Do current upper limb orthotic classification systems help clinicians choose and design effective orthoses? A scoping review with expert interviews.

BACKGROUND: Orthosis (orthotic) fabrication is an essential part of the treatment plan for many upper extremity conditions. PURPOSE: We aim to comprehensively identify the current body of evidence about the purpose, structure, scope, and application of available orthotic classification systems. Our secondary aim was to know if the current classification systems can be used as a decision guide for clinicians. STUDY DESIGN: A scoping review. METHODS: A scoping review of research studies identified through data-based and gray literature was conducted to determine studies that addressed classification systems of the orthosis (orthotic) in the hand and upper limb. Two investigators screened study titles and abstracts and did the data extraction. To do a comprehensive review, all the hand therapy associations were contacted and asked to share their specific orthosis classification system. To answer our second aim, we discussed our findings with the experts in a panel. RESULTS: Twelve different classification systems were identified, which were developed with different aims. Five classification systems classified orthosis based on their function (n = 5, 50%); one based on therapeutic goals and proposed a decision algorithm. Two of the proposed systems were aimed at helping in decision-making or offering an algorithm for therapists to help them choose the proper orthosis. The expert panel process identified that the current classification systems could not help clinicians select proper orthosis for their patients. CONCLUSIONS: There are different classification systems which were developed with various aims. However, none of those can help clinicians make informed decisions about appropriate orthosis choices for their patients.

Outcomes Following Surgical Interventions for Isolated Lunotriquetral Interosseous Ligament Injuries: A Systematic Review.

Ulnar-sided wrist pain can be attributed to various bony and ligamentous structures. The purpose of this review is to compare outcomes following surgical interventions for isolated lunotriquetral (LT) interosseous ligament injuries in adults. We assessed 202 procedures from 9 retrospective case series studies of low to moderate quality based on the Structured Effectiveness Quality Evaluation Scale. The comparative outcomes (ie, range of motion, pain, strength, quality of life, complications, return to work, and patient satisfaction) were aggregated and categorized under arthrodesis, capsulodesis, ligament repairs and reconstruction, and ulna shortening osteotomy procedures. Although the comparison of outcomes was largely inconclusive due to the heterogeneity and the omission of preoperative characteristic data, we did observe higher complications and reoperation rates post LT arthrodesis. It is recommended that all outcomes be standardized and presented uniformly with best practices developed to better characterize the injury's severity and integrity in future studies.

A description of the barriers, facilitators, and experiences of hand therapists in providing remote (tele) rehabilitation: An interpretive description approach.

BACKGROUND: Telerehabilitation is increasingly being used to meet the rehabilitation needs of situations where face-to-face therapy is not possible. Nevertheless, reports on barriers and facilitators of implementing this method from the perspective of therapists still need to be made available. PURPOSE: To investigate the experiences of hand therapists when implementing telerehabilitation, examining the difficulties, barriers, and facilitators encountered during its implementation. STUDY DESIGN: Qualitative study. METHODS: This study used a purposive sampling method to recruit therapists with varying experiences in telerehabilitation and conducted semi-structured interviews. Data collection and analysis continued iteratively until thematic saturation was achieved. A total of 14 therapists were interviewed via Zoom. The interviews were recorded, transcribed, and qualitatively analyzed using thematic analysis. The process of interpretive description guided interviews and analysis of the interviews to identify key barriers and facilitators in providing telerehabilitation. RESULTS/DISCUSSION: Six main themes and 10 corresponding sub-themes were constructed concerning facilitators and barriers to telerehabilitation: factors related to the patient, therapy, therapists, injury, technology, and policy. Therapists implemented different coping strategies in their interventions and measurements to facilitate treatment. However, some interventions, such as orthotic fabrication, could not be done online. Educating therapists, providing a standard method, and integrating with in-person rehabilitation can overcome the barriers to telerehabilitation in hand therapy. CONCLUSIONS: Technology was the main facilitator and, on the other hand, a barrier to providing online hand therapy interventions. Therapists generally reported high satisfaction and usability of this method. Despite all barriers, telerehabilitation can be implemented as a part of hand therapy interventions alongside face-to-face therapy as a hybrid method. The barriers and facilitators experienced and raised by therapists can be added to what is already known regarding telerehabilitation in hand therapy. They might be applied to guide therapeutic procedures and upcoming studies.

A systematic review of biopsychosocial prognostic factors of recovery after a proximal humerus fracture.

BACKGROUND: Proximal humerus fracture (PHF) is a common upper extremity injury. PHF often causes prolonged disability and interferes with independent function. PURPOSE: This study reviewed and summarized prognostic factors of recovery following PHF and classified them within the International Classification of Functioning, Disability and Health (ICF) with each domain sub-categorized by modifiability. STUDY DESIGN: Systematic review. METHODS: We searched MEDLINE, CINAHL, EMBASE, and PsychINFO from the date of database inception to March 2019 and updated searches in December 2021. Studies included examining an association between prognostic factors and recovery with at least a 6-month follow-up. Two independent reviewers used the Quality in Prognosis Studies tool for methodological bias and levels of evidence. Designs showed wide variability in terms of characteristics of the included population, definition of recovery, assessment of prognostic factors, and outcome measures used. This prevented pooled estimates from being produced. Prognostic factors linked to ICF domains were possible. RESULTS: Twenty-three studies including 4323 participants aged ≥18 met inclusion criteria. The risk of bias was low (35%), moderate (30%), and high (35%) across the included studies. Moderate evidence showed a significant association between pre-fracture functional independence and post-fracture complications with recovery. Fracture type, structural deformity, medication use, age, and gender were prognostic factors with inconclusive evidence. We assigned a weak level of evidence to the remaining 20 factors due to limited data. Immediate rehabilitation, compliance to post-fracture rehabilitation exercise, task-oriented exercise, and pain self-efficacy (i.e., coping behavior) are modifiable and are tapped into the ICF contextual factors. CONCLUSIONS: An array of factors that fit within an ICF biopsychosocial framework have been investigated as potential mediators of outcomes after PHF. The evidence is incomplete conceptually and in terms of research design quality. Preoperative functional status is predictive of functional recovery emphasizing the importance of healthy aging.

Understanding individuals' perspectives and experiences of recovery following a proximal humerus fracture: an interpretive description.

PURPOSE: Proximal humerus fractures are common in older adults and optimizing their outcomes following this injury can be challenging. This study explored recovery from the perspective of individuals who experience proximal humerus fracture. MATERIALS AND METHODS: We conducted in-depth semi-structured interviews (n = 14) with participants (aged 45 and over) recruited from a hand clinic in London, Ontario using a purposive sampling technique. The exploratory interviews were audio-recorded, transcribed, and analyzed using interpretive description approach. RESULTS: Four themes emerged from the narratives of individuals: challenges of day-to-day activities, coping as you go, recapturing valued life roles, and support matters. CONCLUSIONS: Recovery after PHF seems relative to contexts and manifests within numerous scenarios. Based on individuals' narratives, the context produces a mosaic that contributes to unique recovery perception and experience. Awareness of the context emphasizes the complexity inherent in recovery and may guide healthcare professionals' efforts toward care for their patients.IMPLICATIONS FOR REHABILITATIONIndividuals with proximal humerus fracture experience recovery as a personal and dynamic process occurring in their diverse contexts.Healthcare professionals need to recognize the significant impact of context on individuals' physical, emotional, and social life following proximal humerus fracture (PHF).A multidisciplinary treatment plan might be desirable where people with PHF and health care professionals collaborate as a whole.Building a multidisciplinary health team including healthcare professionals, peer support, and case management may remove some barriers and facilitate the transition to recovery.

The use of occupation-based interventions and assessments in hand therapy: A cross-sectional survey.

INTRODUCTION: The purpose of this study was to gather information on how hand therapists incorporate occupation-based interventions in their clinical practice and what outcome measures hand therapists use to measure the occupational performance of their clients STUDY DESIGN: Cross-Sectional Survey Design. METHODS: The 16-item Survey was distributed to members of the American Society of Hand Therapists on two occasions. RESULTS: Three hundred eleven hand therapists responded to the survey. Hand therapists use a variety of occupation-based interventions (OBI) in clinical practice and most believe they are important. Findings from this study reveal that incorporating an occupation-based assessment along with or in place of an assessment of body functions and structures is not performed routinely. One hundred twenty-six (41%) respondents indicated that they use occupation-based activities 26-50% of the time with their clients. DISCUSSION: The top three OBI interventions used by hand therapists included dressing tasks, cooking and meal preparation, and in hand manipulation of coins and medication. The lack of understanding of the theoretical models regarding occupation-based interventions may be a barrier toward implementation of occupation-based interventions and assessments as many hand therapists may have trained under a medical model. CONCLUSION: Most respondents to this survey indicated that they believe OBI should be performed by hand therapists and use them routinely in practice. The most frequently used type of assessment was the DASH (Disabilities of the Shoulder Arm & Hand). The least frequently used assessment was the Short Form 36 and patient specific occupation-based assessment.

An Interpretive Descriptive Approach to Understanding Osteoporosis Management from the Perspective of People at Risk of Fracturing.

Purpose: Adherence to both non-pharmacological and pharmacological fracture prevention interventions is often low in people with osteoporosis. Understanding how patients acquire information about osteoporosis management is important for understanding both the initial decision-making and ongoing adherence. This study explored the narrative of people living with osteoporosis and their personal experience getting information about their osteoporosis management. Methods: An interpretive descriptive method was used for this qualitative study. In-depth interviews were conducted with 13 Canadian participants (age range 51-90) who knew that they had osteoporosis or osteopenia. Participants were asked to participate in one-on-one interviews to address the type of health professionals providing osteoporosis management advice focusing specifically on advice received about exercise, nutrition, and falls prevention. Interviews were transcribed verbatim and coded sentence-by-sentence. Results: People with osteoporosis rely on physicians for advice related to pharmacological treatment needs, and other health professionals for non-pharmacological needs such as exercise advice, nutrition advice, and falls prevention advice. People value non-professionals, such as family members and close friends, who may or may not have osteoporosis, to discuss or corroborate health professional advice, or to validate their belief system. Conclusion: Training patients to more effectively engage in conversations with their healthcare providers may be a strategy to improve the quality of communication and its translation into adherence to best practices in managing osteoporosis.

An interpretive descriptive approach of patients with osteoporosis and integrating osteoporosis management advice into their lifestyle.

INTRODUCTION: Although osteoporosis-exercise recommendations have been established, implementation of the information remains a challenge for people with osteoporosis. This study aimed to understand how participants integrate osteoporosis management advice into their lifestyle and the challenges they might face. METHODS: Integrative descriptive methods were used for this qualitative study. In-depth interviews were conducted with 13 Canadian participants (age range 51-90) that knew they had osteoporosis. Participants were asked to participate in one-on-one interviews; discussing exercise, nutrition and falls prevention for people with osteoporosis. RESULTS: The following themes emerged from this study: understanding fragility fractures and fall risk, knowledge acquisition through personal and vicarious experience over the lifespan, awareness of environmental risks and opportunities, understanding the effect of exercise on the bones and in life, challenges managing exercise expectations, attitude towards non-pharmacological management. CONCLUSION: Participants recognized the benefit of non-pharmacological management for managing osteoporosis, but sometimes found it difficult to integrate into their daily activities due to lack of time or knowledge. Participants weren't always clear on which component of their osteoporosis management should be prioritized.

Comparison of finger kinematics between patients with hand osteoarthritis and healthy participants with and without joint protection programs.

STUDY DESIGN: This is a cross-sectional, clinical observational study. BACKGROUND: Finger range of motion (ROM) and functional performance are critical in many daily activities. Hand osteoarthritis (H-OA) is a prevalent disease that impairs both variables. Little quantitative research has been performed on finger kinematics during activities of daily living (ADLs) across health status and method of performance (with or without joint protection programs). PURPOSE: The purpose of this research is to examine the effects of H-OA and method of performance on ROM in the thumb, index, and middle digits (flexion/extension and abduction/adduction) during ADLs. METHODS: This study was conducted using 10 healthy participants (mean age: 28 years) and nine participants with H-OA (mean age: 72 years). All participants performed baseline ROM movements followed by 9 activities of daily living. These activities involved prehension type grasps and were performed with and without the recommended joint protection procedures specific to each task. Thumb IP and MCP, index distal interphalengeal (DIP) and proximal interphalengeal (PIP), and middle DIP and PIP joints were continuously recorded using an electromagnetic tracking system for ROM analysis. RESULTS: Participants with H-OA had a statistically significant decrease in ROM when comparing values measured in the healthy cohort during active ROM (25° decrease) and ADL ROM (25° decrease) in the flex/ext direction. Similarly, following joint protection instruction, a statistically significant decrease in ROM was found during tasks in the flex/ext direction (healthy participant decrease in ROM: 17°, H-OA decrease in ROM:10°) CONCLUSIONS: This study demonstrated that people with hand arthritis move through a smaller arc of motion when performing some functional tasks as compared with the controls, and that with instruction on joint protection techniques, participants made significant changes in the amount of movement used to perform tasks, which supports a proof of principle of joint protection.

Virtual health care & telehealth: Current therapy practice patterns.

STUDY DESIGN: Survey Study. PURPOSE: To investigate recent practice changes with respect to the provision of virtual visits by hand therapists due to the COVID-19 pandemic by asking about changes in the frequency of virtual visits, the assessments and treatments currently provided virtually, and the opinions of therapists on the future on virtual visits in hand therapy practice. METHODS: The survey was distributed to the American Society of Hand Therapists (ASHT), the Australian Hand Therapy Association (AHTA), the Canadian Society of Hand Therapists (CSHT), and the European Federation for the Societies of Hand Therapy (EFSHT). RESULTS: Of the 819 responses, there were 573 therapists (70%) who reported that they currently use virtual visits in their practice. Only 38 therapists (4.6%) were providing virtual visits prior to COVID-19, representing a 15-fold increase in virtual visits since the beginning of the pandemic. Only 26% (n = 213) reported that they used patient-reported outcome measures (PROM) in conjunction with their virtual visits. Approximately 78% (n = 638) said that they thought there is a sustainable future for this method of care in hand therapy practice. DISCUSSION: This survey has helped identify the changing landscape in the provision of rehabilitation and established some of the common assessments and interventions currently utilized by hand therapists in the virtual environment. Next, steps for research are to investigate the reliability and validity of some of the assessments and interventions used, to establish whether virtual care will provide good outcomes for patients, and ultimately understand the optimal combination of conventional therapy and virtual care.

Online learning versus workshops: a rank minimized trial comparing the effect of two knowledge translation strategies designed to alter knowledge, readiness to change, and self-efficacy with respect to rehabilitation outcome measures.

PURPOSE: Traditional face-to-face learning is often replaced by virtual learning because it can be more feasible and cost-effective, and more recently due to the need for social distancing. The objective was to evaluate the effectiveness of two innovative knowledge translation (KT) interventions; in-person stakeholder-hosted, interactive, problem-based seminars (SHIPS) versus online problem-based tutorials (e-PBL) in changing knowledge, readiness to change, and self-efficacy with respect to the use of rehabilitation outcome measures. METHODS: Physical and occupational therapists (n = 124) were recruited from four sites across Canada to participate in either an e-PBL or SHIPS. Evaluations of KT impact measured knowledge, self-efficacy to implement outcome measures in practice, and readiness to change. RESULTS: There were 112 participants who completed the study. Following the intervention, the mean knowledge scores for both groups improved, but there was greater improvement in participants who completed SHIPS. For self-efficacy and readiness to change, there was no significant difference between groups six months following the interventions. E-PBL was as good as a SHIPS for improving and retaining self-efficacy and readiness to change. CONCLUSIONS: Knowledge improved more with workshops than online delivery, while improvements in self-efficacy and readiness to change improved similarly regardless of delivery.Implications for RehabilitationThis study compared the relative efficacy of internet and workshop-based education, focusing specifically on the use of outcome measures in physical and occupational therapy practice.Improvements in the self-efficacy of rehabilitation professionals with respect to outcome measure use had lasting effects regardless of KT intervention type, as it was retained six months following the intervention.Results from this study show that online interventions may be as effective as face-to-face workshops for improving readiness to change and self-efficacy for using outcome measures in practice by rehabilitation professionals.This is valuable information given the recent global pandemic, the need for social distancing, and the potential for learning interventions to focus within the online environment in the future.

Hands-Up program: protocol for a feasibility randomised controlled trial of a combined 6-week exercise and education intervention in adults aged 50-65 with a distal radius fracture.

INTRODUCTION: This pilot study will determine the feasibility of recruitment, retention and adherence for the online combined exercise and education programme (Hands-Up) compared with usual care. METHODS AND ANALYSIS: The proposed randomised controlled trial will be a pilot feasibility study with a 1:1 randomisation to the Hands-Up programme or usual physical therapy. The programme setting is an online home exercise and education program. Outcome assessments will take place at the Roth|McFarlane Hand and Upper Limb Clinic in London, Ontario, which is a tertiary care academic centre. 74 people aged 50-65 years after distal radius fracture will be recruited. Purposeful recruitment will be conducted to include a sufficient number of men in the study. The Hands-Up program includes both exercise and education. Participants will engage in approximately 45 min of a full-body home exercise routine followed by 30 min of education in an online program. The educational modules will focus on fall prevention, nutrition for osteoporosis and learning about osteoporosis. Participants will engage in the program online, twice a week for 6 weeks. Outcomes will be assessed at baseline, 6 weeks and 3, 6 and 12 months. The primary outcome of the study is feasibility. The study will be considered feasible if participants attend >60% of the sessions, 74 participants are enrolled in 12 months and >75% of participants attend the final study visit. For the secondary outcome, physical and self-report outcomes will be assessed. ETHICS AND DISCUSSION: This study has been approved by the institutional ethics review board. The viability of an online exercise and education program for people after distal radius fracture between the ages of 50 and 65 will be evaluated in an attempt to help better prevent, diagnose and manage osteoporosis. This study will be disseminated through peer-reviewed publications, international conferences and social media. TRIAL REGISTRATION NUMBER: NCT03997682.

The impact of cell phone texting on superficial blood flow, touch threshold, and symptoms for individuals with carpal tunnel syndrome.

BACKGROUND: It is unclear how individuals with carpal tunnel syndrome (CTS) are affected by texting, or how the texting performance of those with CTS might be impaired or different from individuals without CTS. OBJECTIVE: The primary purpose of this case-control study was to determine the immediate effects of texting on superficial blood flow, sensory threshold, and symptoms of fatigue, numbness, and pain for individuals with CTS compared to asymptomatic age-matched controls. Another objective was to detect differences in texting performance between the two groups. METHODS: Superficial blood flow, pain, fatigue, numbness, and touch threshold were measured before, and at three time points following a standardized 15-minute texting task. Overall texting speed was compared between groups. RESULTS: Changes in red blood cell concentration after the texting task was not significantly different for either the CTS group or controls for any of the measurement time points. Mean touch thresholds at baseline were 4.0 g/mm2 for the CTS group versus 2.6 g/mm2 for healthy controls; a 53%greater touch threshold. Following the texting task, touch threshold did not change for normal controls, but increased to 6.7 g/mm2 for the CTS group, representing a significant increase in touch threshold from baseline. Texting performance was compromised in people with CTS, and symptoms worsened with a short-term controlled texting task. CONCLUSIONS: Our results suggest that texting performance is limited in individuals with CTS and that texting results in a short term increase in touch threshold values for individuals with CTS. Further study is needed to determine the effect of long term texting on carpal tunnel pressures.

Evaluation of individual finger forces during activities of daily living in healthy individuals and those with hand arthritis.

INTRODUCTION: Measuring finger forces during activities of daily living and how these forces change for individuals with pathologies such as arthritis is valuable to our understanding of hand function. PURPOSE OF THE STUDY: The purpose of this study was to determine the forces of individual fingers during the performance of daily activities in healthy participants and determine the envelope of these applied forces. METHODS: This is a cross-sectional study investigating twenty-five healthy participants (12 female: 22-65 years old and 13 male: 20-53 years old) and participants with osteoarthritis (12 female: 52-79 years old and 9 male: 64-79 years old) examined at one time point. The force sensors were calibrated for each individual using a load cell to provide force output in Newtons. Each participant performed 19 activities of daily living two times. Force was plotted over time for each task, and the maximum force in each finger during that task was evaluated. RESULTS: The range of applied forces was 1.4 ± 0.6 N to 34.8 ± 1.6 N for healthy participants and 2.3 ± 1.0 N to 30.7 ± 3.7 N for those with osteoarthritis. DISCUSSION: Sensors allowed for real-time monitoring of finger forces during tasks of daily life. This provides the opportunity to isolate hand grips based on finger recruitment and provide information about the magnitude of forces during the activity. CONCLUSION: Measurement of individual finger forces can provide more accurate biomechanical models of the hand and determine the effect of disease on hand functions.

Development and Usability Testing of a Web-Based and Therapist-Assisted Coping Skills Program for Managing Psychosocial Problems in Individuals With Hand and Upper Limb Injuries: Mixed Methods Study.

BACKGROUND: Ineffective coping has been linked to prolonged pain, distress, anxiety, and depression after a hand and upper limb injury. Evidence shows that interventions based on cognitive behavioral therapy (CBT) may be effective in improving treatment outcomes, but traditional psychological interventions are resource intensive and unrealistic in busy hand therapy practices. Developing web-based, evidence-based psychological interventions specifically for hand therapy may be feasible in clinical practice and at home with reduced training and travel costs. Hand Therapy Online Coping Skills (HOCOS) is a program developed to supplement traditional hand therapy with therapist-assisted coping skills training based on principles from CBT and the Technology Acceptance Model. OBJECTIVE: This study aimed to describe the development and assess the usability of HOCOS to support hand therapists in the management of psychosocial problems. METHODS: The ADDIE model (Analysis, Design, Development, Implementation, and Evaluation) of system design was applied to create HOCOS. The usability testing of HOCOS involved a 2-stage process. In the first step, heuristic testing with information and communications technology (ICT) experts was completed using two sets of heuristics: Monkman heuristics and the Health Literacy Online (HLO) checklist. The second step involved user testing with hand therapists performing a series of online and face-to-face activities, completing 12 tasks on the website using the think-aloud protocol, completing the system usability scale (SUS) questionnaire, and a semistructured feedback interview in 2 iterative cycles. Descriptive statistics and content analyses were used to organize the data. RESULTS: In total, 4 ICT experts and 12 therapists completed usability testing. The heuristic evaluation revealed 15 of 35 violations on the HLO checklist and 5 of 11 violations on the Monkman heuristics. Initially, hand therapists found 5 tasks to be difficult but were able to complete all 12 tasks after the second cycle of testing. The cognitive interview findings were organized into 6 themes: task performance, navigation, design esthetics, content, functionality and features, and desire for future use. Usability issues identified were addressed in two iterative cycles. There was good agreement on all items of the SUS. Overall, therapists found that HOCOS was a detailed and helpful learning resource for therapists and patients. CONCLUSIONS: We describe the development and usability testing of HOCOS; a new web-based psychosocial intervention for individuals with a hand and upper limb injuries. HOCOS targets psychosocial problems linked to prolonged pain and disability by increasing access to therapist-guided coping skills training. We actively involved target users in the development and usability evaluation of the website. The final website was modified to meet the needs and preferences of the participants.

The Efficacy of Fall Hazards Identification on Fall Outcomes: A Systematic Review With Meta-analysis.

OBJECTIVE: To investigate the efficacy of fall hazards identification programs when compared to no intervention or other fall prevention programs on number of falls, falls incidence, and identifying fall hazards in community-dwelling adults. DATA SOURCES: CINAHL, PubMed, EMBASE, Scopus, and PsychINFO were used to identify articles. STUDY SELECTION: Studies were selected to compare fall hazards identification programs to a control group. Studies were eligible if they were randomized controlled trials and enrolled adults older than 50 years with the incidence rate of falls as an outcome. DATA EXTRACTION: Study or authors, year, sample characteristics, intervention or comparison groups, number of falls, and number of hazards identified in the intervention and control groups, and follow-up were extracted. The risk of bias assessment was performed using the Cochrane Risk of Bias tool. Quality was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach per outcome. DATA SYNTHESIS: A total of 8 studies (N=8) and 5177 participants were included. There was a high risk of bias across the studies mostly due to improper blinding of personnel of the outcome assessor. Pooled estimate effects from 5 studies assessing the incidence rate of falls from 3019 individuals indicated no difference between fall hazards identification programs and control (incidence rate ratio=0.98; 95% confidence interval, 0.87-1.10). CONCLUSIONS: The current study suggests that there may be a benefit for fall hazards programs in reducing incident falls. However, because of a moderate GRADE rating, more large-scale studies with a higher number of falls events and more consistent control groups are required to determine the true effect.

Therapist perceptions of best practice as ordered by referral source: An exploratory survey.

INTRODUCTION: Productive outcomes for the hand therapy patient involve many components. Understanding whether therapists agree with the recommendations they receive, or find these informative, is a first step into understanding how shared decision-making on a treatment plan can be optimized. PURPOSE OF THE STUDY: The purposes of this study include (1) the extent which therapists see variable presentations of primary surgical/management in some indicator exemplars where practices vary from accepted/evidence-based practice; (2) hand therapists' level of agreement with the interventions prescribed on referrals, (3) describe the undocumented complications observed by hand therapists, and (4) report the therapists' perceptions as to the reasons for these complications METHODS: A survey was designed and pilot tested. Multiple-choice questions and free text allowed further explanation. The survey was administered through an electronic mailing to all American Society of Hand Therapy members with available e-mail addresses. Raw survey data were extracted and processed. Descriptive statistics were used to analyze therapists' demographic information. Frequencies of therapists' responses were calculated. RESULTS: Ninety percent of all who responded have been in practice 10 years or more. The mean of the "often and always" ordered interventions was 20%. The mean of therapist perceptions as to whether these ordered interventions are best practice was 14%. Sixty percent reported that they had found an undocumented condition, and 60% reported to have found a postoperative complication. Perceived reasons for complications included the lack of communication and therapy intervention. DISCUSSION: Hand therapists can play an important role in improving patient outcomes. Therapists can provide the health care team information regarding best practice. Additionally, the hand therapist may be who first identifies a postsurgical complication or an undocumented issue. Communication between the hand therapist and referral source is vital in optimizing patient outcomes. CONCLUSION: Hand therapists can play an important role in improving overall outcomes for patients. The inter-professional working relationship between the referral source, hand therapist, and the patient is a complex phenomenon and communication between the hand therapist and referral source is vital.

The effectiveness of joint-protection programs on pain, hand function, and grip strength levels in patients with hand arthritis: A systematic review and meta-analysis.

STUDY DESIGN: Systematic review with meta-analysis. INTRODUCTION: Joint protection (JP) has been developed as a self-management intervention to assist people with hand arthritis to improve occupational performance and minimize joint deterioration over time. PURPOSE OF THE STUDY: We examined the effectiveness between JP and usual care/control on pain, hand function, and grip strength levels for people with hand osteoarthritis and rheumatoid arthritis. METHODS: A search was performed in 5 databases from January 1990 to February 2017. Two independent assessors applied Cochrane's risk of bias tool, and a Grading of Recommendations Assessement, Development and Evaluation (GRADE) approach was adopted. RESULTS: For pain levels at short term, we found similar effects between JP and control standardized mean difference (SMD; -0.00, 95% confidence interval [CI]: -0.42 to 0.42, I2 = 49%), and at midterm and long-term follow-up, JP was favored over usual care SMD (-0.32, 95% CI: -0.53 to -0.11, I2 = 0) and SMD (-0.27, 95% CI: -0.41 to -0.12, I2 = 9%), respectively. For function levels at midterm and long-term follow-up, JP was favored over usual care SMD (-0.49, 95% CI: -0.75 to -0.22, I2 = 34%) and SMD (-0.31, 95% CI: -0.50 to -0.11, I2 = 56%), respectively. For grip strength levels, at long term, JP was inferior over usual care mean difference (0.93, 95% CI: -0.74 to 2.61, I2 = 0%). CONCLUSIONS: Evidence of very low to low quality indicates that the effects of JP programs compared with usual care/control on pain and hand function are too small to be clinically important at short-, intermediate-, and long-term follow-ups for people with hand arthritis.