth Scale. Exclusion criteria was a diagnosis of multiple strokes, cerebellar/brain stem strokes, UE improvement without therapy, and extreme pain in affected UE. Also any neuromuscular diseases, balance/gait issues, aphasia, cognitive dysfunction and history of robot training, CIMT, or Botox. This study has three groups, two intervention groups which consist of the robot-assisted training (RT), the movement therapy (MT) group, and the control group. Each group received 1 hour sessions 3 times a week, for 10 weeks. The RT group received 20 minutes of therapist-led standardized occupational therapy as well as 40 minutes of robot-assisted self-training using the ReoGo-J upper-limb rehabilitation device. The MT group received 40 minutes of robot-assisted self-training using the ReoGo-J device and 20 minutes of therapist-led Constraint Induced Movement Therapy (CIMT) training. The control group received 40 minutes of self-training and also received 20 minutes of therapist-led standardized occupational therapy which included joint range of motion exercises, ADLs, correct-movement exercises, and stretching. There were 40 participants selected to be in each of the three intervention groups, before drop outs. There were various sites, each participant taking part of the intervention in the setting they were selected from.

Results: Primary Outcome Measure: FMA-UE which examines gain and loss of motor control in the affected limb. Items specifically related to the shoulder/elbow/forearm were additionally analyzed Secondary Outcome Measures: The Modified Ashworth Scale was used to assess muscle tone. The Motor Activity Log (MAL-14) scale was used to measure the amount of use of the affected limb and the quality of movements. The Action Research Arm Test was used to measure upper limb function and the Motricity Index was used to assess muscle strength. The Stroke Impact Scale measured quality of life. These measurements were taken at baseline, after 5 weeks of treatment, and then after 10 weeks of treatment. After 10 weeks of treatment there were no significant differences between primary and secondary outcome scores of the RT group and control group. After 10 weeks of treatment there were no significant differences between primary and secondary outcome scores of the RT group and MT group. There was a significant difference between the MT (0.67±0.11) and Control group (0.30±0.11, P =0.047) in the change of MAL-14, MT also met MCID requirements for meaningful change in this measure. No other differences occured between groups.

Conclusion: Training of research members was not described which could effect variability in outcome measurement. Participants and therapists were not blinded. The FMA-shoulder/elbow/forearm was not a valid and reliable tool since it included only specific items from the FMA-UE. Confounding variables such as age, time after stroke, degree of sensory and motor deficits could have impacted results. This study did not yield statistically significant results in examining whether robotic training could improve UE function as compared to traditional OT in hemiplegic/hemiparetic chronic stroke patients. The use of robotics may not be the best solution for chronic stroke patients and future research is needed to identify an optimal therapy treatment for this population.

Authors: Marisa D'Imperio | Sarah Doerrer

A CRITICALLY APPRAISED PAPER ON VIRTUAL REALITY REHABILITATION IN CHILDREN WITH BRAIN INJURY: A RANDOMIZED CONTROLLED TRIAL

Purpose: This study examined the impact of combining a virtual reality (VR) rehabilitation system with occupational therapy (OT) in hospital rehabilitation setting. Participants were children with brain injuries impacting upper limb function (ULF). The intervention included VR-based therapy and conventional OT to discover if VR impacts ULF in this population. This article is clinically relevant because implementing VR with traditional OT is an emerging practice that can enhance voluntary movement and therapeutic outcomes more than just conventional OT alone, specifically in pediatric brain injury populations. VR is becoming a more accessible tool that can be introduced to rehabilitation clinics to motivate children during therapy in a fun, engaging way to yield functional outcomes. Limitations in this study include lack of generalization due to location and population, general focus on children with cerebral palsy (CP), and lack of total immersion in the VR system. Future research should include a more diverse population, a greater variety of brain injuries, and VR experiences with varied levels of immersion.

Methods: Participants were from rehab institutions in Korea and China. Children aged 3-18 with CP or other brain injuries experiencing upper limb (UL) dysfunction were included. Children with severe intellectual disabilities, visual impairments, UL injections, chemo denervation, constraint-induced therapy, surgery, or changes to their antiseizure medications were excluded. Participants were randomly assigned to either the control or intervention group. A total of 80 children were enrolled in the study, however two dropped out (control group). The control group had 40 children (38 after dropouts) and received two 30-minute sessions of conventional OT daily in a 1:1 setting. Each OT session consisted of 10 minutes of the following: stretching, strengthening exercises, and task-oriented training. The intervention group (40), had a different regimen: one 30-minute session of VR training using the RAPAEL Smart Kids VR tool, and one 30-minute conventional OT session each day. The intervention was administered five days a week for four weeks, with a follow-up at eight-weeks post-intervention. Assessments were administered by one common blind assessor. All therapies were carried out by OTs blinded to group assignments. This blinding technique promotes unbiased evaluation of outcomes in all participants. Assessments were used at baseline, 4-weeks intervention, and 8-weeks post-intervention. The Upper Limb Physician Rating Scale (ULPRS) assesses arm movement patterns. The Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) measures functional skills in performance of activities of daily living (ADL), mobility, social-cognitive, and responsibility. The Melbourne Assessment of Unilateral Upper Limb Function-2 (MA-2) measures unilateral quality of UL movement. Each shows strong validity and reliability. Different computerized three-dimensional motion analysis (3DMA) programs measured joint angles in the UL: Vicon and OptiTrack, a gold standard; and Motion Analysis Corporation, used in biomechanical analysis. These measures offer insights into the efficacy of therapeutic interventions, assessing functional parameters, and facilitating outcomes in pediatric rehab.

Results: The ULPRS showed improvement in movement for both groups but was not significant. The PEDI-CAT (interval data) show significant improvement in ADLs (p<0.01). A Mann-Whitney U test compared functional differences within both groups. The social-cognitive domain improved in the VR group, but without significance. Mobility and responsibility show no significance between groups. The VR groups show significant improvement in all subscales of the MA-2. A linear mixed model was used to analyze ordinal data from the MA-2 and ULPRS. Independent T tests compare improvement between groups. Bonferroni was used on selective tests to reduce possibilities of false positives. Kinematic data (3DMA) measured joint angles of ULF. Forearm supination range of motion (ROM) was significant in the VR group (p=0.02), change was noted between baseline and the 8-week for both groups. Wrist extension ROM improved in the VR group, with no significance. The spatio-temporal parameters show improvement for control, with no significance. All statistical tests used were appropriate for the scales of measure. Results show potential for VR in improving functional outcomes but continued research is needed.

Conclusion: VR training shows enhanced dexterity, performance of ADLs, and forearm supination in children with brain injury. VR training is equally as effective as conventional OT for ULT in this population. Incorporating VR may complement therapy by offering motivation and enhancing motor learning. Further research could generalize the effectiveness of VR with traditional OT. Clinics can consider VR as an additional intervention to yield improved functional outcomes in pediatric clients.

Authors: Alison Liechty | Kate Ashby | Gretchen Bachman

CRITICALLY APPRAISED PAPER: "PHYSICAL EXERCISE AND OCCUPATIONAL THERAPY AT HOME TO IMPROVE THE QUALITY OF LIFE IN SUBJECTS AFFECTED BY RHEUMATOID ARTHRITIS: A RANDOMIZED CONTROLLED TRIAL"

Purpose: The objective of this randomized controlled trial was to evaluate the quality of life in patients with rheumatoid arthritis (RA) after a 30-day period of consistent physical exercise and occupational therapy (OT) interventions performed at home. This study is categorized as a level 1B. The study emphasizes the importance of occupational therapy (OT) guidance in enhancing the quality of life for outpatients with rheumatoid arthritis (RA). Through a 30 day at-home program of joint economy (combining physical exercise and OT interventions), results noted significant improvements in patient engagement of daily activities. Joint economy guidance was delivered by an occupational therapist, encouraging patients to effectively manage their RA symptoms within their own environment. The study suggests OTs can provide direction and personalized intervention plans to address the unique needs of RA patients to promote self-efficacy and overall quality of life. The study states further research is needed to explore long-term effectiveness.

Methods: This study was carried out at the Internal Medicine Department of ARNAS Civico-DI Cristina-Benfratelli Hospital in Palermo, Italy. There were 86 females and 74 males who enrolled, for a total of 160 outpatients with rheumatoid arthritis who were originally receiving care at the Rheumatologic Healthcare ambulatory in 2023. The exclusion criteria consisted of being younger than 18 years old, refusing informed consent, having deformations of joints that prevent physical exercise, and being severely anemic. The inclusion criteria consisted of a diagnosis of RA, being at least 18 years-old or older, and providing informed consent. Randomization was computer generated with 80 participants in each group. Intervention Group: Participants were provided a brochure containing information on rheumatoid arthritis, joint economy techniques, and detailed instructions for the exercises, which were to be performed at home. An OT and kinesiologist provided initial instructions and guidance for performing joint economy techniques. Exercises included flexing and extending of various joints, such as the ankle, knee, cox-femoris, elbow, wrist, and shoulder. Specific OT techniques were focused on the correct positioning of hands, body balance, and joint protection strategies during daily activities. Participants were to perform 20 to 30 minutes each day, six days a week, with one rest day, for a total of 30 days. Control Group: These participants were given the same brochure as the intervention group. The group was to continue with their daily activities and medical treatments from healthcare providers, but no additional interventions were given for the 30 days.

Results: Outcome measures were performed pre and post intervention and included: Health Assessment Questionnaire (HAQ): Measures physical disabilities. The measurement is based on the ability to perform activities such as dressing, grooming, walking, and hygiene. Short-Form Health Survey (SF-12) - Italian Version: Measures physical health, bodily pain, general health, vitality, social functioning, and role limitations, based on emotional and mental health. Disease Activity Score (DAS 28): Measures the presence of synovitis within 28 joints. Both C-reactive protein (CRP) (DAS28crp) and erythrocyte sedimentation rate (ESR) (DAS28esr) are used to measure RA activity. Significant improvements were found in outcomes from joint economy intervention for patients with RA. Enhancements in Disease Activity Score (DAS28) for both the Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP), with statistical significance at (p = 0.005 and p = 0.004, respectively). The Health Assessment Questionnaire (HAQ) scores showed significant enhancement (p = 0.009), as well as improvements in the SF-12 Mental Component Score (p = 0.010). The study analyzed the results using Fisher’s exact test, z-test, Mann-Whitney U test, and Wilcoxon signed-rank test.

Conclusion: Limitations included participant drop out not addressed, compliance of performing the exercises at home was not measured, and there was no follow-up post intervention. The study solidified that self-management increases self-efficacy, improving individuals’ independence and overall quality of life. It is critical that patients are performing physical exercises correctly to produce greater results in the management of their rheumatoid arthritis symptoms. To ensure the performance of exercises, it is important to have an occupational therapist that is available for educational purposes and support. Lastly, the authors believe further research is needed to reinforce these findings.

Authors: Elise Jernigan | Laurie Rogers

CRITICALLY APPRAISED PAPER: Klevberg G, Zucknick M, Jahnsen R, Eliasson AC. Development of hand use with and without intensive training among children with unilateral Cerebral Palsy in Scandinavia. Developmental Neurorehabilitation. Dev Neurorehabil. 2023; 26(3):163-171.

Purpose: The purpose of this longitudinal cohort study was to investigate the efficacy of Constraint Induced Movement Therapy (CIMT) in children with UCP. It aimed to demonstrate the long-term positive effects on motor function development. The study aimed to provide insight into the optimal developmental window, allowing for improved neuroplasticity in children with UCP.

Methods: Norwegian participants were selected based on registration through the Norwegian Quality & Surveillance Registry CP (NorCP) with previous intensive hand training & completion of 2 AHAs (Assisting Hand Assessment). Swedish participants' selection included data collection from 2004. Inclusion criteria included classification of brain injury, ages, & the availability of AHA scores. Exclusion criteria included those no parental consent, no hx of CIMT, failing to meet brain injury criteria, lacking registration with NorCP, & non-residences of Norway or Sweden. The Norwegian cohort received tx at a regional pediatric rehab unit. The Swedish cohort received tx at Karolinska Hospital. Baby-CIMT & CIMT sessions were provided by a trained parent, teacher, or OT. The first experimental group, CIMT, had sessions for 2hr/day for 2mo (80-120 hrs). The 2nd experimental group, Baby-CIMT, received tx during a 6wk period for daily 30mins of training for a total of 30-40 hrs. Baby-CIMT training time was reduced due to age. The CIMT & Baby-CIMT groups n=195, while the non-intervention (NIT) group n=139. The total participants, n=334. Group 1, CIMT, n=144. The intervention took place in the home or preschool & was provided by a trained parent or teacher. This intervention lasted around 2mo (80-120 hrs). Group 2, NIT, n=139 that received standard pediatric rehab services. An OT or PT provided the standard practice interventions. Group 3, Baby-CIMT, n=51. The intervention process was completed in the same manner as the CIMT group. The study used 2 outcome measures which are both reliable & valid to assess functional abilities & manual dexterity. The AHA & MCAS were selected as both have good inter-rater reliability. AHA evaluates the affected hand in bimanual play by using a scale for performance. The second is the MACS or the mini-MCAS which was developed to categorize manual handling abilities of the CP population by their ability levels. This study relies on the AHA & the MACS which measure functional abilities, manual dexterity, & developmental progress in the UCP population.

Results: Findings showed intensive training could prolong periods of developmental growth for children receiving CIMT. The Baby-CIMT group did not show a significant change (p=.45) compared to the NIT group, but showed a positive trend. Statistical tests were appropriate. Pearson’s correlation coefficient & Fischer’s exact test were used to compare the categorical data. Welch’s Independent T-test was used to compare continuous variables of the AHA & MCAS, which is appropriate as this analysis does not require equal variance between populations. A one way between groups ANOVA was used to compare the means between training groups, appropriate for more than 2 independent groups. Tuckey’s test was used to compare the means between sessions for the AHA (simultaneous pairwise comparisons). Significance was not noted (p=.342) between countries. Tables represent the data used for analysis. There were limiations to this study. Selection bias & convenience sampling were noted as participants were only from two countries, age, registration in NorCP, or a hx of intensive training leading to lack of generalizability. Measurement bias was also reported due to subjectivity of the reading of both the AHA & MCAS. Lack of blinding could result in a bias of the subjective reading of the outcome measures. Intervention bias was seen in experimental groups as tx were given by either trained teachers or parents. The NIT only received standard care. The study did not run a power analysis, however, because of the large sample size & limited variable, adequate power is inferred. Group size may have led to differences in reported significance. Data was adjusted based on the participants' country of origin, but not on group size. Authors also state Botox injections may have skewed final results. CIMT participants did not meet the recommended hours for training, instead averaged 80-120 hrs. No dropout rate was reported, but participants remained the same through the study.

Conclusion: Standard interventions & earlier implementation facilitate neural connections that can transmit information to an affected limb. The study concludes that brain ability to self-repair & make motor adaptations, intensive training should occur when a child is young. There is a need for more long-term studies that support early interventions among the UCP population. Future research could compare CIMT protocol on older children, focus on other countries with different standard practices of intensive hand training, & improve generalizability of CIMT in other populations.

Authors: Victoria Bagley | Amy Bates | Gretchen Bachman

CRITICAL APPRAISAL PAPER: “SENSORY INTERVENTIONS ON MOTOR FUNCTION, ACTIVITIES OF DAILY LIVING, AND SPASTICITY OF THE UPPER LIMB IN PEOPLE WITH STROKE: A RANDOMIZED CLINICAL TRIAL”

Purpose: The purpose of this single-blind randomized controlled trial was to understand the effect of exteroceptive and proprioceptive stimulations on motor function, spasticity of the upper limb, and activities of daily living in chronic phase post-stoke patients. This study is a level 1B. Some of the most common abnormalities OTs address in these patients, is impaired muscular coordination and pain that impacts range of motion (ROM), and can cause permanent deformity in the UE. One of the areas that isn’t typically considered in rehabilitation programs, but is another common abnormality that reduces quality of movement and activity in the affected side, is sensory deficit. This can cause reduced feedback from objects, weakness in fine motor and manipulation skills, and decreases the use of the affected limb. Results of this study concluded that the use of exteroceptive and proprioceptive stimulation are effective techniques for OTs to improve motor function, ADL participation, and spasticity in chronic stroke patients. These interventions are inexpensive, noninvasive, and easy to perform, so can be easily implemented into conventional therapy practice in any setting.

Methods: Convenience sampling was used to recruit N=60 who were referred to the Red Crescent Clinic of Isfashan Province in Iran. N=30 were randomly allocated into both an intervention and control group by encoded envelope. Inclusion Criteria Adults 50+ y/o who had experienced one stroke, were in the chronic phase, had the ability to detect the 4.31 monofilament in their fingers, were a Brunnstrom’s Stages of Stroke Recovery stage 4 or higher, and had the cognitive ability to understand instructions. Group 1: Intervention Group N=30 received exteroceptive and proprioceptive stimulations, in addition to convention OT interventions. An OT performed these interventions, as well as those for the control group, at the clinic for 6 weeks, 4x a week, in 45min sessions. - Exteroceptive stimulations were applied to the C6, C7, and C8 dermatomes to stimulate elbow and wrist extensor sensory nerves in the superficial layer of the skin, normalizing tone and motor development: fast brushing (6min-30s on, 1min off), icing (3 fast stimulations 2-3 times, for 5min), and stretch pressure (3min), with a 3min rest period between each technique. - Proprioceptive stimulations were used to activate muscle spindles, tendons, and joints to increase movement and control over motor response in the UEs: 10min of weight bearing and heavy joint compression in the side-sitting position for 5min and in quadruped for 5min. Stretch pressure was then performed for 5min (3s on, 3s off), wherein the pads of the thumb, index, and middle fingers were placed on the corresponding dermatome and pressed together. Group 2: Control Group N=30 received conventional OT interventions: exercises for strengthening and improving UE ROM and fine movement.

Results: Evaluated 3x- before beginning the intervention, at week 3, and at week 6, by an independent OT blinded to group allocations and interventions - Fugl-Meyer Assessment (FMA): Motor function; article reports high intrarater and interrater reliability - Barthel Index (BI): Independence in ADL performance; article reports sufficient validity and reliability - Modified Ashworth Scale (MAS): Muscle tone/spasticity; article reports excellent validity and reliability A homogeneity data analysis and independent t-tests (p<0.05) were performed, which found the same distribution of age and duration post-stroke and no statistical difference between groups for any outcome measure at baseline; FMA: p=0.7, BI: p=0.941, MAS: p=0.1 - FMA: Results are statistically significant, suggesting that exteroceptive and proprioceptive stimulations together, did improve motor function of the UE- Week 3: p=0.000 & Cohen’s d (d) effect size= 0.81; Week 6: p=0.000 & d=0.73 - BI: Results are statistically significant, indicating the interventions did improve ADL performance- Week 3: p=0.000 & d=0.74; Week 6: p=0.000 & d=0.55 - MAS: Results are statistically significant, demonstrating the interventions were successful in decreasing UE spasticity- Week 3: P=0.001 and d=-0.43; Week 6: P=0.002 and d=-0.43

Conclusion: Limitations- Focused only on UE, Small sample size, No follow-up, no exclusion criteria was listed. This was the 1st study that used exteroceptive and proprioceptive stimulations together to measure motor function, ADL performance, and spasticity. No statistical difference was found between groups at baseline for any outcome measure or variable; however, after the 3rd and 6th week of interventions, participants motor function, ADL performance, and spasticity of the UE improved compared to the control group. Effect sizes for all measures also demonstrated the strong relationship between variables. Despite these evidential conclusions, it is recommended that practitioners additionally reference similar studies which have found similar outcomes.

Authors: Lauren Hirst | Sarah Doerrer