My current full time job is in a 200-bed acute hospital with acute inpatient and out-patient departments. My caseload is composed mostly of adults from 21 to 100 years old, and on rare occasions, we get pediatric consults from our NICU,and pediatric units. I have been trying to build our out-patient clinic dealing mostly with neurological and upper extremity cases for three years. It has been a slow, difficult journey, loaded with a lot of growth and learning opportunities. Just recently, we purchased capital equipment for our OT department including standardized evaluation kits, assessment tools and supplies. One is the DASH (Disabilities of the Arm, Shoulder and Hand) Outcome Measure to determine functional outcomes for our hand and upper extremities patients. The current practice of occupational therapy here in the Texas Rio Grande Valley area has been challenged as to the usefulness of its contribution in adult and elderly patient care in the acute hospital setting. It is extremely hard to establish a service differentiation in the public consumer mindset between the services of a physical therapist and an occupational therapist since there is very few function-based research done on standard occupational therapy interventions, and even fewer documenting evidence that ties the positive results with improved functional performance. Most of the out-patient hand therapy clinics which have been in existence for an established period of time are owned and managed by physical therapists and physicians. A majority of my time is spent collaborating and networking with the nurses, case managers, physical therapists, physicians, and our administrators to assist us in marketing the services that we provide.
Iris Luanne De La Calzada, OTR/LBoston UniversityMay 2009
Purpose Limitations of researchIntroduction Implications forThe “patient-oriented” practice/policiesapproach My practice scenarioWhat is the difference? ReferencesThe questionSearch methodsMajor findingsConsistencies andinconsistencies
To look at evidence-basedinformation on the superiority of apatient-oriented handrehabilitation program overconventional methodsTo determine the significance ofthe role of occupational therapistsin such programsTo determine the various ways ofimproving service delivery in out-patient hand clinic
Work-related upper extremity injuries Loss of productivity Increased medical costs for injured workers Increased disability payments for employersMOST COMMON CAUSES: SPRAINS & STRAINS POOR BODY MECHANICS & POSITION FALLS United States Bureau of Labor Statistics Fact Sheet. (November 20, 2008). Nonfataloccupational injuries and illnesses requiring days away from work, 2007. Retrieved on March 24, 2009 from website: http://www.bls.gov/news.release/pdf/osh2.pdf
WHAT IS IT?a concept that uses an ongoing investigation of factorsthat increase quality of care delivered based on :1. Functional outcomes2. Client satisfaction3. Overall reduced worker’s compensation cost - uses a client-centered toolkit -patient is an active participantHarth, A., Germann, G., Jester, A. (2008). Evaluating the effectiveness of a patient- oriented hand rehabilitation programme. The Journal of Hand Surgery (European Volume),33E(6). 772-778. *
Mossberg, K. and McFarland, C. (2001). A patient-oriented health status measure for outpatient rehabilitation. American Journal of Physical Medicine & Rehabilitation, 80(12). 896-902.
The Question:For adults with work-related upper extremity injuries,does a patient-oriented hand rehabilitation result inearlier return to work and improved functionaloutcomes than conventional occupational therapyintervention?
Consistently good results in 3 studies in terms offunctional outcomes using the patient-orientedapproach compared to traditional approach
Adults: 16-64 years No RCTs, all 6 studies withRacial, ethnic, or different non-RCT designssocioeconomic groups not 4 measured work as outcomeconsidered with good results4 of 6 studies had more male Attitudes toward return toparticipants work and actual return toVarious orthopedic /non- work after discharge notorthopedic injuries and exploreddisorders DASH was a useful toolNo mention of training for CIQ scores with poorprofessional providers correlationOnly 1 study with exclusiveoccupational therapy
Weak, AOTA levels I-IV Patient-orientedOTs as contributors approach is NEW!No RCTs done within last US healthcare is not5-10 years government controlledSample sizes >20 All studies found did notLack of uniformity on measure occupationalresearch methodology therapy contribution in hand rehabilitation inLack of practice standards isolationin quality assuranceStrongest evidence fromstudies completed abroad
Complete more RCTs in the Focus on role of OTs in theUnited States transition to from medicalPromote OTs as primary model to patient-orientedresearchers or team leaders service deliveryor consultantsResearch payment and MY PRACTICE SCENARIO:reimbursement system Advocate the creation of RTWAdvocate patient-oriented and hand rehabilitationhand rehabilitation and RTW programsprograms as added employee Adapt the patient-orientedbenefits service deliveryEmphasize OTs ‘ responsibility Use evidence-based data ason the psychosocial guide for practicecomponents
ReferencesCase-Smith, J. (2003). Outcomes in hand rehabilitationusing occupational therapy services. American Journalof Occupational Therapy, 57. 499-506. *European Federation Societies for Hand Therapy (EFSHT)Education Committee (2008). European Certified Hand Therapist Profile. Retrieved on January 27, 2009 from website: http://www.eurohandtherapy.org/documents/EFSHT_Hand_Therapist_Profile.pdfHand Therapy Certification Commission (2001). Who is ahand therapist? Retrieved on March 19, 2009 from website: http://www.htcc.org/about/index.cfmHarth, A., Germann, G., Jester, A. (2008). Evaluating theeffectiveness of a patient-oriented hand rehabilitationprogramme. The Journal of Hand Surgery (EuropeanVolume),33E(6). 772-778. *Goodman, G., Browning, M., Campbell, S., Hudak, H.(2005). Evaluation of an occupational rehabilitationprogram. Work Journal, 24. 33-40. *Lieberman, D., &Scheer, J., (2002). AOTA’s evidence-based literature review project: An overview. AmericanJournal of Occupational Therapy, 56 (3). 344-349.Matheson, L., Isernhagen, S., Hart, D. (2002). Relationshipsamong lifting ability, grip force, and return to work.Journal of the American Physical Therapy Association,82(3). 249-256. *Mossberg, K. and McFarland, C. (2001). A patient-oriented health status measure for outpatient rehabilitation. American Journal of Physical Medicine & Rehabilitation,80(12). 896-902.
Pomerance, J. (2009). Return to work in the setting of upperextremity illness. Journal of Hand Surgery, 34A.137-141.Rempel, D., Harrison, R., and Barnhart, S. (1992). Work-relatedcumulative trauma disorders of the upper extremity. Journal of the American Medical Association, 267(6). 838-842.The German Federal Ministry of Education and Research. (2006). Patient-oriented research. Retrieved on January 27, 2009 from website: http://www.bmbf.de/en/6647.php#topTschernetzki-Nielson, P., Brintnell, E., Haws, C., Graham, K. (2007). Changing to an outcome-focused program improves return to work outcomes. Journal of OccupationalRehabilitation, 17. 473-486. *United States Bureau of Labor Statistics (2007, May). Occupational Employment and Wages:Occupational Therapists. Retrieved on April 14, 2009 from website:http://www.bls.gov/oes/2007/may/oes291122.htmUnited States Bureau of Labor Statistics Fact Sheet. (November 20, 2008). Nonfataloccupational injuries and illnesses requiring days away from work, 2007. Retrieved on March 24, 2009 from website: http://www.bls.gov/news.release/pdf/osh2.pdfWong, J., Fung, B., Chu, M., Chan, R. (2007). The use of disabilities of the arm, shoulder, and hand questionnaire in rehabilitation after acute traumatic hand injuries. Journal ofHand Therapy, 20. 49-56. *