A research agenda for Hand Therapy

SCIENTIFIC/CLINICAL ARTICLES

A Research Agenda for Hand Therapy Joy C. MacDermid, BScPT, MSc, PhD Elaine E. Fess, MS, OTR, FAOTA, CHT Judith Bell-Krotoski, OTR, FAOTA, CHT Nancy M. Cannon, OTR, CHT Roslyn B. Evans, OTR/L, CHT William Walsh, MBA, OTR/ L, CHT Robert M. Szabo, MD, MPH Georgiann Laseter, OTR, FAOTA, CHT Evelyn Mackin, LPT

ABSTRACT: A survey, to which 401 hand therapists responded, was conducted to establish research priorities in the field of hand therapy and to investigate barriers to hand therapy research. Results indicated that reimbursement issues, particularly those generated by managed care, were reported to have adversely affected quality of patient care, job satisfaction, job security, and ability to conduct research. Research priorities were defined in this study, and the need for clinical trials to determine the effectiveness of hand therapy interventions was found to be urgent. Research questions identified by respondents reflected both the traditional disorders treated by hand therapists, such as tendon repairs, and a greater concern with issues concerning cumulative trauma. Barriers to research were reported by respondents, and ways in which professional organizations could meet clinicians’ needs in conducting and utilizing research were highlighted. J HAND THER. 2002;15:3–15.

Karan Gettle, OTR, MBA, CHT and Gregory Santore, MBA for the American Hand Therapy Foundation Board of Directors

A clinical profession is built on frameworks of theory and research that define the nature of the profession and the specific methods it uses to accomplish its unique mission. Hand therapy is the clinical discipline that devotes itself to minimizing impairment, disability, and handicap resulting from pathology of the upper extremity. The scientific foundation of hand therapy determines which methods hand therapists use to achieve treatment goals, assuming that an evidence-based approach to practice is accepted. Basic science research establishes the foundation for many elements of theory and practice in hand therapy, which often leads to innovative treatment concepts. In tandem with basic science research, the role of clinical research in hand therapy is to establish the reliability and validity of clinical evaluation, to determine the outcomes predictable with hand therapy, to define the factors that affect outcome, and to identify the effectiveness of hand therapy treatments. Hand therapy has foundations in physical and Correspondence and reprint requests to Joy C. MacDermid, BScPT, PhD, Codirector, Clinical Research Laboratory, Hand and Upper Limb Centre, St. Joseph’s Health Centre, P.O. Box 5777, London, Ontario, Canada N6A 4L6; or Assistant Professor School of Rehabilitation Science, McMaster University, 1400 Main Street, IAHS, Hamilton, Ontario, Canada; e-mail:

occupational therapy and thus shares some of the scientific foundations developed by these two disciplines. However, if hand therapy is to be recognized as an independent discipline, it must have its own science. In the past, certain key publications have provided important early support for the concept that hand therapy is, in terms of clinical practice, an independent discipline. These publications include a hand therapy practice analysis1 and results of the hand therapy certification process.2 Establishing research priorities and identifying the specific research designs required to address issues of clinical importance are critical factors in documenting and enhancing the scientific basis of all professions, including that of hand therapy. For example, the American Physical Therapy Association (APTA) recently recognized the need to establish a research agenda and use that agenda to more efficiently focus research resources.3 In a parallel manner, funding agencies in hand therapy, like the American Hand Therapy Foundation (AHTF), that seek to support the profession and its scientific basis must establish their own research agendas, which directly reflect the priorities of hand therapists with regard to clinical practice and research. January–March 2002

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PURPOSES Agenda guidelines derived from experienced practicing hand therapists are critical for identifying and prioritizing the utilization of hand therapy research resources. Therefore, the purposes of this study were to identify:

Structured questions on the survey asked therapists to select options relating to: ■

Their view of the importance of support for a variety of potential research and education programs that AHTF might provide

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Sources of recent research findings

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The primary resources that inform hand therapists about new research

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Issues that affect their selection of a specific intervention for their own clinical practice

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How research validation contributes to treatment selection in hand therapy

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How they spend their time in clinic

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What conditions they treat (and percentage of time for each)

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Their interest in participating in research

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The primary disorders treated by hand therapists

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The most pressing concerns of practicing hand therapists

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The research priorities of hand therapists as defined by specific clinical issues, research designs required to address these issues, and the specific topics of research questions

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The extent to which hand therapists participate in research activities, compared with other professional activities

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The perceived barriers to the participation of hand therapists in research activities

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Hand therapists’ views on priorities for action by, and in support of, the AHTF

METHODS Sampling Frame A mailing list consisting of the names of experienced hand therapists was compiled from a roster of all certified hand therapists, obtained from the Hand Therapy Certification Commission, and from a register of active charter members of the ASHT. This composite list was used for a single mailing of the survey questionnaire.

The Survey The survey was a 20-item questionnaire that was coded to permit analysis of the various responses while protecting the anonymity of the respondents. Open-ended items gave therapists an opportunity to list up to three of their most pressing concerns and the most critical clinical research questions affecting their hand therapy practices. These open-ended responses were important in allowing therapists unrestricted input in naming their priority issues and research questions. Using the same open-ended format, therapists were also asked what makes it difficult for them to participate in research activities, whether they contributed to AHTF, and, if they did not contribute, why. 4

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Demographic questions included type of facility, case load, job title, experience, and employer support for education and dues. Response categories for questions on demographics were adapted with permission from the Hand Therapy Certification survey.2 All returned coded responses were summarized in descriptive format.

Data Analysis Research questions reported in an open-ended format by hand therapists were categorized by a single hand therapist/clinical researcher/epidemiologist into three grouping variables. First, the clinical area, if TABLE 1. Survey Participants No.of participants

401

Years of hand experience

13.6 (range, 3–33)

No. of hand patients treated per day

11.6 (range, 0–25)

Types of hand therapy practice: Therapist-owned clinic Outpatient hospital Corporation-owned clinic Physician-owned clinic Other HEALTH MAINTENANCE ORGANIZATION Inpatient hospital

35% 31% 18% 10% 4% 1% 1%

Position held by respondent: Senior therapist Staff therapist Facility owner Clinic supervisor Department supervisor Sole charge therapist Facility supervisor Other

24% 21% 17% 13% 7% 7% 2% 8%

Employer contributes to continuing education

80%

Employer contributes to dues

47%

Participant is ASHT member

84%

Participant contributes to American Hand Therapy Foundation

53%

FIGURE 1. Research resources used by hand therapists. ASHT indicates American Society of Hand Therapists; ASSH, American Society for Surgery of the Hand. Black indicates critical; white, very important.

stated, was categorized. Second, the type of research study required to answer the question was described and assigned to one of the following categories: 1) outcome, in which the outcome of treatment for a group of patients was the question; 2) effectiveness, in which the relative outcomes or effectiveness of different treatment choices was the question; 3) etiology/causation, in which the topic of the study was the delineation of factors that cause or contribute to pathology or outcomes; 4) prevention/screening, in which the purpose of the study was to evaluate methods to prevent or screen for pathology; 5) psychometrics, in which the measurement properties of clinical evaluation methods was the question; 6) natural history, in which the progression of disease or rate of recovery after treatment was the prime question; 7) correlational/descriptive, in which phenomena or the relationships between phenomena are described; and 8) economic, in which costs associated with pathology or interventions are evaluated. The third and final grouping variable classified the specific topic of the research questions, when stated, into appropriate categories, such as splinting and exercise.

Responses on Survey Objectives Resources That Inform Hand Therapists about New Research According to survey respondents, their primary source of learning about new research was the Journal of Hand Therapy, with 96% of respondents viewing it as critical or very important (Figure 1). The Journal of Hand Surgery and Continuing Education were also highly rated. A variety of other sources of information are used by hand therapists, but to a lesser extent. How Research Validation Contributes to Treatment Selection in Hand Therapy Survey respondents indicated that they consider a variety of factors when selecting treatment interventions (Figure 2). Most important of these is competency gained during training, although research validation, accessibility, the time required for treatment, and reimbursement were considered either critical or very important by 60% to 80% of respondents. Conditions Treated by Hand Therapists

RESULTS A total of 1,600 surveys were mailed, and 123 were returned undeliverable; 401 surveys were returned and tabulated (response rate, 27%). This rate was considered acceptable given the rate of outdated addresses, the fact that hand therapists tend to be “over-surveyed,” and the expected response rates for single-mail surveys. Most respondents indicated interest in the topic of the survey by providing detailed answers and extra comments. Table 1 shows characteristics of the respondents, a majority of whom were practicing clinicians.

Hand therapists spend their time treating a wide variety of conditions, with cumulative trauma disorder, tendon injuries, and fractures being the most prevalent (Figure 3). Pressing Concerns of Hand Therapists The areas of prime concern for hand therapists are shown in Figure 4, top. Details of the nature of the concerns, if provided, are shown in Figure 4, bottom. In general, the most pressing concern of hand therapists was reimbursement (253 responses). The detailed responses showed that managed care was the primary source of this concern. January–March 2002

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FIGURE 2. Factors that influence treatment selection by hand therapists. Black indicates critical; white, very important.

FIGURE 3. Ranking is the cumulative sum of reported percentage time allocated to each diagnosis by each therapist. CTD indicates cumulative trauma disorder; RSD, reflex sympathetic dystrophy.

The ability of therapists to manage their clinical practices was the second highest concern, and fears about practice management were often related to managed care. Education/competency was the next highest concern of hand therapists; when more detail was provided, access, cost, and availability were mentioned. A number of hand therapists also had worrisome professional issues. Lack of recognition of hand therapy as a specialized profession (by referral sources and through increased reimbursement) was often cited. Issues specific to occupational therapy were cited by 39 respondents and most frequently related to lack of reimbursement for occupational therapists. Research Priorities of Hand Therapists Examples of (unclassified) research questions posed by hand therapists are shown in Table 2. Many 6

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of the research questions mentioned by respondents did not relate to both a specific clinical area and a specific topic. For example, a question about the effectiveness of iontophoresis often was not stated in relation to a specific clinical problem. Thus, 54% of research questions identified by survey respondents applied to hand therapy in a general sense. Where a specific clinical area was noted, it was tabulated as shown in Figure 5, top. Repetitive strain injuries/cumulative trauma disorders were the conditions that generated the most questions. Others specific non-traumatic disorders that are classified as cumulative trauma pathology were also cited—e.g., carpal tunnel syndrome, tendinitis, and nerve compression. In relation to traumatic hand injuries, flexor and extensor tendon injuries generated the most research questions. The research designs required to answer the research questions of hand therapists are shown in

FIGURE 4. Concerns of hand therapists. Top, areas of concern. Bottom, specific concerns.

Figure 5, middle. Overwhelmingly, hand therapists posed questions about clinical effectiveness, that is, questions requiring clinical trials. Outcome studies were the second most commonly required research study. Natural history studies most frequently related to the time to recover from a variety of conditions, indicating that therapists need to know what to expect of natural recovery and how hand therapy is able to modify that process. Causation studies most frequently related to factors contributing to cumulative trauma disorders. The specific topic mentioned most frequently by responding hand therapists (Figure 5, bottom) involved modalities; in this category, iontophoresis was frequently mentioned. A number of therapists reported that insurance companies deny reimbursement for this modality because its effectiveness is

unproven or because it is considered experimental. Interestingly, “modalities” are of greater concern to hand therapists than to the physiotherapists involved in establishing the APTA Research Agenda. Hand therapists also wanted to know which therapeutic option for a specific clinical problem was “the best” or best of two or more stated choices. A number of treatment options and approaches are available for most rehabilitation problems, necessitating a need for these comparative trials. The effectiveness of splinting, in particular was mentioned by 96 respondents. Timing or frequency of treatment was mentioned by a substantial number of responding hand therapists as an important issue. Therapists expressed a need for proof that the few visits allowed for many conditions Text continues on p. 11

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TABLE 2. Specific Research Questions Posed by Hand Therapists Treatment effectiveness: 1. Does iontophoresis reduce inflammation? 2. Which has a better result for cumulative trauma disorder (CTD)—early or late treatment? 3. Which is more effective for management of scar iontophoresis or silicone gel? 4. What is the effectiveness of splinting in arthritis? 5. Does phonophoresis really decrease inflammation? 6. Does delayed treatment of patients result in poorer outcomes? 7. Does hand therapy by a hand therapist provide better outcomes that generalized care? 8. Does hand therapy by certified hand therapist provide better outcomes in complex injuries? 9. Does custom splinting reduce stiffness more than off-the-shelf splinting? 10. Do strengthening programs help cumulative trauma patients? 11. Do nerve gliding exercises help cumulative trauma patients? 12. What is the most effective edema control method? 13. Which treatment is most effective for reducing scar proliferation? 14. What is the most effective technique for decreasing scar adherence? 15. Does high voltage interferential current reduce pain? 16. Does TENS reduce pain? 17. Which splint is most effective for lateral epicondylitis? 18. What is the effectiveness of static progressive splinting? 19. Does extension night splinting in early stages of Dupuytren’s contracture reduce the need for surgery? 20. What method of ice application provides the most penetration? 21. What is the efficacy of pulsed ultrasound on inflammatory conditions? 22. Which tendon protocol provides the best results for zone 1 flexor tendons? 23. Can early motion provide better results with revascularization/replantation? 24. How effective are modalities? 25. What is the effectiveness of high-voltage galvanic stimulation? 26. Do thermal modalities increase tissue extent ability? 27. Do patient who see certified hand therapists have better outcomes? 20. What is the best treatment for repetitive stress injury? 21. Does muscle stimulation allow patients to recover faster? 22. Does work hardening improve outcomes? 23. Does pulsed ultrasound help with localized neuritis? 24. Does iontophoresis with sodium chloride (NaCl) minimize tendon or scar adhesions? 25. Are specific types of massage more beneficial? 26. What is the efficacy of micro-current? 27. Which is more effective for postural realignment—deep tissue work or strengthening? 28. What is the most effective method for applying a contrast bath? 29. Does early motion benefit patients with metacarpal or phalangeal fractures? Outcomes: 1. For what percentage of patients does conservative management of carpal tunnel syndrome reduce symptoms and hasten return to work? 2. What is the outcome for patients with overuse tendinitis? 3. What is the average outcome by diagnosis? 4. What is the outcome for patients who have CTD and have been treated preoperatively? 5. What are the outcomes for multiple trauma? 6. What are the outcomes for patients with reflex sympathetic dystrophy?

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7. 8. 9. 10.

What are the outcomes after zone 1 flexor tendon injury? What are wound healing protocols and their outcomes? What are the outcomes attributable to certified hand therapists? What are the outcomes for patients who have delayed referral to therapy?

Natural history/recovery: 1. 2. 3. 4. 5.

What is the time to recover from CTD? What is the time to recover from wrist fracture? What is the time to recover from tendon repair? What is the normal course of arthritis in the digits? What is the normal course of recovery of scar tissue?

Screening/prevention: 1. 2. 3. 4. 5. 6.

How do we prevent CTD? Does stretching at work prevent CTD? Does early therapy prevent reflex sympathetic dystrophy? Do strengthening programs prevent CTD? Does hand therapy prevent re-occurrences of CTD? Does hand therapy minimize the number of second procedures for carpal tunnel syndrome? 7. Does preemployment screening minimize the incidence of CTD? Correlational: 1. What is the relationship between strength and function? 2. What is the relationship between outcome and patient satisfaction? 3. What is the relationship between impairments and disability? 4. What is the relationship between intensity of therapy and outcomes? 5. What is the relationship between therapist training and outcomes? Causation/etiology: 1. What is the relationship between motor planning skills and development of CTD? 2. Does lack of physical fitness cause CTD? 3. What levels of force or repetition cause CTD? 4. What are the effects of traumatic hand injuries on balance reactions? 5. What are the factors that predict return to work? 6. What are the factors that predict outcomes? Psychometrics: 1. Which outcome measure is most responsive in patients with distal radius fractures? 2. What is the reliability of our evaluation procedures? 3. Which outcome measures predict ability to return to work? 4. What is the reliability and validity of assessment tools? 5. What is the validity of Semmes-Weinstein monofilament tests? 6. Need a screening questionnaire for CTD. 7. Need a screening tool for alcohol, tobacco, substance abuse. 8. Need a questionnaire for patients with elbow problems. 9. Need a questionnaire for patients with cubital tunnel syndrome. Economic: 1. What are the costs of treatment by certified hand therapists compared with the costs of treatment by general therapists? 2. What are the costs of continuous passive motion? 3. What are the costs of hand therapy for different diagnoses? 4. What are the costs for patients who have delayed hand therapy compared with costs for patients who have early hand therapy? 5. What are the costs associated with different treatment protocols?

FIGURE 5. Research priorities of hand therapists. Top, clinical areas. Middle, required research designs. Bottom, specific topics. RSI indicates repetitive strain injury; CTD, cumulative trauma disorder; RSD, reflex sympathetic dystrophy; CTS, carpal tunnel syndrome.

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FIGURE 6. Activities performed by hand therapists. Ranking is the cumulative sum of percentage time allocated to each activity as reported by each therapist.

FIGURE 7. Research experience of hand therapists.

FIGURE 8. Reasons reported by hand therapists for restricted participation in research. The asterisk (*) indicates that competing priorities were not stated (64%) or that the lack of time is related to work (23%), family (8%), or other interests (5%). The dagger (†) indicates other reasons that include fear of failure, lack of equipment, and lack of opportunity.

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FIGURE 9. Priorities of hand therapists for action by the American Hand Therapy Foundation. An asterisk indicates an activity that falls outside the mandate for a charitable organization.

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are insufficient to provide optimal outcomes and a need for research to demonstrate this. Other therapists noted that research is needed to evaluate whether specialized hand therapy provides better outcomes than general therapy. This type of question was similar to the third major category of the APTA Research Agenda, i.e., “What are the optimal characteristics of an intervention to achieve a desired effect or outcome?“ Extent to Which Hand Therapists Participate in Research The percentages of time that hand therapists spend performing a variety of hand therapy functions are shown in Figure 6. Evaluation, splinting, modalities, other treatment, documentation, supervision, professional development, and pursuing reimbursement were the activities most frequently performed by hand therapists. Very few respondents spent a substantial amount of time doing research or writing. Along the same lines, relatively few hand therapists have conducted data analysis or designed a study, although a larger number have experience in collecting data (Figure 7). Perceived Barriers to Research for Hand Therapists A number of factors contribute to hand therapists’ lack of involvement in research, and most of these relate to constraints on therapists’ time (Figure 8). Work was frequently cited as demanding too much time, thus diminishing the ability of therapists to participate in other ventures such as research. Lack of knowledge was the second most frequently reported perceived barrier to hand therapy research.

Priorities for Action by the American Hand Therapy Foundation When asked where AHTF funds should be allocated, clinical research studies and outcome studies were most highly rated by the respondents. Research education for clinicians was ranked third, and UENet was fourth. Therapists felt that hand therapy research was important and suggested a number of ways to increase the research skills of hand therapists, including research fellowships, continuing education for clinicians, and graduate fellowships to allow therapists to achieve higher degrees. Hand therapists reported that research should be the highest priority for the AHTF (Figure 9). Funding research, facilitating outcome studies, and providing research education for clinicians were highly ranked as activities to which AHTF should allocate its resources (Figure 10). In terms of the type of research that the AHTF should fund, outcome research and clinical research were the most frequently cited (Figure 11). Other objectives, including public relations and political action, were requested infrequently by responding hand therapists (Figure 9), but these fall outside the mandate (for research and education) of the AHTF. The majority of hand therapists (55%) reported that they financially support the AHTF, although the annual ASHT membership donation rate is below 10%. Thus, this 55% may reflect those therapists who have ever made donations to ASHT or its fund-raisers. Hand therapists who had not contributed to AHTF cited competing financial priorities as their main reason for lack of support (Figure 12). When details about the nature of the conflict were provided, the competing demand most commonly mentioned was other professional organizations. A number of therapists reported that, with parent organizations, state organiJanuary–March 2002

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FIGURE 10. Priorities of hand therapists for allocation of American Hand Therapy Foundation funds.

FIGURE 11. Priorities of hand therapists for research funding, by type of research.

FIGURE 12. Priorities of hand therapists for allocation of American Hand Therapy Foundation funds.

zations, and professional organizations like the ASHT, there were too many organizations to support.

DISCUSSION This survey provided an overview of issues that affect the research needs, research questions, and research capabilities of hand therapists. While we, the 12

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authors, had a primary interest in establishing research priorities, we felt that it was necessary and important to view research priorities in relation to more broadly based professional concerns. The study showed that managed care and shrinking resources have had a profound effect on hand therapists. Their primary concern was reimbursement. Lack of reimbursement was stated as a primary concern by the

majority of hand therapists and was said to affect quality of care, job security, job satisfaction, and issues involving control of hand therapy practices. The need to see a higher volume of patients, and the pressure this brings, are consequences of shrinking reimbursement. This pressure was cited as a major factor limiting the ability of therapists to conduct research. The paradox is that, while clinicians universally recognize the critical need for research studies to prove the effectiveness of their interventions and thus improve patient care and reimbursement, the demand to see so many patients limits the ability of therapists to participate in such research projects. When resources, such as time and money, are limited, it becomes all the more essential that available resources be directed to the issues of highest priority. This survey identified the highest priority research questions that would affect practicing hand therapists. An overwhelming need for research into clinical outcomes and clinical effectiveness was cited by respondents. For the purposes of this project, outcome studies were defined as studies to determine the outcome of an intervention, whereas effectiveness studies were defined as those that investigate the optimal treatment from two or more alternatives (including placebo). Both types of study provide data on clinical outcomes and relate directly to clinical practice. The distinction between them is important, however, because an outcome study does not require randomization, whereas an effectiveness study requires a randomized controlled trial. Outcome studies report the average outcome, time to achieve outcome, factors that can affect outcome, time to return to work, and associated complications. However, to prove that a treatment is effective, a comparative trial with randomization is necessary. Both types of studies are important. Hand therapists without experience in research may be able to conduct outcome studies more easily than randomized controlled trial studies. In fact, a number of hand therapists expressed an interest in collecting data for outcome studies and wanted AHTF to coordinate such projects. However, an important finding of this current study is that although therapists have a strong sense of a need for outcome studies, most of their clinical questions can, in truth, be answered only through randomized trial studies. Interestingly, despite the fact that clinical research reports of outcomes and treatment effectiveness are the type of research primarily sought by clinicians, such studies do not appear to be the primary research available in therapy journals.4 A review of the type of articles published in Physical Therapy showed that the majority of studies did not investigate clinical treatments.4 In actuality, many published studies used non-impaired subjects, further limiting their application to clinical practice.

On a more positive note, when analyzed over time, the number of studies that used group designs was increasing. Interestingly, the research design “case series,” which was discouraged for publication in the past because it was considered to have low internal validity as a research design, contains the kind of information of interest to clinicians and may have greater acceptability when framed as an outcome study. Case series study design may present an avenue for greater involvement of clinical therapists in writing clinically focused research. The mismatch between the research needs of clinical professions and the literature in their scientific journals has been noted4 and relates in part to the difficulties in conducting clinical trials, which tend to be expensive and time consuming. In the infancy of the hand therapy profession, issues of acute care management predominated. This survey shows that cumulative trauma disorders now constitute a significant portion of the hand therapy caseload. While traditional areas of acute-care hand therapy expertise still generate research questions, the problems of cumulative trauma patients have generated critical new fields of inquiry. From the questions posed by the survey respondents with respect to cumulative trauma, it was apparent that lack of understanding of the causes of cumulative trauma disorders hampers the ability of hand therapists to design effective interventions. Establishing research priorities is important in all clinical professions. This study elicited open-ended responses from a large number of clinicians and categorized the responses according to the area of clinical practice, the type of study required, and the specific aspect of hand therapy to be evaluated. Regarding the validity of our survey, other authors5 have used a smaller sample than ours but have repeated their survey to refine their research questions. This process (Delphi) was used to take 58 initial research questions and narrow them to the 11 that had the most potential for benefiting patients and reducing health care costs for a group of Canadian physiotherapists. A follow-up literature review confirmed that none of the questions had been answered. The questions generated by these physical therapists were similar in nature to those posed by respondents in the present study, in that treatment effectiveness was the primary concern and issues such as the timing of treatment, modalities, and the effects of early motion were of clinical interest. They differed in terms of the patient populations, with the physical therapist group being more concerned about lower extremity pathologies.5 More recently, the American Physical Therapy Association (APTA) developed a clinical research agenda designed “to support, explain, and enhance physical therapy clinical practice” by facilitating research that would be useful to clinicians.3 The January–March 2002

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process that the APTA used started with consultation with experts who were nominated by academic institutions, state chapters, and sections. The first draft agenda, of 128 questions, was disseminated widely among the members for comment. The field review version of the agenda was mailed to all members of the APTA Research Section, all administrators of physical therapy education programs, all component presidents, a random sample of 500 specialists, and a random sample of 500 members. Respondents rated each question on importance and how often it would be used in clinical practice. A total of 227 responses were received. Next, a research agenda was created, which listed a number of research questions and their priority rankings. Although the processes for generating the research agendas differed between the two professions, as did the classifications of the clinical questions, common themes can be found in the APTA research agenda and the questions reported in this current study. Treatment effectiveness was highlighted as a priority issue by both groups. Funding by the APTA Foundation now requires that study designs reflect compliance with their research agenda. Hand therapy researchers should consult research agenda publications to ensure that their research studies meet the needs of the clinical bodies or funding agencies with which they expect to pursue funding or publication. The need to increase clinical research is well accepted.5–13 Therapists responding to our survey indicated that this was the most important priority for AHTF. Interestingly, education was a common concern for hand therapists, but most therapists expected the AHTF to focus on research, even though education is also within the AHTF mandate. This may reflect the fact that postgraduate education is available through a variety of sources, including professional organizations at international, national, and state levels that are concerned with the upper extremity as well as private companies and universities. The expectation by hand therapists that AHTF should focus on research may be appropriate, given the limited options for hand therapy research, compared with postgraduate education, from alternative sources. A number of authors have specifically emphasized the need for clinicians to become more involved in research .4,6,9,13–21 The demands of clinical practice make research involvement difficult for hand therapists. This has also been reported for occupational therapists22,23 and physical therapists.23 Hand therapists were able to suggest a variety of supports that could help improve their participation by increasing their research skills and opportunities. Previous authors have noted that workplace learning circumstances, formal research courses, involvement with other researchers and administrative support were important in increasing research involvement 14

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for occupational therapists.8 This study suggests that the same is true for hand therapists and that it has implications for university curricula, continuing education courses, and clinical environments. All three can provide educational mechanisms that will support hand therapy clinical researchers. Collaboration with others, apprenticeships, and coinvestigations were perceived needs in this study and in others.22,24 The need for researchers to interact is present at all levels of research, and clinicians want their professional organizations to facilitate this involvement. The ability of professional foundations to support the scientific foundations of their profession depends on their insight into the needs of the profession. Information such as that provided by this study assists with optimal allocation of resources. Also important is the extent to which the professional foundations are able to accrue resources. The primary reason cited by therapists for non-support of AHTF was competing financial considerations, particularly with reference to the number of professional organizations that were perceived as important. Increased awareness of the goals of AHTF and an increased focus by AHTF on the specific concerns of hand therapists may mean that hand therapists will direct more of their funds to their research foundation (AHTF). This study surveyed hand therapists to determine research priorities and research barriers for hand therapists. Reimbursement problems could be partly abated by a stronger scientific basis for therapeutic interventions. The strength of hand therapy specialization depends on a strong scientific base. With limited research funding, high demands on clinicians, and the relatively small number of hand therapy researchers, it is imperative that professional organizations aiming to support hand therapy adopt the concept of “evidence-based” practice. It is hoped that this survey will provide information on which efforts can be made to increase the number of hand therapy research activities and their relevance. Acknowledgments The authors thank Katrina Fraser MacDermid for assistance with mailing the survey, Jan Smith for assistance with data management, and the Hand and Upper Limb Centre for mailing and staff support.

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