AHTA FingerPring Issue 124 | Jul-Sep 2020

Heading in here Issue 124 | Jul - Sep 2020

Helping hands FEATURES

UPDATES

Can Hand Therapy skills be taught in an online environment?

Education opportunities

New splint design for de Quervains Tenosynovitis Tendonous mallet injury, what can possibly go wrong?

Goniometry assessment and documentation quality improvement project

New corporate partners Reports Reaccreditation Guidelines for Accredited Hand Therapists

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In this issue PUBLISHED BY

Australian Hand Therapy Association Incorporated ABN 72 874 453 636 PO Box 5111 West Busselton WA 6280 T: +61 8 9778 9070 E: enquire@ahta.com.au ahta.com.au EDITOR Louise Brown E: communications@ahta.com.au ADVERTISING SALES Wendy Rowland T: 02 8776 1861 E: Wendy.Rowland@ahta.com.au

NEXT ISSUE MATERIAL DEADLINE Booking

25 Sep

Material

25 Oct

DISCLAIMER While every effort has been made to ensure the accuracy of information, the Australian Hand Therapy Association Inc. (AHTA) will not accept any responsibility for errors or omissions or for any consequences arising from reliance on information published.

Views expressed are those of the writers and are not necessarily the opinions of, or are endorsed by the AHTA unless otherwise stated.

Copy in this newsletter cannot be reproduced without the written authorisation of the AHTA. The AHTA welcomes contributions but reserves the right to accept or reject any material.

FEATURES

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Education opportunities

9

Can hand therapy studies be taught in an online environment?

11 16

New splint design for de Quervains Tenosynovitis Tendonous mallet injury, what can possibly go wrong?

23

Goniometry assessment and documentation quality improvement project.

28

What is ‘intention to treat’?

29

Fundamentals of Hand Therapy, January 2020 Gold Coast

30

Hunter Hand Rehabilitation Centre

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From the Editor Contact Us References

REPORTS

32 33 37 38 39 40 42 43

President Chief Executive Officer Professional Practice Membership Credentialing Council Membership survey results Communications States and Territories ahta.com.au l 3

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From the editor Spring is a welcome change...

Deadlines for upcoming issues of FingerPrint

After the bleak conditions of this winter, spring is a welcome change in more than one sense. It always seems imbued with a sense of hope and a fresh start, which we sorely need this challenging year.

As one door closes, another one opens - right? It’s the same for FingerPrint! Once an issue is published we are already working behind the scenes on the next issue.

If you intend to submit something for the newsletter please let us know so that we can plan appropriately, particularly with the festive season just around the corner and office closures during this time. The final material deadline for the next issue (December 2020) is 25 October 2020. Deadline information can be found on the contents page of each FingerPrint so that you can plan your submissions appropriately. If you have any questions at any time, please just email.

This edition of the newsletter has a variety of clinical submissions, such as a novel splint design for de Quervains, and some extremely relevant research, such as that into teaching hand therapy online. We have also reinstated site profiles, to help get to know therapists and practices around the country.

A member recently asked whether you can download the newsletter to keep a copy of it – yes, you certainly can!

With the newsletter in digital format now, and no hard copies printed, you can access the newsletter by signing in to the members area of the AHTA website, where you can download a copy as a PDF to keep or print. Just open the newsletter, and see the download button beneath it.

Thankyou to our member who raised this.

As always, thankyou to the members who have submitted research, case studies and other submissions.

If you are interested in submitting an article but are unsure, please get in touch with me via email.

Just for interest’s sake...

Did you know you can download this newsletter as a PDF to keep or print?

You can also find previous issues on the AHTA website in the members section.

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Looking after your mental health Everyone is facing challenges this year, in varying degrees.

The Department of Health has collated useful free resources and links online to help you access this information. If you want to learn more about options to support mental health, options for financial counselling and helpful information for parents, visit the website for details.

AHTA weekly eNews Our weekly eNews emails are being sent out with vital association updates. Be sure to check your junk folder if you haven’t been receiving them and add us to your safe senders list to ensure you don’t miss out!

This platform allows us to consolidate information usually sent across multiple emails and to get this

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information to members in a timely manner.

Regular updates such as SIG meetings and webinar dates are added to the eNews, along with course dates. We also feature the hard work of our volunteers and a wrap up of articles of interest from relevant journals.

We recently featured our Hand Therapy Awareness Week Local Legend, Nick Criticos, along with his patient Verity. They were presenterd their prizes from Wendy Rowland, AHTA CEO and Emma Ellison, Performance Health. Congratulations once again to you both.

A milestone for Sarah Dixon Sarah recently reached 10 years with the association, tirelessly working behind the scenes to manage the day to day tasks of the growing organisation as well as helping to grow the association, always with her cheerful manner. Thankyou Sarah!

If you are not subscribed to our eNews please visit here to register your details.

Google groups Our Google group members are highly active right now, sharing their wealth of knowledge and experience with each other. To get involved, please email communications@ahta.com.au

Louise Brown Communications Officer Letters to the editor are welcome and may be emailed to communications@ ahta.com.au. Letters should not be more than 300 words and must be accompanied by the therapist’s name (published) and contact information.

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Corporate Partners The AHTA is delighted to announce our new corporate partners.

These partners have committed to support the association for three years. The financial support provided by these partners enables the AHTA to expand and improve services to members and the profession.

We urge our members and colleagues to demonstrate their appreciation by supporting these companies as their preferred providers.

OPC HEALTH OPC Health has been servicing the Health Industry since 1981, holding contracts with major health services and government bodies as a preferred supplier. We take pride in providing the highest level of service to our customers and strive to continue this tradition by partnering with Health Industry innovators; leading us to partner with the AHTA today.

As one of Australia’s leading hand therapy suppliers, we are committed to supporting the industry and are looking forward to continuing our long-standing relationship with the AHTA. OPC Health offer an extensive range of supplies and equipment from market-leading brands, which are continusouly reviewed for improvement and development.

They offer AHTA members competitive pricing, 24/7 online ordering, free shipping on products purchased online, speedy delivery times and access to a national support network of territory managers and health professionals.

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Performance Health is the home of Rolyan, TheraBand and Biofreeze.

As manufacturer of these world leading products, we are proud to continue our association with the AHTA. Rolyan is our core hand therapy brand, with the full range of thermoplastics manufactured at our factory in Wisconsin, US. TheraBand invented the progressive resistance band system and offers an extensive range of rehabilitation and hand exercise products.

Biofreeze is the number 1 selling pain relief cold therapy gel in the US, and provides clinically proven, fast, long lasting, penetrating pain relief. It is available in a roll-on which is perfect for smaller joint application.

Ask our local team to sample or provide education on all our products. At Performance Health we back our products and guarantee the lowest price on Rolyan, TheraBand and Biofreeze with orders despatched same day from our national distribution centre. Call us on 1300 473 422.

Maurice Blackburn have a long and proud history of working with physiotherapists, occupational therapists and their patients.

Maurice Blackburn is passionate about engaging with health service providers. We know that access to expert legal guidance and support can help even the most experienced practitioners ensure their patients are receiving access to and proper funding for the best possible care.

In addition to professional support and guidance, our highly skilled legal team is ready and able to provide AHTA members with personal legal assistance. As a starting point, and as part of the Maurice Blackburn’s ongoing commitment to AHTA members, we offer you and your family free telephone advice.

OPC HEALTH

PREFERRED DISTRIBUTOR OF THE

As one of Australia’s leading hand therapy suppliers, we are committed to supporting the industry and are looking forward to continuing our long-standing relationship with the AHTA. OPC Health offers the followings benefits to all AHTA members: • An extensive range of supplies and equipment from market-leading brands, which are continuously reviewed for improvement & development • Competitive pricing • 24/7 online ordering • Free shipping on all products ordered online • Speedy delivery times • Access to a national support network of territory OPC Health 151-159 Turner St managers & health professionals Port Melbourne, Vic, 3207

1300 672 937 (1300 OPC YES) sales@opchealth.com.au opchealth.com.au

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Education opportunities Helena Hayes In light of the recent developments in Melbourne and the inability to move presenters around the country for courses, we are reviewing course locations and delivery methods.

We appreciate your patience as we review the schedule and find solutions to enable our education program to continue.

Please refrain from emailing/calling the office regarding a course that you may be enrolled to attend – we will be in touch once we have more information.

The best thing that we can suggest to you is to ensure you are receiving our weekly eNews, as regular updates will be issued through this medium.

As always, we do recommend you take out travel insurance to protect yourself if you need to travel to attend a course. The AHTA will do all we can to accommodate you at another course should government restrictions prohibit you from attending one of our courses.

Online Learning Many thanks go to Karen Fitt, Crystal Goodwin and Christina Harwood who presented courses online in August. Your expert knowledge, flexibility and willingness to keep our education program going in these uncertain

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times is greatly appreciated. We would also like to take this chance to acknowledge the wonderful volunteers who have given their valuable time to help out at these sessions, including: Hamish Anderson, Rebecca Crowley, Shannon Edwick, Elizabeth Giuffre, Jennie Graetz, Barb Hall, Jessica Holding, Sandra Hookins, Luke McCarron, Georgia McGuiness, Jeff Sanderson and Susie Stinton. We hope that everyone enjoyed the courses.

Starting in September, our Orthotics Courses will be delivered in a hybrid model of online learning coupled with practical hubs in cities around the country. The November Introduction to Hand Therapy course will move to online, check the website for all of the details.

New Elective Our newest elective, Pain Management Skills, is underway online - with the first cohort nearing the halfway mark.

This exciting new elective course aims to give participants an opportunity to learn how to help patients better manage chronic or persisting pain problems in the context of hand therapy practice.

Using an online webinar format, and between webinar activities, the program provides participants with an opportunity to develop competence in the application of core Cognitive Behavioural Therapy (CBT) methods for managing patients with persisting pain.

The course consists of 7 webinar

sessions (each of 90 minutes duration) conducted over a 2-3 month timeframe. In each session, participants explore and learn about specific strategies, which must then be applied between sessions.

Participants will be provided with all course materials, workbook, headset for use during the webinars, ongoing assessment tools for use with patients and a copy of the book ‘Manage Your Pain’ by Michael Nicholas et al.

There is a second cohort that will start in mid October, all of the details are on the website. Be quick if you wish to be involved, there are limited places of 10 per course.

We hope to have a review of this course featured in the next edition of FingerPrint.

Summary We are doing all we can to ensure that the education program can continue in some form and are attempting to make it available to as many people as we can – this obviously depends on the course content, presenters’ availability and location and so on.

We will update everyone as soon as possible, we are working through the courses chronologically - and the situation is still changing day to day.

The Credentialing Council are reviewing applications for extensions for AHT applicants and those reaccrediting.

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Can hand therapy skills be taught in an online environment?

Andrea Bialocerkowski Higher education institutions have been providing distance education and online learning for decades, and telehealth has grown in popularity as a treatment approach with technological advancement.

Yet, due to COVID-19 we have all been plunged, unexpectedly, into a new work environment; one that relies on technology for human interaction. Evidence from metaanalyses of hundreds of studies on the effectiveness of online learning have concluded that online education is as effective if not better than traditional education (Nguyen 2015, Means et al 2010).

Within these meta-analyses, individual studies have found an increase in student grades, engagement, and satisfaction and a decrease in failure and withdrawal from study (Nguyen 2015). This may be attributed to online learning being more flexible and structured than traditional, faceto-face learning. Yet anecdotally, we hear reports that we feel more comfortable and learn more easily in a familiar, traditional classroom setting. So how does this relate to

teaching hand therapy skills? And can these skills be taught in an online environment?

Almost 20 years ago, US-based physical therapists conducted a study to determine the effectiveness of telehealth for teaching specialised handassessment techniques to physical therapists (Barden et al 2000).

Five hand assessment skills were taught to 42 therapists: 1) volumetrics of the hand; 2) total active movement of the index finger; 3) joint mobilisation of the interphalangeal joint of the middle finger; 4) grip strength; and 5) twopoint discrimination of the ulnar nerve. The sample was stratified to one of three training groups: self-

study, direct face-to-face teaching, telehealth teaching. Detailed study materials were provided to the self-study group. The face-to-face group received demonstrations of the hand assessment techniques plus practice time, which totalled 3.5 hours. The telehealth group received the same instruction and practice time as the face-to-face group but over a telecommunications platform. Therapists were assessed by a single examiner, on their competence to undertake each hand assessment technique prior to and following the training.

Results indicated that the level of competence prior to training was equivalent across the three

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groups. Following training, a significant difference was found in the level of competence between the self-study group and both the direct teaching and telehealth groups. This finding suggests that therapists in the direct teaching and telehealth groups learned the hand assessment techniques equally well. They also learned significantly better than those in the self-study group. Based on these results, the authors concluded that “telehealth may be used as effectively as the conventional method and more effectively than self-study to teach these five assessment skills�.

Although there are limitations associated with this study, it does provide evidence that hand assessment skills can be taught in an online environment.

Are these results surprising to you?

Do you feel more comfortable engaging in familiar methods of learning, like the ones you experienced when you were a student? The key take home message is that because the mode of instruction is different, then teaching, facilitation and engagement methods used by teaching staff are also different.

Likewise, learners should hold different expectations. Evidence gained from health professional engagement with Massive Open Online Courses suggests that selfregulatory processes (such as goal setting, self-efficacy, learning and task strategy and help-seeking) all need to be modified when learning online (Milligan and Littlejohn 2016). So, as a consumer of professional development what are your expectations of online learning? How can you modify your beliefs and behaviours to facilitate deep, active learning, irrespective of how the learning is delivered?

References

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New splint design for de Quervains Tenosynovitis Jodie Robertson There is consensus in clinical practice and the medical literature that splinting for de Quervains Tenosynovitis can improve symptomalogy.

It is accepted practice that the wrist and thumb (excluding IP joint) need to be influenced by the splint in order to have effect on the Extensor Pollicus Brevis (EPB) and Abductor Pollicus Longus(APL) tendons. However, there is very little consensus on splint design with many iterations being offered to patients.

De Quervains Tenosynovitis is now understood to be more of a tendinosis rather than a tendinitis/ tenosynovitis, with histopathology studies finding myxoid degeneration rather than acute inflammatory cells (Pensak, M., Bayron, J. and Wolf, J., 2013). The tendons involved are the Extensor Pollicus Brevis and Abductor Pollicus Longus at the 1st Dorsal compartment and then under the extensor retinaculum at the wrist.

The mechanism of degeneration remains unclear and it is proposed that repetitive movements of the wrist and thumb, specifically ulna deviation in combination with thumb flexion-extensionabduction and/or opposition eg turning a door handle, or turning a tap, produces micro tears which may cause collagen disorientation,

mucoid changes and thickening of the extensor retinaculum (Pensak et al 2013). Splints are generally aimed at reducing the repetitive movements of the thumb and wrist and local steroid injections are frequently used in combination with splinting.

It is now generally recognised as a self-limiting process in the majority of patients and those with concurrent depressive symptoms are strongly correlated with greater disability (Menendez et al 2015, Pensak, M. et al 2013).

Splints generally have potential to reinforce disability and secondary gain from this condition, and may not be useful and even harmful for certain patients.

Splint design in hand therapy practice for de Quervains Tenosynovitis varies amongst practitioners and clinics. Factors to consider in splint design in this patient group are: • Age • Employment type • Activity status • BMI • Irritability of condition • Cost/affordability Some splint design offerings include: • Custom made rigid thermoplastic immobilising the wrist and thumb

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• Semi-custom neoprene splint with mouldable thermoplastic insert (radial gutter) • Off the shelf semi-rigid splint with plastic or metal inserts for reducing movement at the thumb and/or wrist • Other Splints are offered to patients to immobilise or significantly reduce the movement of the thumb and wrist in effort to “rest” the EPb/ APL tendons and reduce pain and /or inflammation. Many patients respond favourably to any of the above splints, however, some problems arise from the general design which immobilises the wrist and thumb in all rays of movement.

These include: • Wrist / thumb stiffness • Aching • Poor function and poor compliance • Difficulty weaning from splint • Dependence on splint • Negative effects of immobilisation (especially associated with rigid splinting) It is therefore desirable that the splint is worn for the shortest duration possible to achieve symptom relief but also minimise the negative associations of disuse, poor function and maladaptive movement patterns.

A new splint design, first seen/ published by Orfit, introduces the concept of controlled motion where the aggravating movement, i.e. wrist radial deviation/ thumb extension for the EPB/APL is immobilised, but some wrist flexion and extension can occur with the splint on.

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The proposed advantages of this splint could be: • Improved function of the immobilised limb due to less biomechanical limitations in flexion/extension movements • Reduced negative effects of immobilisation on thumb, wrist and upper limb generally (such as weakness, reduced muscle mass, joint stiffness, reduced tendon nutrition) by allowing some movement at the wrist joint • Improved compliance due to less rigidity /impact on function • Reduced dependence on splint and easier weaning off splint

Trials This new splint design has been trialled on 3 patients with differing presentations: 1. Acute presentation: < 2 weeks onset 2. Subchronic: 8 weeks since onset 3. Chronic /recurrent presentation: 3 months since onset, 12 months from initial episode 1. Acute presentation: 28-year-old active female ambulance officer, 2 weeks since onset, no steroid injection.

Splinting: initial splint immobilising the wrist and thumb for 2 weeks, then modified for controlled motion.

Rationale: the acute presentation with 8/10 pain and positive Finkelstein’s test with thumb opposition alone, painful wrist motion indicated that the tissues would benefit from a short period of immobilisation followed by the controlled motion splint to

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allow return to normal function within the splint and without the biomechanical disadvantages of full immobilisation. Minimal time immobilised and therefore minimal risk of disuse or neuroplastic changes.

2. Subchronic: 65-year-old female active retiree, regularly gardening and house renovating.

Rationale: had attempted different versions of semi-rigid splinting without success and patient presented with hypersensitivity, poor movement patterns including withholding movement at shoulder/ elbow and wrist to minimise pain. Tissues in degenerative stage, not inflammatory therefore immobilisation likely to lead to further deterioration. Active lifestyle means controlled motion splint more likely to be tolerated but still limit aggravation of condition by preventing overuse of thumb/ wrist with activity.

3. Chronic/Recurrent presentation: 48-year-old female part time office worker, active mother with recurrent de Quervains, 3 months duration, 12 months since previous episode.

Rationale: at this stage, the condition will be of more degenerative nature, where traditional immobilisation and the negative effects of tendon weakness, poor nutrient exchange and joint stiffness, reduced forearm muscle mass and reduced strength will likely negatively effect tissues and outcome. The controlled motion splint combats these effects but still effectively rests the EPB/APL tendons. The

improved movement in the splint means improved overall function and use of the arm, thereby limiting the â&#x20AC;&#x153;broken wingâ&#x20AC;? fear based behaviour pattern that can sometimes occur with recurrent symptoms and makes splinting difficult.

Results and Impressions The controlled motion (CM) splint was well tolerated by all patients, however the acute presentation needed pressure relief over the radial styloid (theraputty and foam). All 3 presentations required splint modifications to reinforce the joins/hinges. The 2 patients that had experience with a rigid splint first (7 days for sub chronic, 14 days for acute) both preferred the CM splint. Clinically, the Finkelsteinâ&#x20AC;&#x2122;s test was negative on the first visit following introduction of the splint and remained that way until discharge. The inclusion of hydrocortisone and local anaesthetic (HCLA) was beneficial in combination with the splint for acute and chronic presentations.

All patients received isometric wrist stability exercises concurrent with splint use and progressed to dynamic stability exercises (disturbance based exercises) prior to discharge.

It was our clinical experience that generally less time in a splint was needed to relieve symptoms than with usual splint designs.

Discussion The CM splint has been a welcome addition in the armoury for treating this condition, however there are some things to consider regarding these results. The patients were carefully chosen for their open

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Table 1.

Splint application

Splint duration Outcome: Steroid - Finkelstein’s test injection - splint use - RTW

Day 14

24 Days

- negative 0/10 - no splint use - full duties

Yes

Sub-Chronic Day 7

21 Days

- negative 0-2/10 - occassional splint use - N/A pending

No

Chronic

28 Days

- negative 0/10 Yes - none to rare use of splint - full duties

Acute

Day 1

minded attitudes and willingness to try something different which may have contributed to a positively skewed placebo effect.

The inclusion of HCLA injection in 2/3 patients was also likely to have contributed to the success of the splint. The role of dynamic tape and use of exercise were not independently compared for their value, however all 3 patients received these as part of their treatment regime in addition to splinting.

It is proposed that because the splint design allows for some wrist motion in the flexion/extension plane, it doesn’t restrict the patient functionally as much as a rigid splint. Neuroplastic changes that occur with immobilisation are minimised with this design and patients potentially are not as “disabled” by their splint and their behaviour was still essentially “normal”. Additionally, the deleterious effectors of immobilisation are minimised with this design, but the essential aggravating movements are still minimised to allow symptom relief and in this case study, less overall time in the splint.

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Fabricating the Controlled Motion Splint The splint is a circumferential thumb spica splint that is halved and 3 hinges are attached to control the wrist motion.

Equipment: • thermoplastic • velcro - hook and loop • Orficast strips x 3 or thermoplastic strips x 3 5-8 cm x 1cm • rivets (optional)

Instructions 1. Fabricate a forearm based circumferential thumb spica.

2. Cut the hand piece from the forearm piece at the level of the radiocarpal joint.

3. Roll edges of hand piece and forearm piece. The forearm piece can be positioned below the radial styloid or moulded over foam to minimise direct pressure over the EPB/APL tendons at the retinaculum of the wrist.

4. Attach Velcro strips to hand piece and forearm piece and place on patient.

5. Prepare Orficast strips. These need to be the length between the bottom of the hand piece and the top of the forearm piece, approximately 5-8cm.

6. Using a pen, mark on the thermoplastic hand piece and forearm piece, the precise location for Orficast strips.

7. Volar Ulnar border of hand piece attaches to Volar Ulnar border of forearm piece.

8. Dorsal Ulnar border of hand piece attaches to Dorsal Ulnar border of forearm piece.

9. Radial border of hand piece attaches to radial border of forearm piece.

10. Fit to patient as per usual.

A forearm based volar thumb spica can also be considered depending on therapist and patient preference and level of support needed.

Helpful hints: 1. Pressure relief over radial styloid is useful especially if very sensitive.

2. Use concurrent dynamic tape so thumb/wrist are supported and to provide tactile feedback when not using splint.

3. Instruct to use only as needed.

4. It is better to make a circumferential splint in the first instance that can be easily cut down rather than trying to adapt a volar thumb spica if you think you might consider this design down the track from an initial appointment.

References and recommended reading.

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Now supporting the AHTA Maurice Blackburn Lawyers have a long and proud history of working with physiotherapists, occupational therapists and their patients.

Our team can support hand therapists to: • run educational workshops to help members understand their legal obligations, rights and entitlements • provide members with resources to support any legal needs that may arise, such as responding to subpoenas or appearing in court • achieve a better commercial outcome when treating compensable patients.

We can also provide support to your patients. If they are unable to work or their quality of life is impacted by injury, patients may be entitled to a range of benefits. These entitlements can provide the financial support your patients need to get on with life.

Find out how Maurice Blackburn Lawyers can help you and your patients by contacting us:

1800 810 812 health@mauriceblackburn.com.au mauriceblackburn.com.au

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Tendonous mallet injury, what can possibly go wrong?

Elizabeth Witherow Tendonous mallet injury is defined as disruption to the continuity of the terminal tendon, resulting in lack of active extension of the distal interphalangeal joint (DIP) (Alla, Deal & Dempsey, 2014, Bendre, Hartigan and Kalainov, 2005).

While seemingly an ‘easy’ injury to manage when compared with complex multi-trauma, failure in mallet injury management has been reported in up to 48% of cases, resulting in ongoing lag, stiffness, swan neck deformity and other sequalae which affect function and cosmesis of the hand (Warren, Norris & Ferguson, 1988).

The following is a mallet finger case study and a review of relevant literature.

Case study “K” is a right hand dominant 47-year-old woman who sustained a tendonous tissue mallet to her left middle finger while hanging out washing. An ultrasound was completed via her GP, with a fourmillimetre gap in her tendon fibres identified.

“K” presented to a plastics clinic four weeks following her injury and was seen on the same day.

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A paddle pop stick was used to support her finger since the time of injury, still bending her DIP within the orthosis and removing it for hygiene. A 14-degree lag was recorded at the initial appointment, however “K” reported this was initially much worse. An xlite circumferential DIP extension orthosis was fabricated for full time wear, as well as a finger based dorsal blocking orthosis at 30 degrees PIP joint flexion which could be removed for hygiene. A review was booked for two weeks to check skin integrity and orthosis fit given oedema. A summary of active motion measures and intervention is included in Table 1.

A circumferential xlite DIP extension orthosis was fabricated for “K” as well as a dorsal PIP 30 degree flexion orthosis. I opted to use this material given I felt the large grids allow easier hand washing/drying within the orthosis; however, a concern with this material is potential for collection of oedema. An additional benefit of xlite is its tacky nature which I typically find helps reduce slippage.

However, in this case “K” returned with the orthosis upside down at nine weeks post immobilisation. It is unknown how this occurred, and “K” reported no pain or concerns on presentation. This positioning resulted in skin indentations from the rope like structure of the xlite, which necessitated a change of material. In addition to indentation

due to orthosis malpositioning, I have previously been cautious in positioning of the xlite due to potential for pressure injury. At this time an Orfit circumferential DIP orthosis was adopted and the dorsal blocking PIP orthosis was increased to 60 degrees of flexion.

I opted to use a dorsal blocking orthosis given “K’s” natural tendency for PIP hyperextension, and to improve approximation and reduce tension through the terminal tendon through volar and distal migration of the lateral bands with PIP flexion. Given the delayed presentation, age and natural hyperextension posture I opted for full time wear of the dorsal blocking orthosis. I further Increased the position of flexion, following the orthosis malpositioning, to increase tendon approximation.

Image 1 & 2 taken at 20 weeks post

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Table 1.

Week

Therapy

AROM DIP (-lag, +hyperextension)

0

Oedema. Natural PIP hyperextension position. Circumferential xlite DIP extension orthosis. Finger dorsal block 30 deg PIP flexion full time

-14/

2

Reduced oedema, pain if knocked, nil change to therapy

5 7

Did not attend Continue orthoses

9

Good PIP flexion. DIP orthosis upside-down. ORFIT DIP extension orthosis full time, PIP dorsal block increased to 60 deg flexion No change PIP pain and stiffness. Continue DIP orthosis. Dorsal block 30 deg flex PIP, night only

-32/

16

Pain reduced, improved PIP flexion Wax, 10x loose hooks. Continue DIP orthosis full time, dorsal block night

18

Ktape full time, 3 x daily 15 reps hooks, orthosis between exercise, dorsal block night

+10/ pre -6/20 post therapy +4/22

20

“K” fearful of orthosis removal. Ktape full time, buddy tape middle to index for inclusion.

Occupational use encouraged. DIP orthosis protective wear “K” report gradual DIP drop with time. Orthosis melted in car. Figure 8 orthosis PIP flexion ½ day. Putty rolling, intrinsic plus, pinch, fists, desensitisation

+18/ pre +12/14 -6/32

“K” forgot DIP orthosis last 3 nights and using hand normally but slightly lighter activity.

3 point pinch: (R)4.5, (L) 2.75, Grip (R) 13, (L) 10, Cease exercise, orthosis. Occupational use and isolated DIP flexion encouraged

-4/30

11 14

22 24

Following malpositioning of the orthosis, the extensor lag persisted despite an additional short period of immobilisation, and a further ‘full period of immobilisation’ was Image 3 & 4 taken at 24 weeks post

-8/

completed.

-12/ -4/

Image 5 & 6 taken at 2 years post

I made the decision to slowly wean the orthosis, with initial wear between exercise. On further removal of the orthosis, I adopted use of ktape and tubigrip buddy socks in an attempt to provide some dynamic extension support.

At two years post initial therapy management, “K” reports no associated pain or functional limitations. This case study certainly didn’t follow the typical pathway of tendinous mallet finger management. I was particularly surprised by the successful outcome following the orthosis malpositioning. I hypothesise the success may be the result of a ‘new trauma’ caused by the orthosis malpositioning, effectively another acute mallet injury at nine weeks.

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Literature Review

Gender and oedema

Patient history and presenting factors influencing successful mallet outcome

Warren, Norris and Ferguson (1988), in a study comparing orthosis type, observed women had poorer outcomes compared with men. Similarly, oedema has been associated with poorer outcomes reportedly due to reduction of venous, arterial and lymphatic flow which may impact healing capacity (Tocco et al, 2013, Valdes, Naughton, & Algar, 2015).

Several patient factors have been reported as impacting success in management of mallet injuries including age, gender, oedema and time until injury management, degree of presenting lag (Maitra & Dorani, 1993, Tocco et al, 2013, Valdes, Naughton, & Algar, 2015).

Age Increasing age has been reported in multiple studies as poorly influencing the outcome of mallet injury (Groth, Wilder & Young, 1994, Maitra & Dorani,1993, Oâ&#x20AC;&#x2122;Brien & Bailey, 2011, Tocco et al, 2013, Valdes, Naughton, & Algar, 2015). Maitra and Dorani (1993) reported failure in 85.2% of participants aged over 41 years, similarly Groth, Wilder and Young (1994) reported poor outcomes associated with a participant mean age of 47.9 years. Tocco et al (2013) also reported failed or poor results in all participants aged 60 years and over.

While no studies have specifically explored why age impacts outcome, Jones and Peterson (1988) suggest there may be a familial disposition, identifying 20 mallet injuries in seven family members, 17 of which were of non-traumatic origin.

Additionally, family members with atraumatic injury also reported carpal tunnel (71%) and trigger finger (42%) symptoms. The authors proposed an underlying genetic or biochemical cause of these injuries (Jones & Peterson,1988).

18 l AHTA NEWSLETTER l JUL-SEP 2020

Timeframe until management Mallet injuries presenting within three to four weeks are typically classified as acute injury while those later than three to four weeks are considered chronic (Duncan & Flowers, 2015). In a survey of Dutch hospitals, 66% of respondents reported they would manage chronic mallet injuries conservatively while 13% would surgically repair (Haagsma et al, 2015). A European Federation of Societies for Hand Therapy consensus report states therapists felt a greater time between injury and treatment resulted in a poorer outcome (EFHST, 2008).

Garberman, Diao and Peimer (1994) in a study conducted to investigate early versus delayed presentation found no difference between those presenting on average four days compared with eight weeks post injury.

Orthosis type and position Many studies have sought to identify the most effective orthosis for management of mallet injury, and although stack orthoses have been associated with significantly greater skin complications, systematic reviews have failed to

identify a superior orthosis type (Handoll & Vaghela, 2004, Lin & Samora, 2018, Valdes, Naughton, & Algar, 2015, Witherow & Peiris, 2015). In a survey of practice, 78% of clinicians use custom thermoplastic orthoses (Cook, Daniels & Woodbridge, 2017) however a large number of different orthosis types have been studied.

Orthoses type could be classified according to the following criteria: custom thermoplastic, DIP rigid immobilisation non thermoplastic, PIP and DIP immobilisation, 3D printed and non-rigid methods.

PIP/DIP immobilisation

Image 7 & 8 Pipflex: Evans & Weightman (1988); POP: Warren, Norris & Ferguson (1988).

Traditionally Plaster of Paris (POP) was used for mallet immobilisation, however, was associated with functional limitations and subsequent

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financial burden, migration, skin necrosis and required regular replacement (Mason, 1954, Smillie, 1937, Stack,1969). Subsequent immobilisation methods shifted toward DIP immobilisation only to promote mobilisation and function.

The Pipflex orthoses reported a study by the creator without further investigation (Evans & Weightman,1988).

Custom thermoplastic

2017, Vernet, 2019, Warren, Norris & Ferguson, 1988). Aluminium orthoses have also been regularly investigated in either a volar, dorsal, clam shell or Mexican hat format with skin maceration the greatest concern reported (Kalantari; Maitra & Dorani, 1993, O’Brien & Bailey, 2011, Pike, 2010, Wilson & Khoo, 2001). Quickcast was included in one study without significant issue reported (Tocco et al, 2013).

The Abouna orthoses reported in studies by the creator (Abouna, 1965, Abouna & Brown,1968) report skin laceration as a complication caused by the metal coated material.

Image 9 Lever style: O’Brien & Bailey (2011); Figure 8: Saito & Kihara (2016).

Several forms of custom thermoplastic have been studied including stack style/lever type, circumferential, figure 8, dorsal, sugar tong, glued dorsal (Botero, 2016, Kinninmonth & Holburn, 1986, Mak, Aitkens & Novak, 2016, O’Brien & Bailey, 2011, Pike, 2010, Saito & Kihara, 2016, Tocco et al, 2013, Tolkein et al, 2017, Vernet, 2019).

Image 10 Abouna orthosis: Warren, Norris & Ferguson (1988); Stack orthosis: Warren, Norris & Ferguson1988);

A more novel design includes the Alam prosthetic device (APD) made from dental impression silicone putty in a clinical pearl article (Padiachee et al, 2016), although this is without clinical trial.

3D printed

Image 13 Gupta et al (2019); Zolfagharian (2020).

More recently 3D printing orthosis have emerged in the literature, with the aim of reducing material waste, improving fit, ventilation, hygiene and preventing slippage.

Only one of these studies reports patient trials however the article focuses on method of production rather than participant outcome (Choi, Seo & Lee, 2019, Gupta et al, 2019, Zolfagharian, 2020).

Non-rigid

DIP based non-thermoplastic The Enid orthosis utilises a wooden spatula, cork, felt and tape and is only reported by Mason (1954).

The stack orthosis has been included in several traditional and more recent studies. Issues with correct fit, maceration, discomfort and treatment failure have been reported in addition to successful management (Botero, 2016, Maitra & Dorani, 1993, O’Brien & Bailey, 2011, Stack, 1969, Tolkein et al,

Image 11 Quickcast: Tocco et al (2013).

Image 14 Moon sock: Thomas (2006); Taping O’Conor (1997)

Image 12 Aluminium dorsal Mexican hat: Wilson & Khoo (2001);

Thomas (2006), in a practice forum recommended use of a shaped lycra sock following full time immobilisation to potential lag. While both the double finger elastic bandage and adhesive tape were recommended as forms of

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mallet management without rigid immobilisation and clinical study (Hovgaard & Klareskov, 1988; O’Connor, 1997).

Positioning Blood supply to the dorsal skin of the DIP has been described as “precarious” (Lester et al, 2000). Rayan & Mullins (1987) explored the degree of natural hyperextension of the middle finger DIP and how this relates to blanching/blood supply to a healing terminal tendon. Passive DIP hyperextension ranged from five to 45 degrees with blanching occurring at approximately 50% of natural hyperextension range (Rayan & Mullins,1987). Ill-fitting orthoses may cause compression and additional potential for ischemia (Wilson & Khoo, 2001).

A therapist practice article reported 9% of therapists immobilise the PIP (Haagsma et al, 2015) while all therapists adapt to include the PIP in the presence of swan neck deformity using a position of 15 to 40 degrees flexion (Cook, Daniels & Woodbridge, 2017).

Okafor, Mbubaegbu, and Williams (1997) found 29% of cases at fiveyear follow-up developed swan neck deformity following mallet injury management. One study using tape for immobilisation also included the PIP in near full flexion (O’Connor,1997). Saito and Kihara (2016) included the PIP in 30 degrees flexion for 3 weeks followed by DIP extension figure 8 orthosis, reporting improved results compared with a DIP orthosis alone. Tocco et al (2013) on the other hand, advocated PIPs free of the orthoses to allow lateral band

20 l AHTA NEWSLETTER l JUL-SEP 2020

migration during flexion with hand use.

clinical significance when treating mallet finger.

From an anatomical perspective the literature is conflicting. Kaplan (1959) and Abouna and Brown (1968) reported that the MP and PIP should be extended to relax the dorsal apparatus. On the basis of these earlier anatomical studies, there was a shift from POP including the PIP in flexion to DIP extension only orthoses.

Since this time, tendon gapping following terminal tendon injury has been found to be a result of DIP flexion, rather than retraction of the proximal end of the tendon via intrinsic pull. Tendon connective tissue attachment to the middle phalanx periosteum helps prevent such retraction (Bendre, Hartigan and Kalainov, 2005; Katzman et al, 1999). As a result, Katzman et al (1999) suggest inclusion of the PIP is not required.

In any case, ideal positioning is key with one millimetre of tendon gapping found to result in a 25-degree DIP lag, highlighting the importance of good tendon approximation and calling into question whether a lag is due to poor healing requiring further management versus an elongated tendon (Schweitzer and Rayan, 2004).

In contrast, Schweitzer and Rayan (2004) advised following their kinematic study that the DIP and PIP impact terminal tendon excursion and should be immobilised, with reduction of terminal tendon tension when the PIP is moved from extension to flexion (Nu et al, 2018).

Furthermore, PIP flexion pulls the dorsal apparatus distally, advancing lateral bands by 3mm and when combined with DIP hyperextension approximates the tendon ends at the DIP in a relaxed manner (Bunnell as cited in Saito & Kihara, 2016, Evans & Weightman, 1988).

Lin and Srauch (2014) also reported PIP flexion reduced tone of the dorsal apparatus over the middle phalanx, although felt it was not of

Orthosis regime Immobilisation timeframe

Timeframes for full time orthoses wear vary greatly within the literature, with one Irish hospital survey reporting four to eight weeks, a Dutch survey six to eight weeks and British four to 12 weeks (Cook, Daniels & Woodbridge, 2017, Haagsma et al, 2015, Minchin & Spirtos, 2012). Clinical protocols suggest six weeks for acute and eight weeks for chronic tendon immobilisation (Duncan and Flowers, 2015). One study directly investigated orthosis timeframes for mallet injury and felt there was insufficient evidence for any specific timeframe (Pratt, 2004).

Post immobilisation orthosis wear There is also some variation in use of orthosis following the full-time immobilisation period and some studies fail to address how an ongoing lag post full-time immobilisation has been managed.

Practice surveys indicated 92% of clinicians advocated further immobilisation in event of failed management, although they failed to define ‘failure’ (Cook, Daniels & Woodbridge, 2017, Minchin

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& Spirtos, 2012). One study also suggested the ongoing spontaneous improvement of extensor lag for a further six months without intervention (Pike, et al, 2010).

Pike (2010) reported an additional four weeks immobilisation in the presence of a 20-degree lag. In the absence of lag, some studies continued night/protective orthosis wear for zero to four weeks at night/protective wear (Minchin & Spirtos, 2012, Saito & Kihara, 2016).

The definition of failed mallet management varies with impairment measures, author discretion and formal definitions such as the Abouna and Brown Criteria and Crawford Criteria, further adding to confusion around when further immobilisation may be required (Abouna and Brown, 1986, Alla, Deal and Dempsey, 2014, Garberman, Diao and Peimer, 1994, Tocco et al, 2013).

Mobilisation No specific studies were located investigating optimal mobilisation following full time orthosis wear.

Cook, Daniels & Woodbridge (2017) reported education regarding activity modification is typically provided by 90% of therapists with advice such as avoiding lifting and twisting. Exercise included a combination of tendon glides, and passive DIP range from 10 weeks (reported by 37% of therapists) and strengthening at eight weeks (reported by 71% of therapists).

Frequency of exercise is reported in studies; however, choice of this frequency is not reported (O’Brien & Bailey, 2011, Saito & Kihara, 2016).

Other factors influencing outcome Adherence Not surprisingly, adherence is also key in the success of managing mallet injury. Groth, Wilder & Young (1994) found only 59.1% of subjects were adherent with appointment attendance, mallet orthosis wear and therapy regime.

Poor results were recorded for 82% of the non-adherent population and 61.5% of adherent subjects had excellent results. While not obviously collected as data, the author concluded with increased demands of the therapy regime, there was reduced adherence (Groth, Wilder & Young, 1994).

Health literacy Health literacy has also been identified as a cause of reduced adherence in mallet injury management, with 33% of people deemed to have potentially limited or inadequate health literacy which resulted in a significant increase in the presence of extensor lag (Roh et al, 2016). In a study by Novak, Mak, and Chang (2019), both written and video education were used in management of mallet injury, with the authors concluding participants supported the use of both mediums.

• Should degree of lag or gap distance impact our management?

• Does presence of trauma in injury result in a better outcome with tendon mallets than no trauma?

• Is there an ideal orthosis (circumferential, volar, dorsal) and material to use?

• Should the PIP be blocked into PIP flexion initially? If so, how much flexion and for how long?

• What is the ideal timeframe for full time immobilisation?

• Should orthosis wear be limited to night post full-time immobilisation?

• Is there an optimal mobilisation regime post full-time immobilisation? Should this include any supports such as the moon sock, tubigrip or taping?

• When is it too late to begin managing a tendon mallet injury?

• How long is too long to immobilise a mallet?

References

Clinical considerations Clinically, I continue to have several questions around how to best achieve successful results with clients following mallet injury including: • Should we manage potential ‘high risk’ categories such as age, gender, delay in management differently?

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22 l AHTA NEWSLETTER l JUL-SEP 2020

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Goniometry assessment and documentation quality improvement project Part 1 - Diagnostic Phase Tasha Forbes Background

Project Goal

The Joondalup Health Campus (JHC) Hand Therapy clinic is staffed by four full time equivalent Occupational Therapists (OTs) (including one junior rotational post). This includes three senior and two junior therapists. In 2019 the clinic received 2252 referrals, with the most common conditions related to wrist and hand fractures, and soft tissue injuries involving tendon, ligaments or lacerations. A preliminary review of goniometry as an objective assessment for joint range of motion (ROM) found consistent variation between the four permanent staff members in relation to the method of assessment and documentation of results.

This project aims to determine the extent of, and reduce, variation between therapists whilst undertaking and documenting goniometry assessment in the JHC Hand Therapy Clinic.

Lean Six Sigma (CSSC, 2018) is being used as the conceptual method and framework to investigate, understand and create sustainable change for this quality improvement project. Reducing variation in goniometry assessment and documentation will decrease waste (time and resources), improve flow (streamline the patient journey through the rehabilitation process and improve access to the service) and decrease preventable complications and delays in functional recovery.

Project Scope The project is being undertaken in the JHC Hand Therapy clinic between April-November 2020 and will consider goniometry assessment and documentation in relation to: Outpatients Most hand therapy patients receive treatment in the outpatient clinic.

The project will focus on the four permanent OTs, as the rotational therapist is upskilled by these staff (and is presumed to develop the style of those providing the teaching).

Active range of motion Assessment and documentation of active ROM will be the focus of this project. Passive ROM will not be considered due to additional variables that may influence the assessment (Lewis et al., 2010).

Finger and wrist joints Finger and wrist ROM are most commonly assessed within the

clinic. Any findings in relation to these joints will apply to thumb, elbow and shoulder ROM documentation.

Assessment To include all factors relating to goniometry assessment including equipment used, placement of goniometers and interpretation of measurement.

Documentation All factors relating to goniometry documentation, interpretation of measurement and notation style.

Literature Review Goniometry is a commonly used assessment tool in hand therapy to objectively measure and document joint ROM (Lewis et al., 2010; Mulder & Wittmeier, 2009; van Kooij et al., 2017). Sources of variation may be equipment based, therapist-based or patient-based (for example pain, oedema, time of day) (Lewis et al., 2010; van Kooij et al., 2017). Patient-based factors are unable to be controlled via a process or system, therefore the focus for standardisation of goniometry assessment is the equipment used and therapist actions (van Kooij et al., 2017). It is recognised that the accuracy of different goniometers can

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vary, and different therapists may choose to measure the same joints with different goniometers, and therapists may place the goniometer in different positions, use different anatomical landmarks as reference points, or read the measurement differently (Groth & Ehretsman, 2001; Lewis et al., 2010; Szekeres et al., 2016; van Kooij et al., 2017). Notation variations may include documentation of joint hyperextension, lack of joint extension and use of standard form (Mulder & Wittmeier, 2009).

Therapists use goniometry to document and evaluate change to assist in determining potential causes for limitations and to guide implementation of therapy interventions (Szekeres et al., 2016; van Kooij et al., 2017). For patients, goniometry provides feedback, a sense of accomplishment, confidence and motivation to engage with therapy. Despite the frequent use of goniometry in hand therapy clinics throughout the world, there is no accepted standard for either assessment or documentation (Lewis et al., 2010; van Kooij, 2017). The ASHT Clinical Assessment Recommendations provide a guide as to commonly used techniques, with reference to the literature where available (Gibson, 2015). Differences within clinics may exist due to individual therapist preferences, interpretation and experience (Groth & Ehretsman, 2001; Lewis et al., 2010), and, in the absence of an international gold-standard assessment or documentation guideline, it is recommended that individual departments and clinics establish and follow a standard procedure (van Kooij et al., 2017).

24 l AHTA NEWSLETTER l JUL-SEP 2020

Diagnostic Findings A range of activities were planned to determine the extent of variation present within the clinic. These included a patient notes audit, informal discussions, focus group and quantitative data collection (referrals received and outpatient clinic appointments attended).

Restrictions related to COVID-19 prevented the planned focus group session from being completed, and instead an email and further informal discussions were held.

These activities were completed during March-May 2020.

Assessment and documentation differed between therapists and, whilst there was plenty of similarity present, variation was also found (see Table 1).

An unexpected finding during the diagnostic phase of the project was the technique one therapist described to measure radial/ ulnar deviation (in neutral forearm rotation). The clinical reasoning provided was that patients are more likely to achieve neutral rotation, rather than pronation, in the early stages of rehabilitation increasing patient comfort and possible ROM when assessing radial/ulnar deviation. The other reason provided for this positioning was that it limited the potential effect of the proximal-distal migration of the radius and ulna which occurs during rotation. To investigate the clinical reasoning of this technique a brief additional literature scan was conducted.

In 1969 Spilman and Pinkston referenced older literature related to this topic, however these articles

were unable to be sourced. A study

by Marshall and colleagues (1999) found the position of forearm rotation impacted radial/ulnar deviation in males (no significant difference in females) with greater radial deviation in full pronation and greater ulnar deviation in 45° pronation. Unfortunately, this study did not look at the effect of neutral rotation, but instead full pronation (90°) compared to pronation of 45°.

Whilst no conclusion can be made regarding the appropriateness of measuring radial/ulnar deviation in neutral rotation, it does demonstrate the potential effect of attempting to compare measures where patient position is inconsistent. It also raises the question as to why certain positions have been chosen and accepted as standard practice over time within the profession.

Each therapist was able to provide clinical reasoning for their methods, though there was a lack of consensus between therapists as to the minimum requirements for assessment and documentation.

Overall therapist assessment technique was found to be in line with ASHT Clinical Recommendations. There were two exceptions – one therapist’s positioning of the goniometer arm when measuring pronation/ supination and another therapist’s positioning of the patient and goniometer for radial/ulnar deviation. Despite the widespread variation found each therapist felt they understood and were able to interpret their colleagues’ documentation style even where it differed from their own style.

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In summary the diagnostic findings found numerous variations in assessment including goniometer preference and placement, patient positioning and rounding of measurements. Documentation variation included incomplete measures, use of composite and individual joint measures, notation for hyperextension, clarity of type of ROM measured and when it was measured (e.g. pre-treatment or post-treatment).

The next steps of this project are to identify, implement and evaluate solution/s that will reduce variation in goniometry assessment and documentation.

This will include all team members in order to maximise therapist engagement and to develop a comprehensive solution. This phase will be conducted during AugustNovember 2020.

References

Table 1. Key findings

Variation in reported practice compared to actual practice • Differences found in therapists report of documentation methods in discussions/email compared to findings of notes audit • Therapists predominately trained within the clinic were most similar Goniometer preference • • • • •

Variation due to goniometer inherent margin of error Results in variation in placement due to length of arms Variation in increments (2° compared to 5°) Varied depending on joint measured and therapist preference Impacts inter-rater reliability

Goniometer placement • Variation in patient positioning particularly for pronation/supination and radial/ulnar deviation • Variation in goniometer placement and use of anatomical landmarks • Impacts inter-rater reliability Variations in assessment and documentation differed • Difference therapists undertake different aspects differently i.e. numerous instances of 2-3 therapists being similar and the remaining therapist having an alternative (this was not always the same therapist) Therapist habit and routine • Influenced by initial training • Appeared to affect what was measured, when it was measured, how it was measured and how it was documented • Each therapist was able to provide clinical reasoning for their methods • Most therapists used an acceptable technique for assessment • Differences in international organisation recommendations for documenting hyperextension of joints (ASHT ‘–‘ and IFSSH ‘+’) with both methods used in the clinic (therapist preference)

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What is ‘intention to treat’?

Nicola Massy-Westropp Many of us have looked at the Physiotherapy Evidence Database to see what quality and what levels of evidence are available for a treatment of interest.

The PEDro appraisal criteria were developed to appraise the quality of randomised controlled trials, and one of the 11 criteria asks ‘all subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by “intention to treat”.

What does this mean? It means that when the researchers viewed the outcomes, such as pain or grip strength, the analysis was

performed as if subjects received the treatment (or control condition) they were allocated to.

So if one or more of the patients didn’t attend therapy, or left the study, their final scores for pain or grip strength were still included in the final analysis, as if they did receive the full course of treatment.

This is analysed the same way for the patient group who were allocated to the other treatment group.

Hollis and Campbell say that this analysis is helpful if there’s been a change in treatment guidelines, for example, your hospital decides that patients with distal radius fracture treated with plaster immobilisation in the emergency room will all be sent to hand therapy on the day that the plaster is removed.

Following this new protocol in treatment, and its results, would

be a ‘pragmatic study’ rather than an ‘explanatory study’ which looks at treatment and it’s exact effects.

Pragmatic analysis may not give detailed information about the benefits of a particular treatment modality or technique for individual patients.

Some researchers say that the way of analysing your patients’ results forces researchers to account for those patients who were lost from treatment and state their last grip strength or pain measures as their final outcome. For example if your treatment programme is very onerous and several patients drop away, you still have to account for their outcomes in their final analysis instead of only including those who completed your onerous treatment programme. Another example is that you have to count and include patients that didn’t comply with all of the treatments that you prescribed in their home programme.

Intention to treat analysis also means that clinicians must account for any deviations they make to a patients’ treatment programme, as all patients are still counted.

You may agree or disagree with this method of analysis, there’s no proven right or wrong and there are faults with including and excluding patients who don’t complete the treatment to which they were allocated.

28 l AHTA NEWSLETTER l JUL-SEP 2020

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Fundamentals of Hand Therapy January 2020, Gold Coast Melissa Oppenheimer I have been in my current position for 15 years now, as a sole generalist therapist in Northern NSW. Apart from a couple of years in the UK, I have always worked in rural areas with diverse caseloads.

I have become a specialist at being a “jack of all trades” in the OT scheme of things and as such need to keep up to date with a wide range of clinical areas including paediatrics, acute inpatient care, rehabilitation, community care for frail aged clients and people with complex disability, equipment prescription, home modifications, palliative care and hand therapy.

I really love the diversity of my position and the strong sense of community from living and working in a small rural town. Each year I try and focus on one area of practice for my CPD plan and this year I felt it was time for hand therapy.

Hand therapy has been a small but regular component of my caseload over my career. My interest developed as a new graduate in

Mildura when I was working with a client with a complex injury from a boxing machine – back then my support came by phone and fax from the hand therapists at Royal Adelaide Hospital. The referrals I receive are just as random as the rest of my caseload – from tendon repairs, to carpel tunnel syndrome, de Quervains, fractures, nerve injuries, Dupuytrens, camptodactyly and even an infant with Erb’s palsy.

But it might be years between referrals for some injury types, so I find I often need to go back to the texts or phone a friend for the more unusual referrals. I love that I am able to offer this service to my community, and while I believe I achieve good outcomes, I am sure I can do better.

I last did a common hand injuries course 20 years ago, and have attended short hand therapy presentations at various times since at forums and conferences.

As such, I have really appreciated the opportunity to attend the Fundamentals of Hand Therapy course on the Gold Coast in January 2020.

to hand injuries), various tests, and being able to use clinical reasoning to determine the most likely underlying issues and best treatment has made a significant difference to my practice. I feel so much more confident and less reliant on colleagues in the larger facilities within the health service.

It was also reassuring to be able recognise my existing knowledge and experience. The presenters Chris Harwood and Joy Hanna were fabulous and so experienced themselves. I still feel there a gaps in my hand therapy knowledge and I am wanting to know more, so I am hoping to attend the Closed Trauma course in Brisbane in October.

As I self-funded this course, receiving the AHTA regional and remote grant has been a real blessing. Attending courses when you are based in a rural area can be a challenge, and I love that the AHTA moves their courses around the country. The Gold Coast in January was perfect!

Being able to systematically review the biomechanical structures of the hand and upper limb, wound healing (particularly as it pertains

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FEATURE Image 1: HRCC staff

Hunter Hand Rehabilitation Centre Sheree Ashton

Image 2: Treatmemt room

Outline HHRC was established in 2013 and is located in Newcastle, NSW. We share rooms with two Hand, Wrist and Microsurgeons; Dr Tanya Burgess and Dr Brett McClelland.

Apart from all the usual functions of a busy hand therapy practice, we offer a multi-disciplinary Dupuytren’s Clinic. This has run monthly since February 2018.

The Dupuytren’s clinic combines Hand Surgeons, Hand Therapists and Radiation Oncologists. The clinic offers community members education and information on the disease, a thorough assessment of their hand and outline of an appropriate treatment plan.

My favourite things about our clinic: • The team and our purpose built treatment room are a favourite for

30 l AHTA NEWSLETTER l JUL-SEP 2020

me. We have an excellent working relationship with our surgeons and I enjoy working with all of the therapists.

• There is a wide range of resources available: Д Paraffin wax Д A good variety of thermoplastic and velcro colours Д Industrial sewing machine (even though I’m sure it has it in for me!), especially good for making leather splints Д Home made slosh pipes in varying sizes Д Monthly staff Inservices Д InterX and Ultrasound

Therapists Dion Sandoz is the Principal Hand Therapist, working 4 days per week treating patients. He is an OT, CHT

Image 3: Pink Morning Tea, June 2020

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(USA) and an AHTA Accredited Hand Therapist. He enjoys treating trauma patients, Dupuytren’s disease and wrists and doesn’t like when someone’s pain won’t settle.

Rosalie Bell is an OT who has worked at HHRC since 2017. She works 2-days per week with our clinic and part time at the John Hunter Hospital Hand Therapy department. She likes trauma patients and dislikes dirty, smelly hands.

Nicarlia Finch is a full time Physiotherapist with HHRC since February 2018, currently working towards her Accredited Hand Therapist credential. Nic really enjoys the challenge of seeing traumatic hand injuries, the set up of our clinic and that we work so closely with the hand surgeons. She also likes the diversity of the types of patients we get to treat.

Nicole De Carteret is an AHTA Accredited Hand Therapist, CHT (USA) and Physiotherapist. She started part time at HHRC this year. She likes splinting and wound management.

And then there is me, Sheree Ashton, an OT and an AHTA Accredited Hand Therapist, working 3-days per week at HHRC. I have worked here since 2014 and enjoy treating Dupuytren’s disease, de Quervains tendinopathy and trigger fingers or thumbs, as well as scar management and post op care. Making dynamic splints and treating those vague non-traumatic wrist pain cases are less enjoyable.

We have three great admin/ reception staff: one full time and 2 part time, and would be lost without them.

Research Our clinic is involved in research into Dupuytren’s disease. In 2018, in conjunction with Genesis Cancer Care, a randomised controlled trial was performed of radiotherapy versus observation in the management of early progressive Dupuytren’s disease. Furthermore, we will conduct an RCT of radiotherapy versus observation in the adjuvant settings following definitive local therapy with fasciectomy, needle aponeutoromy or collagenase.

Things of interest In June I decided I would get involved in “Go Pink”. This required committing to wear pink every day in June to raise money for breast cancer research through the NBCF. I was motivated to do so because one of our staff members has experienced breast cancer.

When I discussed my intention to do this with Dion (as it would mean not wearing my uniform at work), he wanted us all to join in.

We had two pink days, where all the HHRC staff and the surgeons at Hunter Hand Surgery, including their staff, wore pink and had a big pink morning tea, complete with boobie cup cakes! We raised $827 towards breast cancer research and I am happy to report that our staff member is currently cancer free.

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REPORTS

President A big THANK YOU to everyone who has been involved in keeping the activities of the AHTA running as best they can during these difficult times.

The Professional Practice Committee and staff have done an amazing job establishing many online educational opportunities with great success! Thank you to the presenters of these courses and webinars for your flexibility in adapting to these changes as we continue to explore new opportunities for our members.

I would like to acknowledge Kate Noller, who resigned from her

2021 Course Dates

32 l AHTA NEWSLETTER l JUL-SEP 2020

position at the AHTA in June and thank her for her many years of service with our association.

The advocacy committee has been reformed and is focussing on increasing the recognition of Hand Therapy and the Accredited Hand Therapist credential, in both the private and public health sectors, as per the committeesâ&#x20AC;&#x2122; strategic goal.

The Committee of Management thank you for your feedback in the 2020 Memberâ&#x20AC;&#x2122;s Survey. The feedback we receive via this survey drives the activity of each committee and also contributes to the associations strategic plan.

Stay safe everyone. We are especially thinking of our members and staff in Melbourne and other areas with high COVID-19 numbers.

Lara Griffiths

president@ahta.com.au

REGULAR REPORTS

Chief Executive Officer This report provides a summary of the activity of the AHTA and its Committees, including the Management Committee meetings.

You will recall in March 2020, the AHTA streamlined its organisational structure and completed its Strategic Plan 2020-2023. The AHTA is now operating efficiently under a new structure comprising four committees and the Credentialing Council working towards four strategic goals: • To deliver best-practice governance and build the capacity and capability of the AHTA; • To strengthen, support and serve the needs of the members; • To advance professional practice in hand therapy through best practice: in education, research and accreditation; • To deliver widespread recognition of hand therapy, practitioners in hand therapy and the Accredited Hand Therapist (AHT) credential.

Terms of Reference (TOR) have been completed following extensive collaboration. All Committees have an Annual Work Plan, which includes strategies to achieve goals and desired outcomes and a timeline for completion of each strategy.

For more information on the AHTA Committees and Credentialing Council, please refer to our website.

The Annual General Meeting (AGM) this year was due to be held at the Conference in Perth on Saturday

Review the Terms of Reference for each committee: Finance Audit Risk and Governance Membership Advocacy Credentialing Council Professional Practice 31 October 2020. While the Conference has been postponed to August 2021, the AGM will still go ahead on Saturday 31 October as planned but it will be conducted via Zoom. The completion of the Annual Report and Financial Statements are underway and will be available to members via an e-notice and on the website 21 days in advance as required by the AHTA Own Rules. The PresidentElect position has been advertised since May and additional vacancies on the MC have been added to the website under ‘Membership’.

Finance Audit Risk and Governance We have closed off the 2019-2020 financial year with a deficit, though we await adjustments from the auditor relating to income received in advance. Given the effects of COVID on our income sources, the President, President-Elect, Treasurer and CEO met late in June to discuss strategies to diversify and develop the associations income streams. This was a productive

meeting, resulting in a prioritised list of ideas which have been incorporated into the Professional Practice, Membership and Advocacy Committees’ plans for the next three years.

This month the Association will take its first step toward moving from its current structure of an Incorporated Association to become a Company Limited by Guarantee, with the decision taken by the Management Committee (MC) in July to proceed with this change of structure.

When deciding between these two types of not-for-profit organisations, the MC had several important facets to consider, including the scope and purpose of the organisation, public perception of the organisation, legal requirements, taxation and fees.

An Incorporated Association is a structure recommended for smaller state-based or community organisations which require a simpler legal structure and less demanding regulation. Company Limited by Guarantee is a structure recommended for organisations who work nationally or internationally, who require greater legal and financial credibility and have larger financial resources.

A company limited by guarantee is regulated under ASIC which is considered to have a vigilant and quality regulatory framework. This means that companies limited by guarantee may be seen as more serious, trustworthy organisations that are recognized as credible companies not only by the public but also by other regulated organisations such as banks and

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insurance companies. This structure does come with more stringent rules, more complex policies and with more duties for the directors (currently known as management committee members). ASIC has a reputation for being a more vigilant regulator, with fines issued when compliance is not carried out in a timely manner. Anecdotal evidence suggests that directors of a company limited by guarantee take their responsibilities more seriously than when these same directors were committee members of an association. Directorship and being on a Board of Directors is something that is popular, and many aspire to achieve in their career.

The process of reviewing and renewing a Constitution can take up to 6-10 months. It is preferable to include a deliberate two-stage consultation process with members to ensure that they are informed and able to provide feedback to the changes. The new Constitution will require member vote at the AGM in August 2021.

The FARG committee have met twice in the last quarter since FingerPrint June 2020.

We have secured two skilled and experienced independent members, Payal Allen, who has been elected as Chair of the committee and Sope Dalley. Payal is currently Manager, Process Governmence & Assurance at MLC Life Insurance. She is CPA qualified and about to complete her MBA at the University of Melbourne.

Payal is a Fellow Member of the Governance Institute of Australia.

Sope is currently Senior Finance Analyst at IXOM. He holds a CPA

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and MBA and brings a wealth of practical experience in financial analysis. He is about to complete a Master of Analytics Management.

We are thankful to have Sope and Payal on board.

The Committee is seeking an independent member with legal expertise. The position was advertised on the Associations Forum Job Board and two applications were received. Though these applicants were of high calibre, their skills and experience were sufficiently represented within the committee. The committee have decided to re-advertise.

Staff have all had their employment contracts reviewed and employment appraisals completed.

I am delighted to announce our new corporate partners: OPC Health, Maurice Blackburn Lawyers and Performance Health.

These partners have committed to support the association for three years. The financial support provided by these partners enables the AHTA to expand and improve services to members and the profession.

We are grateful to have these companies with us on our journey of growth and better recognition and we urge our members and colleagues to demonstrate their appreciation by supporting these companies as their preferred providers.

Membership The Membership Committee have met twice this quarter and have created an Annual Work Plan document covering both what we

currently offer our membership and strategies/ideas of what we want to work on. Initial planning has focused on dividing members into segments to better service the needs of each of these segments.

The membership surveys, conducted late July and closing on 10 August, will provide the Committee with the information it needs to finalise itsâ&#x20AC;&#x2122; Annual Work Plan. You can find the results of the survey after the membership report in this issue of FingerPrint.

On the 16th June 2020, members of the MC, the CEO and Renee Lim (Hunter New England Health, NSW) met to address how to better meet the needs and effectively communicate with hand therapy practitioners working in Public Hospitals. This working party will continue to collaborate to improve membership value for this segment. Initial discussion included advocacy for the AHT credential to department managers, a public therapist grant for education and a specific survey for this group.

Renee and Michelle Odewahn (Auburn Hospital, NSW) have offered to assist the association with connecting with state-based groups working in this sector.

Credentialing The Credentialing Council have finalised the reaccreditation guidelines and these were disseminated to AHT members in August, are on the website and also attached as an appendix to this issue of FingerPrint.

As of July 29th, 52 AHTS currently under mentorship, 23 AHTs have completed the AHT program and

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two have been submitted for approval.

The Credentialing Council has been contacted by a number of members seeking consideration for extensions in their mentoring and courses due to the impact of COVID-19. All requests for course expiry have been addressed with an increase of six months (with the option to increase this time) for all future AHTs. Requirements for face-to-face mentoring which is currently 50%, have been altered to allow the use of teleconferencing. The emphasis has been placed on the synchronous learning aspect, and not so much on the method of communication.

Professional Practice In the last quarter, the AHTA delivered Introduction to Hand Therapy in August, with over 100 participants attending. Feedback is being examined at the time of writing to assess the response to this change of course-delivery mode.

The Assessment and Treatment of the Wrist course was also conducted online in August over two Saturdays.

In late June 2020, a new elective ‘Pain Management Skills’ was offered to members and filled quickly with the maximum number of 10 participants. This course aims to give participants an opportunity to learn how to help patients better manage chronic or persisting pain problems in the context of Hand Therapy practice.

Using an online webinar format,

and between webinar activities, the program provides participants with an opportunity to develop competence in the application of core Cognitive Behavioural Therapy (CBT) methods for managing patients with persisting pain. This course is offered again in October 2020 and February 2021.

Joy Hannah continues to review Fundamentals of Hand Therapy as part of a standard bi-ennial review of all AHTA courses. New elective course options on Wound Management and Imaging are being researched and considered by the PPC. A lot of work has been done this quarter in developing policies and procedures for elective courses and accredited courses. The AHTA website has been updated to provide more information on the definition of these course types.

Several new members have been recruited and on-boarding is in process for the Course Accreditation Working Party.

Accreditation of a Casting Motion to Mobilise Stiffness (CMMS) course is underway.

The Committee of Management are reviewing proposals for the utilisation of Online Learning Platforms through partnerships with other organisations including Griffith University and the Australian Physiotherapy Association (APA). It is anticipated that a partnership with an organisation that has an existing platform will mitigate duplication of resources and expenses associated and provide expertise required to build a suite of online courses for the future.

Since April, the CEO and MC have been in discussions with Griffith University regarding the potential for a Pathway to Master’s program, however, due to the impact of COVID-19, the University is no longer able to provide the association with this much-desired initiative. The University has suggested that it would be able to provide a Micro credentialing program. The association will consult with the individuals who provided their details in response to a question in the Member Survey in the coming months to determine the way forward.

The 2021 conference planning is well underway, with the event scheduled for 26 – 29 August 2021, at the Westin in Perth. The Committee, CEO and Professional Conference Organiser (PCO), YRD, are looking at a potential hybrid delivery, in the event that COVID-19 persists and travel across borders remains problematic.

Advocacy The Advocacy Committee had its first meeting on 3 July 2020, following a long hiatus. Members of this re-established committee include Barb Hall (WA), Jane Aarons (VIC), Sath Segran (WA), Collette Zemlijic (QLD), Chen Li (NSW), Jason Fairclough (NSW) and Lara Griffiths (TAS). The committee has a critical role in leading the delivery of widespread recognition of hand therapy and the Accredited Hand Therapist (AHT) credential and will not only proactively establish communications lines and collaborate with stakeholders but will also address issues affecting members.

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The first meeting of the Committee involved discussion relating to emails received from members seeking clarification on communication that they had received from the Transport Accident Commission (TAC) and Department of Veterans Affairs.

In the first twelve months, the Committee will navigate its way around Worksafe or its equivalent state-based body and the TAC, to establish how well hand therapy is recognised and to lobby for recognition of the AHT and hand therapy practitioners.

Furthermore, this committee will consider the development of a publication Scope of Practice for Hand Therapy and the Accredited Hand Therapist. This publication will serve to provide an overview of the services offered by appropriately qualified and experienced hand therapists and Accredited Hand Therapists in Australia.

One of the positives to come out of the COVID-19 crisis has been the associationâ&#x20AC;&#x2122;s strengthened relationship with the Allied Health Professions Association (AHPA).

There is no doubt that the profile of Allied Health has been raised during this pandemic and we continue to work hard to keep that momentum going. A lot of people are talking about getting back to normal, but is that what we want? Normal for Allied Health has been less than optimal so we have an opportunity to move on to something better.

We will continue our efforts as a collective voice through and with the AHPA and our members to find the recognition that our members deserve.

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Goodbyes Towards the end of June, we said goodbye to Kate Noller, Executive Support Manager, Strategy. Kate began working at the AHTA on 20 July 2015. Kateâ&#x20AC;&#x2122;s dedication, attention to detail and hard work are already sorely missed! I would like to take this opportunity to thank Kate for all that she achieved for the Association and for helping us to grow and evolve to where we are today.

Our Course Coordinator Kylie Bebel has stepped down. Kylie volunteered on the Professional Practice Committee (formerly Education Committee) for three years. Kylie worked diligently to manage course schedules along with presenter training needs and will be missed. Thank you for your hard work Kylie.

The next Committee of Management meeting is scheduled for 14 September 2020.

Wendy Rowland ceo@ahta.com.au

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Professional Practice What strange times we are living in! We would like to firstly extend our thoughts to all of our colleagues experiencing difficult times in Victoria at the moment.

We would like you to know that we are all thinking of you and offer our support and best wishes. We hope you and your loved ones stay well and are able to keep treating/ teaching/working safely through this unsettling time.

The Professional Practice Committee (PPC) were very pleased to introduce our newest Elective Course to you in the last two months, Pain Management Skills for Hand Therapy Clinical Practice, delivered by The University of Sydney.

DEFINITION: “AHTA ELECTIVE COURSE” – a course that is approved by the Australian Hand Therapy Association (AHTA) Credentialing Council (CC) to be used as part of the experiential pathway requirements for the AHTA Accredited Hand Therapist credential.

A course that achieves Elective Course status has met stringent criteria as per the AQF 8 standards and has been reviewed by our Credentialing Council to ensure its comprehensive evidence-based content and quality structure and format. These courses are developed in conjunction with the

AHTA to ensure that it is relevant to our members and that it attracts the maximum CPD hours available to attain the AHT credential.

DEFINITION: “Accredited Course”- An AHTA Accredited Course is a course that has not been developed by the AHTA. It is a course that is submitted via an application by an individual or organisation for the purpose of accreditation.

An Accredited Course is a course that has been developed external to the AHTA and its developers have approached the AHTA to be assessed for accreditation.

Although these courses may not have the same number of hours or rigour as the Elective courses, they are courses that provide quality evidence-based content relevant to the members of the AHTA. They may not provide points towards the AHT credential, however they do provide valuable CPD hours for re-accreditation and are present for clinicians looking to broaden their experience and learning.

courses to be considered for accreditation and encourage you to reach out if you are providing quality CPD for hand therapists. You can reach Jess at accreditation@ ahta.com.au or myself at education@ahta.com.au

Helena Hayes education@ahta.com.au

Our Accreditation Officer, Jessica Holding, has lead accreditation for some time and will now lead a team of volunteers involved in the reviewing of and assessment of course work seeking accreditation by the AHTA. We would like to welcome Stacey Cross and Rachel McDuff to the PPC under the Accreditation Working Party and thank them for volunteering their time and experience to the AHTA. The PPC is always looking for

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Membership I am very excited to be taking on the role as Membership Committee Chair, elected in late May 2020, and would like to thank the Committee of Management for this opportunity.

Our Membership Committee is made up of a fantastic group of volunteers, including members of the Marketing and Communication divisions and the Membership Secretary. We also have a direct link to our State and Territories subcommittee.

I am pleased to report that our committee has hit the ground running and with the help of our CEO, Wendy, we have developed an annual work plan and tracker covering both what we currently offer our members and also strategies and ideas of what we want to work on over the next

38 l AHTA NEWSLETTER l JUL-SEP 2020

12 months. This entire workplan document is focused around our strategic goal; ‘To strengthen, support and serve the needs of the members’.

Part of our initial planning has focused around grouping our members into segments to be better able to service the direct needs of these member groups and thus provide tailored strategies for improvement. One important part of this plan was the development of our demographic and satisfaction member surveys which were released in mid-July.

Please see the initial findings on the following pages. I look forward to further analysing these results as this will help to guide and steer our committee to achieving our strategic objectives, which are; • To improve member services • To communicate effectively with members • To work with the states and territories to ensure that the

members’ needs are being met and membership is highly valued.

It is my hope that over the next year we as a committee will be able demonstrate this to you.

Elizabeth Giuffre MembershipChair@ahta.com.au

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Welcome new members Please join the membership committee in congratulating our newest AHTâ&#x20AC;&#x2122;s and welcoming all of our new members: Accredited Hand Therapist Emma Colby, QLD Judith Feldman, WA Trancy Fong, QLD Kate Hodgkinson, WA Claire Ingham, VIC Anna Munro, QLD Amanda Ranford, WA Alexandra Smallman, SA Anna Wishink, QLD

Associate Member Brittany Atfield, QLD Kirsty Bailey, QLD Stephanie Bui, VIC Ryan Cook, QLD Erin Cunningham, SA Lauren Dale, NT Thomas Davis, VIC Victoria Elliot, NT Angela Ferrarin, VIC Miho Ferravant, SA Arlyn Gamache, SA Rachel Hall, NSW Erin Harders, QLD Racheal Henry, NSW Georgia Holmes, NT Ruth Johnson, WA

Aleisha Jones, QLD Ivan Lee, NSW Amy Lind, VIC Jodie Monks, VIC Kellie Schilg, NSW Ruth Shofay, QLD Jenna Silberstein, WA Alexander Smith, NSW Samuel Speer, VIC Michelle-Marie Townsend, NSW Erica Turner-Brown, QLD Nicole Young, NSW Affiliate Member Benjamin Jones, QLD Alice Robson, SA Emily Soh, QLD

Credentialing Council Please see at the back of this issue of FingerPrint the recently updated Reaccreditation Guidelines for the AHT Credential, which supersedes all previous versions.

Through the review process, the Credentialing Council acknowledged and incorporated member feedback to create new guidelines that aim to strike the balance between maintaining the integrity of the AHT credential while making it achievable for members to maintain their AHT.

One of the aims of the new guidelines was to recognise a broader spectrum of activities, allowing therapists to engage in continuing professional development commensurate with their level and interests. Moreover, it is hoped the updated guidelines will enable more of our members to maintain and engage in their CPD throughout their career and life stages.

I would like to thank all the members who provided feedback and to the Credentialing Council for their tremendous work in establishing these new guidelines.

On behalf of the Credentialing Council,

Dave Parsons membership@ahta.com.au

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Membership Survey Results Last month, the Association conducted its 2020 members’ survey in two parts: Member Demographic Survey and Member Satisfaction Survey and was delighted that 353 and 326 members respectively provided feedback.

Member Demographic Survey Question 1: Your details?

342 respondents provided their name, 339 provided their place of work and 342 provided their email address.

Question 2: Which of the following best describes your current career stage? You can select more than one choice.

• 9% of members describe their career stage as a student, as an Associate Member: Novice or as an Associate Member: Early career; • 17% describe themselves as an Associate member: Mid-career or Associate member: Established; • 39% describe themselves as AHT: Advanced or AHT: Advanced with master’s qualifications; • 6% are AHT: Researchers; • 3% are AHT: Academics; • 16% are Private Practice owners; • 1% are Public Hospital Allied Health Managers • 4% are currently pausing their career • And 5% of members described their career stage as ‘Other’.

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Question 3: Which of the following best describes where you work?

• • • •

62% work in a major city; 31% work in a regional city; 6% work in a rural location; and 1% work in a remote location.

Question 4: Which of the following best describes the setting in which you work?

• 58% work ONLY in private practice or private hospital; • 26% work ONLY in a public hospital; • 2% work ONLY in a University; • .03% work ONLY in community health; • 12% work in a COMBINATION of above settings; and • 1.7% work in ‘Other” settings.

Question 5: You have indicated that you work in a public hospital.

We are committed to learn more and address the needs of hand therapists in the public hospital setting. Would you be open to us contacting you again to explore ideas?

Of the 128 members that indicated they worked in a public hospital, 83% (106) provided their email address and said that they would be open to contact from the AHTA to explore their needs. 17% (22) said that they would not.

Member Satisfaction Survey Question 1: Please rate how satisfied you are with your AHTA Membership?

80% of respondents reported that they were either very satisfied or satisfied. There were 15%

of members that were neither satisfied nor dissatisfied, 4% were dissatisfied, and 1% were very dissatisfied.

Question 2: Would you recommend AHTA membership to a colleague?

92% of respondents reported that they would recommend AHTA membership to a colleague and 8% reported that they would not.

Question 3: How responsive to your professional needs has the Association been over the last 12 months?

• 10% of respondents said extremely responsive, • 48% said very responsive, • 37% somewhat responsive, • 5% percent said not responsive or not responsive at all.

Question 4: Do you use the Journal databases (EBSCO and Science Direct) through the AHTA member portal?

• 61% of respondents said that this was a valuable service, • 19% said that they do not require this service as they access Journal databases using a workplace subscription, • 8% said that they do not need to access Journal databases, • 5% said that they found the databases challenging to access and • 7% selected ‘other’ as the option and left comments.

• 121 members left their email address regarding a review of journal database subscriptions (at Q5).

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Question 6: How much would you value the opportunity to undertake a university qualification in Hand Therapy such as a Graduate Certificate, Graduate Diploma or Masters in Hand Therapy?

59% of respondents said that they would value the opportunity to undertake a university qualification in hand therapy and a further 26% said that they would find this somewhat valuable. Only 15% felt that this would not be valuable.

Question 7: We would like to survey you further about the potential for a University pathway to Masters in Hand Therapy. Please leave your email address if you would be happy to participate.

155 members responded that they would be happy to participate and provided their email address.

Question 8: How much do you value the AHTA’s “Google Group” as a member service?

70% described this service as somewhat valuable – extremely valuable. 9% said this service was not valuable, and 3 % do not know what ‘google groups’ are. A further 18% do not know about google groups. 57 of the 58 members provided their email address to learn more.

Question 9: Have you attended any AHTA courses in the last two years?

56% of respondents said that they had attended an AHTA course, and 44% of respondent said that they have not.

Question 10: How much do you value the AHTA course program?

Question 15: How much do you value the weekly eNEWS?

91% of respondents feel that the course program is extremely valuable, very valuable or somewhat valuable. And 9% thought that the course program was not so valuable or not at all valuable.

40% of respondents reported that the weekly eNEWS is extremely valuable or very valuable. A further 45% reported that it was somewhat valuable and 14% said that it was not valuable.

Question 11: How much would you value the addition of online course options?

98% of respondents thought that the addition of online course options would be valuable. Just 2% thought that online courses would not be valuable.

Question 12: Please rate your overall satisfaction with the AHTA website?

93% of respondents reported that they were satisfied with the AHTA website. 7% said that they were dissatisfied.

Question 13: How much do you value national webinars?

91% of respondents reported that the national webinars have been valuable or highly valuable. 9% were neutral.

Question 14: How much do you value the Special Interest Group (State and Territory) Meetings?

70% reported that they were very satisfied or satisfied, and a further 27% were neutral. There were 3% that were dissatisfied.

Question 16: Do you read the quarterly newsletter FingerPrint?

70% of respondents said that they always or usually read FingerPrint.

21% said that they read it sometimes, and 9% said rarely or never.

Question 17: How much do you value the quarterly newsletter FingerPrint?

57% of respondents said that FingerPrint was extremely valuable or very valuable. 37% said that it was somewhat valuable and 6% said not valuable.

Question 18: Should FingerPrint be available to other key stakeholders that are not members of the AHTA to educate others about the complexity and practice of Hand Therapy?

65% of respondents said that FingerPrint should be made available to other key stakeholders that are not members of the AHTA and 35% said that it should remain a member-only publication.

Question 19: Do you follow one or more of the AHTA’s social media platforms: Facebook, LinkedIn or Instagram?

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51% of respondents said Yes, they follow one or more of the AHTA’s social media platforms, and 42% said that they do not. The remaining 7% left comments.

Question 20: The AHTA currently has a subscription of ten modules in the Exploring Hand Therapy resource. How valuable is this resource to you?

42% responded that these modules are highly valuable or valuable. The remainder were neutral or said that the modules were slightly valuable or not valuable.

Question 21: Would you like the AHTA to expand this online resource to 15?

75% of respondents said that they would like the AHTA to expand this online resource to 15, and the remaining 25% said no, they would not.

Question 22: Please rate your overall satisfaction with customer service from the Staff.

84% of members reported that they were very satisfied or satisfied with the overall customer service from staff. 8% said that they were neither satisfied nor dissatisfied.

Question 23: Please rate your satisfaction with the overall management of the Association by the elected Committee of Management and the CEO. 80% of members reported that they were either very satisfied or satisfied with the overall management of the Association, 16% were neither satisfied or dissatisfied, and 4% were dissatisfied.

1 % respondents answered that they would like to be contacted, 90% answered no, and 9% (27) respondents left their email address.

The Membership Committee and I will provide more information and report on aspects of this membership survey in the coming months. Please be assured that the responses will be scrutinised and discussed to ascertain how we can address issues and comments to meet the needs of each member better.

On behalf of the Membership Committee, Wendy Rowland Chief Executive Officer

Question 24: Would you like the AHTA to contact you to discuss any part of this survey in more detail?

Communications This quarter has been a hectic time. The communications subcommittee continues to work to serve the membership by providing timely access to relevant and interesting news and support, through the weekly eNews, the Google group, and the quarterly FingerPrint newsletter.

42 l AHTA NEWSLETTER l JUL-SEP 2020

The google group has been an invaluable tool it seems in rapidly sharing news and problem solving between our members, for nonclinical issues as much as clinical scenarios given our turbulent times. Popular topics have included complex fracture management, brachial plexus injury, podcasts relevant to hand therapy and pandemic implications for practice including restrictions to practice and PPE requirements. It has grown in size a lot this year and we now have 535 members in the group, sharing knowledge and ideas. I have received plenty of new requests

lately – if you haven’t joined already, send a request to me via email.

Louise Brown communications@ahta.com.au

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States & Territories Over the last few months the hard-working and dedicated team of AHTA Divisional Coordinators; Stephanie, Kate, Leanne (VIC), Margo, Sally, Frances and Amanda (QLD), Charlotte and Andi (SA), Vicky and Jess (WA), Michele, Victoria, Adrian and Susan (NSW), Victoria (ACT) and Jayne (NT) have been hard at work sourcing presenters and holding the SIG meetings via the Zoom Webinar platform.

I am greatly appreciative of the time, effort and determination of this group of volunteers, who in stressful times have ensured that we have been able to continue to provide our membership with some ongoing professional development and educational opportunities.

April saw the States and Territories host 3 webinars; Reconstruction of the Burnt Upper Limb (QLD) which saw 139 attendees, Taping Techniques of Upper Limb Conditions (SA) 187 attendees and Introduction of Trauma Informed Care (QLD) 110 attendees. In May there were 2; Looking at Pain from a Different Perspective (VIC) 211 attendees and ACT Pain Centre; MDT Assessment and Treatment of CRPS (ACT) with 116 attendees. And June saw Chronic Pain and Trauma; Issues to Consider in Your Practice with 103 attendees.

A big thank you must also go to Sara Brito in her role as Digital Education Coordinator for her assistance, support and guidance to the Divisional Coordinators in running and hosting these webinars. Overall the feedback has been very positive and I know that there are more webinars being organised and planned for the second half of this year, so keep looking at the events page of the website to see the latest listings and registration closing dates.

I would also like to use this opportunity to put the call out for some more volunteers, I know WA and ACT are looking for an additional volunteer to assist their current Divisional Coordinators and it would be fantastic if we could also have a representative from TAS, as the position is currently vacant. If you want to put your hand up to be part of a great team and contribute back to this association, or are slightly interested but would like some further information please contact me and I would be happy to chat through the role and put you in touch with the relevant Divisional Coordinators. The ongoing success of networking and opportunities relies on our volunteers and it is a very rewarding position.

NSW Due to COVID restrictions, formal ongoing education opportunities have been limited since the Asia Pacific Meeting in Melbourne in early March.

No doubt individual therapists & their practices have learnt a lot about infection control procedures, Telehealth implementation & have benefited from the shared information from the various NSW Health webinar sessions.

One of our NSW members, Jason Fairclough, has excelled with ongoing work on his Butterfly Traction System which has won two awards at the National Innovation Centre, one of which is a six month sponsored residency program.

His work continues with further product development with the assistance of engineering support at the National Innovation Centre for 3D printing.

NSW will present a National webinar within the next few months, further face to face meetings for the remainder of the year in NSW will be dependant on COVID restrictions.

Michele, Susan, Victoria & Adrian ahtansw.sig@ahta.com.au

Stay safe everyone.

QLD Elizabeth Giuffre stateaffairs@ahta.com.au

As Divisional representatives we are adapting and learning to deliver ongoing SIG meetings via zoom, our national webinar platform. With the help of Sara Brito and Sarah Dixon we have delivered two SIG meetings via the national webinar starring Dr Carl Lisec (Reconstruction of the

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burnt hand) and Martha Druery (Trauma informed care) which had highattendance, positive discussion and feedback. Fingers crossed we are able to go ahead with a planned ‘in person’ SIG towards the end of the year, in accordance with the new AHTA hosting guidelines and the pandemic climate at the time.

We will keep you informed.

of the webinars, we are planning to engage the online learning option (webinar/zoom) in more future SIG meetings.

Member news to note includes one of our AHTs, Germaine Sim commencing her PhD on splinting and the stiff elbow. We will look forward to reading your articles in the future.

The SA Divisional Representatives will continue to look for appropriate professional development opportunities that we can share with all members. We thank you for your understanding during this challenging time and please keep an eye out for updates regarding upcoming events.

Frances, Margo & Sally ahtaqld.sig@ahta.com.au

SA Continuing from the last newsletter, South Australia has been doing well in following the COVID-19 restrictions and flattening the curve. We have opened our door to several states and have gradually eased some of the restrictions in stages. The current protocol states that ‘while physical distancing of 1.5m is still strongly encouraged, density requirements within venues will be reduced to one person per two square meters.’ A COVID-SAFE plan is required for indoor public meetings.

To maintain the connectedness across the hand therapy community, the Divisional Representatives from all states and the AHTA have been working together and organizing webinars that are available to all members. It has been a valuable experience to learn from the interstate experts.

In order to build from the successes

Here in SA, we have welcomed a new Affiliate member, Alice – we look forward to meeting her over the coming months as we are able to resume face to face meetings.

Thank you for your ongoing support.

Andi and Charlotte ahtasa.sig@ahta.com.au

WA 2020 certainly has not panned out quite how we expected it. We have (mostly) been incredibly lucky as a state and have been thinking of all our hand therapy colleagues all over Australia at this difficult time.

We have been lucky enough to have the team at In Hand present at our first meeting back on the 1st of August held at Sir Charles Gairdner Hospital. In accordance with hospital, state and federal guidelines we were able to have 30 people attend in person, as well as making the meeting available via Zoom. We would like to thank Amanda Ranford and Rina Eto for their presentation A Beginner’s guide to frozen shoulder, Linda

Canty for her presentation on Conservative Management of 1st CMC OA and finally Elisha Stefanelli, who presented Trigger finger/ thumb.

We encourage our members to continue to take advantage of the great AHTA webinars, as well as other educational institutions/ doctors who are providing this service. We’re very lucky to have Catherine McCutcheon from HULC doing a Webinar on Wednesday the 23rd of September at 6pm AWST entitiled An Overview of Rheumatological Conditions Relevant to the Hand and Upper Limb Therapist.

The AHTA conference that was scheduled in Perth for October has been postponed until 2021. The conference committee has been working tirelessly to make this one of the best conferences ever and we are very much looking forward to welcoming all our interstate friends when we can actually travel again!

Sarah Fairthorne left the WA committee at the beginning of this year as she is currently on maternity leave. We sincerely thank her for all her hard work over the last 3 years and wish her all the best with baby Freddie.

We are looking for another WA team member so please forward your interest to us if you are keen for this great opportunity to contribute to your profession.

Please fee free to contact us for any further information.

Jess de Jong and Vicky Allbrook ahtawa.sig@ahta.com.au

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Contact us Australian Hand Therapy Association Office

General enquiries 08 9778 9070

Sarah Dixon WA Operations and Membership Manager

enquire@ahta.com.au

Postal Address PO BOX 5111 WEST BUSSLETON WA 6280

02 9778 9070

ahta.com.au

Sarah.Dixon@ahta.com.au

Wendy Rowland VIC Chief Executive Officer

Registered Address Level 1/96 Lytton Road EAST BRISBANE QLD 4169

Kelly Toner SA Education and Communication Manager

02 8776 1861 0414 412 306

02 8776 0205

Wendy.Rowland@ahta.com.au

events@ahta.com.au

MANAGEMENT COMMITTEE Position

Name

State

Phone

Email

President

Lara Griffiths

TAS

03 6348 7216

president@ahta.com.au

President Elect

Hamish Anderson

VIC

03 9510 8999

presidentelect@ahta.com.au

Past President

Position vacant

-

-

pastpresident@ahta.com.au

Treasurer

Rosemarie Koh

VIC

03 9345 5522

treasurer@ahta.com.au

Secretary

Olga Alkin

QLD

07 5447 0967

secretary@ahta.com.au

Education

Helena Hayes

QLD

07 3205 7019

education@ahta.com.au

Communications

Louise Brown

NSW

0419 831 283

communications@ahta.com.au

Marketing & Promotions

Brigette Evans

NSW

02 6331 8354

marketing@ahta.com.au

Membership Secretary

Dave Parsons

WA

08 9266 3790

membership@ahta.com.au

State & Territories Affairs

Elizabeth Giuffre

ACT

02 6244 2154

stateaffairs@ahta.com.au

DIVISIONAL COORDINATORS State

Email

Contacts

ACT

ahtaact.sig@ahta.com.au

Victoria Gorringe

NSW

ahtansw.sig@ahta.com.au

Victoria Tricardos

Susan Dunn

Michele Chim

Adrian Jollow

NT

ahtant.sig@ahta.com.au

Jayne Donovan

QLD

ahtaqld.sig@ahta.com.au

Frances Thomsen

Margo Coffey

Sally Colwell SA

ahtasa.sig@ahta.com.au

Charlotte Nash

TAS

ahtatas.sig@ahta.com.au

Position vacant

VIC

ahtavic.sig@ahta.com.au

Stephanie Everest

Andi Tao Kate Wharton

Leanne Graham WA

ahtawa.sig@ahta.com.au

46 l AHTA NEWSLETTER l JUL-SEP 2020

Victoria Allbrook

Jessica de Jong

APPENDIX

Reaccreditation Guidelines for Accredited Hand Therapists You are required to provide information in three categories: 1. HAND THERAPY PRACTICE (2000 hours per five-year period) 2. ONGOING EDUCATION (20 hours per year totaling 100 hours in a five-year period, congruent with AHPRA guidelines) 3. CONTRIBUTIONS TO THE PROFESSION (25 hours in a five-year period) An AHT may choose to downgrade to Associate status if they are unable to meet to the reaccreditation obligations.

However, they will be required to apply for Reaccreditation as per reinstatement procedures indicated in the AHTA bylaws.

Parental leave: The hand therapy practice requirement may be reduced by 400 hours for each newborn child for whom the AHT is a primary caregiver. A letter from employer must be submitted detailing your parental leave agreement. The reduction may not be carried across reaccreditation periods. Category 2 and 3 requirements must be met in full, within the reaccreditation period of five years.

Learning activities in UE or Hand Therapy are defined as activities that have direct application to the evaluation and treatment of the upper quadrant and or hand therapy patients. In the course description or curriculum, it should state that the upper quadrant, shoulder, elbow, wrist or hand is specifically addressed. Examples include international, national and state hand therapy and surgery meetings, postgraduate courses specific to the upper limb, CHT. Learning activities in other occupational therapy or physiotherapy practice areas are defined as courses that are not directly related to the UE or hand therapy. These courses or academic programs generally involve the clinical application of occupational therapy or physiotherapy evaluation or treatment. These topics have a general application to UE or hand therapy. For example: Pain management, acupuncture, wound care, arthritis, ergonomics, myofascial techniques, and lymphoedema techniques.

Presentations refer to one-off presentations rather than repeated lectures. Repeated lectures may apply to the teaching category. For co-presentations, hours should be allocated according to presenter contributions.

Documentation includes all evidence that supports your log. Hours will not be accepted without the appropriate documentary evidence. You must provide evidence of the date, topic, contact hours and proof of attendance for all learning activities. Hand therapy practice requires an employment verification form / statutory declaration to be completed. Use the online CPD Diary to attach a summary of your evidence.

CATEGORY 1: HAND THERAPY PRACTICE (2000 Hours per five-year period) You are required to maintain 2000 hours of hand therapy practice over a five-year period. Hand therapy practice can be any mix of clinical, administration, supervision, teaching or research.

List your professional hand therapy practice directly in your Member Portal of the AHTA Website in the space provided for â&#x20AC;&#x2DC;hand therapy practiceâ&#x20AC;&#x2122;.

Please ask your employer to complete a Maintaining Membership Employment Verification Form including a Statutory Declaration for self-employed therapists/ sole practitioners. Upload this form as supporting documentation in your CPD Diary. ahta.com.au l 47

APPENDIX

CATEGORY 2: ONGOING EDUCATION - Minimum 20 hours required from this section per year AREA & DESCRIPTION a) Learning activities in UE or Hand Therapy. For example: conferences, courses, state-based hand therapy and hand surgery interest groups, teleconferences for remote based therapists, webinar sessions b) Learning activities in other occupational therapy or physiotherapy practice areas. For example: activities that have a more general application to hand therapy such as pain management, acupuncture, arthritis management, ergonomics and lymphoedema techniques.

SAMPLE DOCUMENTATION REQUIRED Certificate of course or conference attendance.

A signed letter outlining topic with contact hours for interest group/ in-service attendance /webinar sessions HTCC confirmation of a pass grade for CHT exam Certificate of attendance or a signed letter of attendance with contact hours AND a “Reflective Learning” document – you can download the template here for each learning activity (this document will demonstrate how your learning was applied to hand therapy practice)

CATEGORY 3: CONTRIBUTIONS TO THE HAND THERAPY PROFESSION - Minimum 25 hours over five years AREA & DESCRIPTION a) Presentations: Presentations/Formal Papers Examples include state, national or international conferences (therapy or surgical), AHTA Webinars, conducting seminars & workshops Training sessions In-services, interest groups, journal clubs b) Publications: Journal Articles Books/Chapters Publications in peer-reviewed scientific & educational journals or books AHTA media Contributions to newsletters, social media, online blogs c) Teaching: University tutoring or lecturing, in-services or public education activities.

Therapy students on clinical placement Hosting visiting therapists in your hand therapy clinic e.g. remote therapists visiting a metropolitan clinic for hand therapy experience/training or IFSHT overseas visitor program

Teaching/Training therapists overseas

48 l AHTA NEWSLETTER l JUL-SEP 2020

SAMPLE DOCUMENTATION REQUIRED Copy of program, written invitation or abstract. A signed statement from co-authors, employer/organisation confirming the extent of the contribution Evidence of presentation, copy of the program, including duration of presenter’s contribution, in-service attendance list (showing signatures of attendees and presenters) Electronic copy/ official letter of acceptance Copy of the title page and contents, and date of publication. Signed statement if co-authors or research assistant confirming the extent of AHT’s contribution.

Copy of the Newsletter showing entry Copy of approved blog entry on AHTA Website Teaching timetable or signed statement from employer/ contractor Written university confirmation (letter or email) of student fieldwork placement dates Written verification of involvement from rural/ international therapist or agency

Copy of program or signed statement from the Overseas volunteer organisation or the local therapists. Evidence must include date and length of time of presentations

APPENDIX

d) Research / Quality assurance: Conducting a systematic investigation into an issue relevant to the hand therapy field, assisting a researcher by gathering data, projects that promote optimal client care e.g. quality audits, peer reviews, and development of hand therapy related education materials e) Professional leadership: Committee Membership: AHTA Executive Management Committee, Credential Council, Mentor, Subcommittee or working party position International, National or State hand therapy committee position: â&#x20AC;&#x201C; e.g. IFSHT, OT/PT association, state-based hand therapy professional body or equivalent Conference Committee membership: AHTA or International Hand Therapy/Surgery Conference Committee Member State Divisional Coordinators Volunteering: AHTA Courses, Volunteer work overseas / Rural Other: Completion of AHTA surveys (will be clearly stated on the survey if CPD hours are eligible).

A signed statement from researcher or employer indicating the extent of contribution and hours.

Evidence of enrolment in a Higher Degree Research (HDR), including status of candidature

No proof required for AHTA roles

Written verification of involvement from organisation chair, i.e. CEO of OTA Written verification of hours contributed to be signed off

by Conference Convenor Written verification of hours contributed to be signed off

by States and Territories Officer No proof required for AHTA roles Written evidence of involvement required such as an invitation to attend from O/S institution or agency e.g.

Interplast Certificate of completion

Reviewed June 2020; AHT Credentialing Council. Supersedes all previous versions.

The reaccreditation obligation period is five years.

This commences on 1/1/18 or the date of award of Accredited Hand Therapist (AHT), as documented on your certificate.

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Page 11 New splint design for de Quervains Tenosynovitis Papa, J. A. (2012). Conservative management of De Quervain’s stenosing tenosynovitis: a case report. The Journal of the Canadian Chiropractic Association, 56(2), 112–120.

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Chipchase LS(2016). Hand therapy versus corticosteroid injections in the treatment of de Quervain’s disease: A systematic review and meta-analysis. J Hand Ther. 29(1):3-11.

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Illyas , A. (2009) Nonsurgical Treatment for de Quervain’s Tenosynovitis. The Journal of Hand Surgery, 34(5):928-929

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Choi, H, Seo, A & Lee, J (2019). Mallet finger lattice casts using 3D Printing.

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Katzman, B, Klein, D, Mesa, J, Geller, J& Caligiuri, D (1999). Immobilisation of the mallet finger. Effects on the extensor tendon. Journal of Hand Surgery British and European 24B(1), 80-84

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Journal of Hand Surgery, 19A, 850-852 Groth, G.N, Wilder, DM, Young, VL (1994). The impact of compliance on the rehabilitation of patients with mallet finger injuries. The Journal of Hand Therapy, 7, 21-24 Gupta, A, Chaturvedi, S, Bhat, A, Sambeel, M & Saxena, A (2019). and manufacture of customisable finger immobiliser and mallet finger splints Haagsma, A, deBoer, H, Quintus, A, Strikkeling J, Xeebregts, C & Smit, J (2015). Treatment of mallet fingers in Dutch hospitals: a nationwide survey of practice. Journal of Emergency Medicine, 22(2), 211-214 Handoll, HH, Vaghela MV (2004).

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