The Upper Extremity Physician Extender: The US Army Model

CTS3. Ultrasonography of the median nerve included the following measures: cross-sectional areas (CSA), swelling ratio (SR), and palmar displacement (PD). The CTS3 includes questions on a 5-ranked ordinal assessment for CTS symptoms (pain, numbness, tingling, burning, cold, weakness). Data Analysis: Pearson and Spearmen’s Rho analyses and curve estimations were used to correlate the physiologic ultrasonography measures and CTS3 scores of patients (CTS3; subset Questions 1 through 20 including pain and sensory changes) and subjective assessment of weakness (CTS3; subset Questions 21 through 28). Independent t-tests were used to test the difference in symptoms between the Turkish and US samples. The level of significance was set at .05. Results: Of all ultrasonographic measures, palmar displacement had a slight linear correlation with the total CTS3 score (rho ¼ 0.330; P ¼.65). When questions were independently analyzed, palmar displacement was significantly correlated to parts of CTS3. Significant correlations were found between the frequency of night pain and night numbness and PD, with rho ¼ 0.437, P ¼.012 and rho ¼ 0.374, P ¼.035, respectively. Correlations between PD and frequency and severity of unexpectedly dropping objects were rho ¼ 0.509, P ¼.003 and rho ¼ 0.514, P ¼.003, respectively, and the correlation between difficulty manipulating objects was r ¼ 0.393, P ¼.026. Crosssectional areas and swelling ratio of median nerve did not correlate to any questions of the subtest. The only difference was that Turkish patients had less perception (P ,.05) of hand coldness than US subjects, but for both groups the coldness perception was minimal. Both groups, the most bothersome symptom was a sense of weakness followed by pain and numbness. Conclusion: The magnitude of palmar displacement (bowing of the flexor retinaculum) correlates with specific symptoms perceived by the patients, which are exactly the symptoms most often used for diagnostic purposes by clinicians during the history phase of the examination. Further exploration of the nature of relationships is needed using nonlinear models of analyses. Patients

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from Turkey experienced the same symptoms in similar intensity as patients from the US. Future studies investigating the morphology of the wrist are needed to confirm the results also in US patients. This study is relevant for hand therapists, because it adds knowledge about CTS as a disease and adds confidence to the diagnostic value of symptoms of dropping objects, manipulating small objects, and the frequency and night pain and numbness expressed by patients. This study showed the benefits of interdisciplinary and cross cultural collaboration.

The Upper Extremity Physician Extender: The US Army Model. Robinette Amaker, PhD, OTR/L, CHT, FAOTA US Army Occupational Therapists (OTs) are trained as physician extenders in upper extremity neuromusculoskeletal evaluation and treatment. In the role of physician extender, OTs are trained and credentialed to work independently in support of the orthopedic caseload in both a hospital and deployed environment. OTs undergo a rigorous year-long, 3-phased training program. Phase 1 includes a 6-month preceptorship under the supervision of a hand surgeon. During Phase 1, OTs demonstrate the basic knowledge necessary to be successful in the training program. During this phase they attend hand rounds, assist in fracture clinics, and learn to rehabilitation upper extremity disease and trauma. Phase 2 is a 2-week comprehensive didactic training program designed to train OTs in the evaluations required for an upper extremity exam. This phase also includes a cadaver dissection, and classes and practicum in ordering and interpreting radiographic studies, nerve conduction studies, and laboratory studies; ordering medications and pharmacologic agents, and ends with a comprehensive final examination. Phase 3 includes a 6-month residency designed to demonstrate proficiency and competence in all of the aspects trained in Phases 1 and 2. Here the OT performs the role of physician extender and completes other requirements such as operating room observations, hands-on

assistance with fracture reduction and treatment, case studies, journal/ literature reviews, and diagnosis reviews. Once OTs satisfy the requirements of upper extremity physician extender, they are credentialed by their local hospitals and are able to perform in the role, autonomous of physician direct supervision. In the primary care role, OTs may be required to diagnose and treat fractures, order laboratory tests and radiographic studies that may lead to a diagnosis of rheumatoid arthritis, or diagnose and rehabilitate a cumulative trauma disorder. This presentation is designed to describe the role of upper extremity physician extender including the requirements leading to credentialing, as well as review 2 cases completely evaluated and treated by a US Army OT, who would normally be diagnosed by an orthopedic surgeon. This role saves time and money for the military, and OTs who undergo and succeed at this rigorous training program are force multipliers. This 5-minute clinical paper is designed to describe a program, briefly discuss 2 cases, and enlighten the audience as to the role of upper extremity neuromusculoskeletal evaluator. Reference: Army Regulation 40e68, Clinical Quality Management; February, 2004. Dynamic Pulley System for Management of Flexion Contractures Following Zone II Tendon Repair: A Case Study. Kimberly Goldie Staines, OTR, CHT, Hector SalazarReyes, MD, Marcus Crawford, MD, Morgan E. Norris III, MD, DDS Introduction: Advanced understanding of flexor tendon anatomy, biomechanics, nutrition, and wound healing have allowed us to simultaneously return motion while protecting the repaired tendon laceration during healing. The early motion protocol described by Dr Harold Kleinert (1977) utilizing dynamic traction with protected finger flexion and resisted extension is one such method. A common complication of this treatment is small finger proximal interphalangeal (PIP) joint flexion contractures in zone II repairs. Progressive resistance during finger extension is felt to be responsible for development of flexion contractures. There is a clinical