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Narrative Medicine and Hand Therapy: Reflecting on Case Examples
the inter-rater and intra-rater reliability of PRIME, as well as to establish normative values for intrinsic muscle strength in children. Methods: With IRB approval and parental informed consent, typically developing children in local summer day camps were recruited for the study. Four intrinsic muscle groups were tested in each hand: thumb palmar abduction (APB), thumb opposition (OP), index finger abduction (first DI) and little finger abduction (hypothenar mm). We calculated mean, standard deviation, intraclass correlation coefficient (ICC) and smallest detectable difference (SDD) using SPSS software (Chicago, Ill) for inter-rater and intra-rater reliability. Regression analysis was performed for normative values by age, gender, and hand dominance. Results: 30 children (15 boys, 15 girls), ages 7–16, participated in the study. ICCs ranged from 0.85 to 0.94 for inter-rater reliability and 0.88–0.98 for intra-rater reliability. BlandAltman plots presented an even distribution across the zero line indicating minimal skew. Normative data is presented as growth curves with 10th, 50th and 95th percentiles delineated for both boys and girls. Conclusions: PRIME is a reliable tool for the quantification of intrinsic hand muscle strength. Age and gender specific normative values in typically developing children can serve as a clinical resource for clinicians. Relevance: Intrinsic hand muscle strength is a clinically important parameter for evaluation of function, surgical decision making and rehabilitative tracking. There is a need for reliable and reproducible objective measures of pediatric hand strength in congenital, traumatic, and degenerative neuromuscular conditions.
OBJECTIVES 1. Introduce intrinsic strength measurements in children as a routine part of clinical evaluation. 2. Establish reliability of a novel device for the specific purpose of measuring intrinsic hand muscle strength. 3. Provide normative values for intrinsic hand muscle strength
in typically developing children as a clinical resource for affected populations.
DEVELOPMENT AND IMPLEMENTATION OF A HAND THERAPY EXTENDED SCOPE DIAGNOSTIC CLINIC FOR BOTH ELECTIVE AND TRAUMA HAND CONDITIONS TO ENHANCE PATIENT CARE Robyn-Lee Rose, Guy’s & St Thomas’ NHS Foundation Trust, United Kingdom Purpose: A changing and competitive health market demands the need to review existing services and develop new ways of working in order to improve and maintain service delivery. Developing the role of the extended scope practitioner (ESP) and altering patient pathways through specialist hand units is one way service delivery can be improved to enhance patient care by providing early access to a specialist opinion and investigations. Methods: 100 General Practitioner (GP) referrals for carpal tunnel syndrome (CTS) and first Carpometacarpal osteoarthritis (CMC OA) were selected to attend an ESP clinic audit led by two specialist occupational therapists for diagnosis and implementation of a conservative treatment programme, which was confirmed by a consultant. The ESP clinic was audited against key performance indicators to evaluate ESP effectiveness and improvements in the patient pathway. Results: The ESP can effectively diagnose and manage CTS and CMC OA patients without increasing the demand for surgical opinion or procedures. The ESP is also effective in diagnosing other conditions such as early-onset Dupuytren’s disease, de Quervain’s disease, ganglions and trigger finger. The ESP clinic has developed further to include the assessment and management of acute wrist trauma to support Accident and Emergency in the identification and management of fractures and ligament injuries.
Conclusions: ESP clinics have the potential to improve the patient pathway by providing earlier access to a specialist opinion for a diagnosis and management of both trauma and elective hand conditions thereby improving service delivery. Relevance: ESPs are clinical experts who have demonstrated advanced knowledge and skill who can meet the needs of a changing and competitive health care market to improve service delivery and enhance patient care, which is in line with global health trends.
OBJECTIVES 1. Describe the practical aspects of developing the ESP in terms of implementing a pilot study to determine the need for the role, identify training competencies, determine key performance indicators and obtaining ratification from clinical governance to order specialist investigations such as nerve conditions, blood tests and MRI scans. 2. Present the results of pilot audited against the key performance indicators. 3. Discuss the subsequent development of the ESP role in assessing and managing acute wrist trauma to identify wrist fractures and ligament injuries that have been missed in the Accident & Emergency department and the resultant positive impact on patient care.
NARRATIVE MEDICINE AND HAND THERAPY: REFLECTING ON CASE EXAMPLES Cynthia Cooper, Scottsdale Healthcare, United States of America Purpose: Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values. Incorporating patient values into hand therapy is accomplished through the use of narrative medicine. Narrative medicine is
October–December 2010 e25
practice that includes professionalism, empathy, trustworthiness, and reflection. A narrative approach in hand therapy requires the ability to absorb, interpret, recognize, and be moved by patients’ stories. Methods: This paper reviews the literature on narrative medicine and applies narrative themes to hand therapy intervention in order to maximize the integration of patient values into clinical care. Case examples will demonstrate how narrative medicine may look like casual conversation between the therapist and patient, but what is occurring is actually quite powerful and poignant. This paper teaches specific communication techniques that elicit personal and meaningful information from the patient. Case examples will show how both the patient and the provider participate in the exchange, with the provider listening actively, providing eye contact, reflecting, avoiding interruptions, and asking open-ended questions. Patients feel listened-to when they have opportunities reflect on emotional aspects of the upper extremity problem for which they were referred. The case examples illustrate how use of narrative in hand therapy improves their care. Results: Narrative medicine teaches us that patients’ stories are not trivial; that hand therapists should treat the patient’s illness experience, not just the disease or impairment; and that patients’ medical histories represent only a part of their relevant stories. Hand therapy case examples will portray a scenario for each of these themes and the narrative message of these examples will be clearly explained. Conclusions: The medical model advocates that therapists maintain objectivity and professional distance. Hand therapists need to be structurespecific in order to treat diseases and injuries safely and accurately. But we maximize hand therapy’s relevance and meaning to patients by acknowledging and incorporating the subjective aspects of their experiences and stories. The practice of narrative medicine in hand therapy allows patients’ stories to unfold so that their hand therapy care can incorporate their values and thus be more personalized and meaningful to them.
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JOURNAL OF HAND THERAPY
Relevance: Narrative medicine exemplifies how much richness is illuminated in the revealing of a particular detail. When we listen to patients’ stories, we in effect collaborate with them to create new life stories. Use of a narrative approach uncovers details that reflect patient values, thereby contributing to the practice of evidence-based medicine in hand therapy.
OBJECTIVES 1. Define narrative medicine as it applies to hand therapy. 2. Identify three ways to promote storytelling in hand therapy patients. 3. Name three open-ended questions to elicit patients’ stories.
INNOVATION IN PRACTICE: ONE-STOP CARPAL TUNNEL CLINIC Donna Kennedy, Imperial College Healthcare NHS Trust, Cathy Ball, Jagdeep Nanchahal, United Kingdom Purpose: Carpal tunnel syndrome (CTS) is the most common compression neuropathy and in the United Kingdom in 2000, operative treatment was undertaken for 31% of new cases. In 2008, the National Health Service Improvement Plan stated that no patient should wait longer than 18 weeks from referral to hospital treatment. In response, a One-Stop Carpal Tunnel Clinic (CTC) was developed to provide timely, quality care. Methods: The CTC is a treatment and research clinic, investigating the outcomes of the management of CTS. Prior to attending, patients receive patient information sheet and complete questionnaires. At the clinic, a Surgeon completes an examination and provocative tests and Hand Therapist completes evaluation and nerve conduction studies. Nerve conduction studies are performed utilising portable electrodiagnostic device. Assessment findings and nerve study results are reviewed, a diagnosis made, and treatment administered
on the day. The CTC is innovative; conducted bi-weekly on Saturday mornings, accommodating patients’ schedules; assessment and treatment provided in one appointment, minimising visits and delays; treatment and research clinic; hand therapists work in extended scope role, perform nerve conduction studies Results: Patient satisfaction with the CTC is evaluated with a questionnaire with a high degree of satisfaction reported. Clinical outcome is assessed at three months with the Boston Carpal Tunnel Questionnaire (BCTQ), and at one year with the BCTQ, Michigan Hand Outcomes Measure (MHQ), strength and sensibility. The BCTQ is a disease-specific questionnaire for evaluating symptom severity and functional impairment (Levine et al 1993). Items are rated on a scale of 1 to 5, with lower scores implying milder symptoms and less functional impairment. A paired-samples t-test was conducted to evaluate the impact of treatment on BCTQ scores. In the surgery group (n 5 43) there was a statistically significant decrease in symptom scores from pre-surgery (M 5 3.10, SD 5 0.98)) to 3 months postsurgery (M 5 1.99, SD 5 0.94, t (42) 5 7.73, p , .0005). There was a large effect size for symptoms (.587) and a moderate effect size (.35) for function. In the injection group (n 5 5), there was a decrease in symptom and function scores but this did not approach statistical significance. Conclusions: Results of a patient satisfaction questionnaire and the BCTQ indicate a high level of patient satisfaction and excellent clinical outcomes at three months post-surgery. Relevance: Evidence of the effectiveness of hand therapists in extended scope role; Increased understanding of clinical outcome relative to pretreatment symptom severity; Evidence of patient satisfaction with innovative service.
OBJECTIVES 1. To report on and increase awareness of innovation in practice. 2. To report evidence of hand therapists working in an extended scope fashion, with
OBJECTIVES 1. Introduce intrinsic strength measurements in children as a routine part of clinical evaluation. 2. Establish reliability of a novel device for the specific purpose of measuring intrinsic hand muscle strength. 3. Provide normative values for intrinsic hand muscle strength
in typically developing children as a clinical resource for affected populations.
DEVELOPMENT AND IMPLEMENTATION OF A HAND THERAPY EXTENDED SCOPE DIAGNOSTIC CLINIC FOR BOTH ELECTIVE AND TRAUMA HAND CONDITIONS TO ENHANCE PATIENT CARE Robyn-Lee Rose, Guy’s & St Thomas’ NHS Foundation Trust, United Kingdom Purpose: A changing and competitive health market demands the need to review existing services and develop new ways of working in order to improve and maintain service delivery. Developing the role of the extended scope practitioner (ESP) and altering patient pathways through specialist hand units is one way service delivery can be improved to enhance patient care by providing early access to a specialist opinion and investigations. Methods: 100 General Practitioner (GP) referrals for carpal tunnel syndrome (CTS) and first Carpometacarpal osteoarthritis (CMC OA) were selected to attend an ESP clinic audit led by two specialist occupational therapists for diagnosis and implementation of a conservative treatment programme, which was confirmed by a consultant. The ESP clinic was audited against key performance indicators to evaluate ESP effectiveness and improvements in the patient pathway. Results: The ESP can effectively diagnose and manage CTS and CMC OA patients without increasing the demand for surgical opinion or procedures. The ESP is also effective in diagnosing other conditions such as early-onset Dupuytren’s disease, de Quervain’s disease, ganglions and trigger finger. The ESP clinic has developed further to include the assessment and management of acute wrist trauma to support Accident and Emergency in the identification and management of fractures and ligament injuries.
Conclusions: ESP clinics have the potential to improve the patient pathway by providing earlier access to a specialist opinion for a diagnosis and management of both trauma and elective hand conditions thereby improving service delivery. Relevance: ESPs are clinical experts who have demonstrated advanced knowledge and skill who can meet the needs of a changing and competitive health care market to improve service delivery and enhance patient care, which is in line with global health trends.
OBJECTIVES 1. Describe the practical aspects of developing the ESP in terms of implementing a pilot study to determine the need for the role, identify training competencies, determine key performance indicators and obtaining ratification from clinical governance to order specialist investigations such as nerve conditions, blood tests and MRI scans. 2. Present the results of pilot audited against the key performance indicators. 3. Discuss the subsequent development of the ESP role in assessing and managing acute wrist trauma to identify wrist fractures and ligament injuries that have been missed in the Accident & Emergency department and the resultant positive impact on patient care.
NARRATIVE MEDICINE AND HAND THERAPY: REFLECTING ON CASE EXAMPLES Cynthia Cooper, Scottsdale Healthcare, United States of America Purpose: Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values. Incorporating patient values into hand therapy is accomplished through the use of narrative medicine. Narrative medicine is
October–December 2010 e25
practice that includes professionalism, empathy, trustworthiness, and reflection. A narrative approach in hand therapy requires the ability to absorb, interpret, recognize, and be moved by patients’ stories. Methods: This paper reviews the literature on narrative medicine and applies narrative themes to hand therapy intervention in order to maximize the integration of patient values into clinical care. Case examples will demonstrate how narrative medicine may look like casual conversation between the therapist and patient, but what is occurring is actually quite powerful and poignant. This paper teaches specific communication techniques that elicit personal and meaningful information from the patient. Case examples will show how both the patient and the provider participate in the exchange, with the provider listening actively, providing eye contact, reflecting, avoiding interruptions, and asking open-ended questions. Patients feel listened-to when they have opportunities reflect on emotional aspects of the upper extremity problem for which they were referred. The case examples illustrate how use of narrative in hand therapy improves their care. Results: Narrative medicine teaches us that patients’ stories are not trivial; that hand therapists should treat the patient’s illness experience, not just the disease or impairment; and that patients’ medical histories represent only a part of their relevant stories. Hand therapy case examples will portray a scenario for each of these themes and the narrative message of these examples will be clearly explained. Conclusions: The medical model advocates that therapists maintain objectivity and professional distance. Hand therapists need to be structurespecific in order to treat diseases and injuries safely and accurately. But we maximize hand therapy’s relevance and meaning to patients by acknowledging and incorporating the subjective aspects of their experiences and stories. The practice of narrative medicine in hand therapy allows patients’ stories to unfold so that their hand therapy care can incorporate their values and thus be more personalized and meaningful to them.
e26
JOURNAL OF HAND THERAPY
Relevance: Narrative medicine exemplifies how much richness is illuminated in the revealing of a particular detail. When we listen to patients’ stories, we in effect collaborate with them to create new life stories. Use of a narrative approach uncovers details that reflect patient values, thereby contributing to the practice of evidence-based medicine in hand therapy.
OBJECTIVES 1. Define narrative medicine as it applies to hand therapy. 2. Identify three ways to promote storytelling in hand therapy patients. 3. Name three open-ended questions to elicit patients’ stories.
INNOVATION IN PRACTICE: ONE-STOP CARPAL TUNNEL CLINIC Donna Kennedy, Imperial College Healthcare NHS Trust, Cathy Ball, Jagdeep Nanchahal, United Kingdom Purpose: Carpal tunnel syndrome (CTS) is the most common compression neuropathy and in the United Kingdom in 2000, operative treatment was undertaken for 31% of new cases. In 2008, the National Health Service Improvement Plan stated that no patient should wait longer than 18 weeks from referral to hospital treatment. In response, a One-Stop Carpal Tunnel Clinic (CTC) was developed to provide timely, quality care. Methods: The CTC is a treatment and research clinic, investigating the outcomes of the management of CTS. Prior to attending, patients receive patient information sheet and complete questionnaires. At the clinic, a Surgeon completes an examination and provocative tests and Hand Therapist completes evaluation and nerve conduction studies. Nerve conduction studies are performed utilising portable electrodiagnostic device. Assessment findings and nerve study results are reviewed, a diagnosis made, and treatment administered
on the day. The CTC is innovative; conducted bi-weekly on Saturday mornings, accommodating patients’ schedules; assessment and treatment provided in one appointment, minimising visits and delays; treatment and research clinic; hand therapists work in extended scope role, perform nerve conduction studies Results: Patient satisfaction with the CTC is evaluated with a questionnaire with a high degree of satisfaction reported. Clinical outcome is assessed at three months with the Boston Carpal Tunnel Questionnaire (BCTQ), and at one year with the BCTQ, Michigan Hand Outcomes Measure (MHQ), strength and sensibility. The BCTQ is a disease-specific questionnaire for evaluating symptom severity and functional impairment (Levine et al 1993). Items are rated on a scale of 1 to 5, with lower scores implying milder symptoms and less functional impairment. A paired-samples t-test was conducted to evaluate the impact of treatment on BCTQ scores. In the surgery group (n 5 43) there was a statistically significant decrease in symptom scores from pre-surgery (M 5 3.10, SD 5 0.98)) to 3 months postsurgery (M 5 1.99, SD 5 0.94, t (42) 5 7.73, p , .0005). There was a large effect size for symptoms (.587) and a moderate effect size (.35) for function. In the injection group (n 5 5), there was a decrease in symptom and function scores but this did not approach statistical significance. Conclusions: Results of a patient satisfaction questionnaire and the BCTQ indicate a high level of patient satisfaction and excellent clinical outcomes at three months post-surgery. Relevance: Evidence of the effectiveness of hand therapists in extended scope role; Increased understanding of clinical outcome relative to pretreatment symptom severity; Evidence of patient satisfaction with innovative service.
OBJECTIVES 1. To report on and increase awareness of innovation in practice. 2. To report evidence of hand therapists working in an extended scope fashion, with