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TIMES

VOLUME 18 ISSUE 3 • Fall 2012

T H E

N E W S L E T T E R

O F

T H E

A M E R I C A N

S O C I E T Y

O F

H A N D

Overcoming Barriers to Treat Children in Need

Save the date Future ASHT Annual Meeting Dates

I

Work

Our caseload typically includes flexor and extensor tendon repairs, fractures, nerve repairs, Dupuytren’s release, nerve compression syndromes, arthroplasties–the normal hand therapy diagnoses. However, we do have an exceptional “in.” One of our surgeons, Dr. Brent Bamberger, has performed two surgeries at The Hand Center through Children’s Medical Missions West, at no charge to the families. Through his service with and to this group, I

San Diego, CA

2013 October 24-27

Chicago, IL

CONTENTS

By Kantessa Stewart, OTR/L CHT

have a BS in Occupational Therapy from the Ohio State University and a Post Graduate Certificate in Advanced Hand and Upper Extremity Rehabilitation from Drexel University. I began working for The Hand Center of Southwestern Ohio (located in Dayton, Ohio) in 2005 and became a CHT in 2007. The Hand Center has five hand surgeons on staff, and they refer a large variety of surgical and non-surgical cases. The Hand Center is based out of the Southview Medical Campus in Centerville, Ohio, with satellite offices in Dayton and Sidney. The satellite offices offer specialized services to those patients in outlying/rural areas. The Hand Center office at Wilson Memorial Hospital in Sidney, Ohio, is where we service the Children’s Medical Missions West patients who reside in a nearby host home.

2012 October 18-21

2014 September 18-20 Boston, MA  (Combined ASHT/ASSH meeting)

Children’s Medical Mission West is a non-profit that brings children from underdeveloped countries to the U.S. for free medical care. History

T H E R A P I S T S

have been able to work with two young boys from Africa who sustained severe burns and had extremely disfigured hands as a result of no treatment. These diagnoses would never exist in the United States because medical intervention would have been provided immediately, thus preventing the disfigurement and deformity seen and described below. In treating a patient from the Ivory Coast of Africa, one of the barriers was language. English is extremely limited with the children when they arrive, and I have attempted to pick up a few French terms to interact with the boys. As a general rule, though, we all know food motivates, and this was used to help gain trust, soothe and reward the boys—no language is necessary for this type of bribery. Obtaining an exact medical history is difficult, as the host families know very little of the boys’ history, but the reality of their way of life involves fires for cooking, and the children do fall into them. The first boy I treated from Africa, Morey, was burned on his dorsal forearm, and the scar contracted his dorsal hand to the dorsal forearm. He was burned volarly, and the palm RF and SF were pulled into the contracture, causing his wrist to be in severe flexion. These conditions, despite the visible disfigurement (something I have never seen in person before), did limit functional use of the extremity. However, the boys both continued to attempt use of their injured hands. Unlike adults, children adapt well to limitations, and these boys had certainly continued on page 6

Overcoming Barriers to Treat Children in Need..................................... 1 President’s Letter.................................... 4 Editor’s Letter.......................................... 5 Incorporating Mirror Box Therapy into Hand Therapy Practice.................. 7 Member Highlight................................... 9 Viewpoint............................................... 10 State Chapter News............................... 12 How You Can Influence the Legislative and Regulatory Process............................... 13 Reimbursement Committee................ 13 The Scratch Collapse Test.................... 14 Q and A.................................................... 15 TechnoTips............................................. 16 Division Updates................................... 18 New CHTs............................................... 19

Correction: The “Recognizing the Cost of Freedom” article in the last issue of the ASHT Times was written by Courtney Retzer. Her byline was accidentally omitted.


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Volume 19 Issue 3

www.asht.org • ASHT Times

PRESIDENT’S MESSAGE

State of Our Society

ASHT Times Editor

Lynn Festa, OTR, CHT

American Society of Hand Therapists

15000 Commerce Parkway, Suite C Mt. Laurel, NJ 08054 Phone 856.380.6856 Fax 856.439.0525 E-mail asht@asht.org Web site www.asht.org

ASHT Board of Directors President Dorit Aaron, MA, OTR, CHT, FAOTA President-Elect Sue Michlovitz, PT, PhD, CHT Vice President Maureen Hardy, MS, PT, CHT Secretary/Treasurer Linda Klein, OTR, CHT Secretary/Treasurer-Elect Barbara Winthrop Rose, MA, OTR, CVE, CHT, FAOTA Immediate Past President Jerry Coverdale, OTR, CHT Board Member-at-Large Jane Fedorczyk, PT, PhD, CHT, ATC Board Member-at-Large John Austin, OTR/L, CHT Board Member-at-Large Pam Schindeler, OTR/L, CHT Executive Director Karen Peterson, CAE, SPHR Legislation and Reimbursement Director Tim Mullen, OTR, CHT Research Division Director Rebecca van der Heyde, PhD, OTR/L, CHT Practice Division Director Dan Bash, MS, OTR/L. CHT Education Division Director Gary Solomon, MBA, OT, CHT ASHT Times is the official quarterly news publication of the American Society of Hand Therapists. Views expressed in the articles published are those of the authors and not of ASHT unless expressly stated.

T

Dorit Aaron

his year sprinted out of the gate after a tremendous boost from 2011 with ASHT showing a profit of $122,410. This was a significant success given the losses encountered in 2010 with our annual meeting being combined with IFSHT and our decision to change management companies. This one-year turnaround in operating income was a welcome change.

With this spirit of development and growth, 2012 has taken on several big projects, primarily updating our website from a passive one to a member-centered, interactive one. In addition, we have started an exhibitor advisory board along with a comprehensive sponsorship and advertising program, soon to be evidenced at our annual meeting and on our website. These efforts will result in the ability of our members to gain exposure to the latest products on the market, and ASHT will produce an improved revenue stream. Our educational offerings have increased significantly, with monthly webinars rounding off the various ways education is now available to members. The annual meeting continues to add creative programming to our staple offerings. This year, we have received more than 60 scientific papers, and many will be presented to you at the meeting. We are launching the new Innovation Gallery, we are presenting a combined legislative panel from ASHT/APTA/AOTA to bring you the latest information from Washington and we are welcoming the inaugural AASHsponsored lecture, which cements the excellent relationship we have built with that organization.

Our educational offerings have increased significantly, with monthly webinars rounding off the various ways education is now available to members.

Through this growth, we have maintained our normal operating procedures, with an energetic and competent staff that handles the daily member needs, a dedicated board and division directors and an unofficial “presidential advisory board” made up of past presidents who have been selflessly offering their ideas and suggestions to me throughout this year. All this under the direction of our wonderful executive director who leads our charge to provide the members with the tools they need to navigate in this ever-changing environment. I’m looking forward to welcoming all of you to our Annual Meeting in San Diego, where we can all “make waves” together towards the future. Dorit H. Aaron, OTR, MA, CHT, FAOTA President, American Society of Hand Therapists www.asht.org Houston Hand Therapy www.HoustonHandTherapy.com


ASHTTimes Times ASHT 5

www.asht.org • ASHT Times 5

Volume 19 Issue 3

EDITOR’S LETTER

“I have lots of new stuff—I know you will enjoy them.”

Lynn Festa, OTR, CHT

DANA DECKER

n past editorials I have used quotes from famous people, but in this edition, I thought I would give credit to one of my personal favorites—my local wine merchant. Every time I step into his shop, the quote above is his anticipated and standard greeting. After he gets my requests for the number of whites and reds, he scurries around the store. Every few bottles he may hold one up, and say, “This is really good!” before he is off to gather the other gems he wants to make sure I get to enjoy.

I

As I was coordinating this edition, my goal was to highlight some “new stuff.” Just as the wine merchant spans the globe on the lookout for something unique, we, as hand therapists, do the same. In all our travels, be it through the wonders of the Internet, or the opportunity to attend conferences in fun destinations (go San Diego!), we, in all aspects of our trade (clinicians, researchers, educators), are doing the same—always on the lookout for something to make us better at what we do. What sparked this analogy is the fact that no bottle of wine he sells me usually costs more than $15. From the taste, I recognize there are few reasons to ever spend more than that. As you read through the educational articles, you will quickly learn that one of the new treatment techniques beautifully explained by Tara Packman, Mirror Therapy, can cost as little as a few dollars. Lorna Kahn eloquently describes the scratch collapse test. Cost for this test? Free. Once the hand therapist has the understanding of the how and why of both of these innovative and effective options, it can be added to our ever growing repertoire of tools to enhance our patient care and outcomes. Given the current state of healthcare, the ability to expand our knowledge and improve our skills without adding exorbitant costs is as rewarding as a nice glass of wine. May we all continue to enjoy the fruits of our labor. Cheers, Lynn Festa OTR CHT

(

Tip for red wine lovers: the 2009 Hardin cabernet (Napa Valley) is really rebottled Caymus.

)

ASHT ASHT Chapter Chapter Contacts Contacts Alabama Chapter Chapter Alabama

CindyPowell, Powell,OTR, OTR,CHT CHT Cindy cindy@gulfcoasttherapy.com cindy@gulfcoasttherapy.com

California Chapter Chapter California

MargaretPhyllips, Phyllips,OTR, OTR,CHT CHT Margaret president@asht-ca.org president@asht-ca.org

Louisiana Chapter Chapter Louisiana

JaimeMendoza, Mendoza,OTR, OTR,CHT CHT Jaime jaime.m@labordetherapy.com jaime.m@labordetherapy.com

Michigan Chapter Chapter Michigan

LodiaRunco, Runco,OTR, OTR,CHT CHT Lodia lrunco@runcowaste.com lrunco@runcowaste.com

Missouri Chapter Chapter Missouri

DavidLevy, Levy,MS, MS,OTR/L, OTR/L,CHT CHT David davidlevy.cht@gmail.com davidlevy.cht@gmail.com

New Jersey Jersey Chapter Chapter New

DavidSkolnik, Skolnik,OTR/L, OTR/L,CHT CHT David skolnik2@optonline.com skolnik2@optonline.com

Pennsylvania Chapter Chapter Pennsylvania TerryTaylor, Taylor,OTR/L, OTR/L,CHT CHT Terry taylort@msx.upmc.edu taylort@msx.upmc.edu

South Carolina Carolina Chapter Chapter South

DougLauber, Lauber,OTR/L, OTR/L,CHT CHT Doug djlauber@excelrehabclemson.com djlauber@excelrehabclemson.com

Texas Chapter Chapter Texas

MollyM. M.Hudson, Hudson,OTR, OTR,CHT CHT Molly mhudson86@hotmail.com mhudson86@hotmail.com

Wisconsin Chapter Chapter Wisconsin

TeresaD. D.Casagranda, Casagranda,PT, PT,DPT, DPT,CHT CHT Teresa terespt@aol.com terespt@aol.com


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Volume 19 Issue 3

www.asht.org • ASHT Times

Overcoming Barriers to Treat Children in Need continued from page 1

figured out how to complete simple daily tasks, despite their marked deformity. Once Dr. Bamberger decided his surgical intervention, my job post-operatively was the same as with any other patient who undergoes surgery. Morey underwent a skin graft to cover the volar skin loss deficit when the wrist was relocated to a neutral position. The small finger had been intact, but buried in scar and was amputated in surgery. The ring finger was sensate and thus spared in surgery with a z-plasty to help extend the finger into a more functional position. Initially, treatment was more involved with dressing changes, making sure the grafts were intact and protective splinting for the wrist. Despite the z-plasty on the RF, this was not immobilized, and Morey began to use it nearly immediately after surgery. Between the combined age and lifestyle of Morey, he was able to rally quickly after surgery. I used simple tasks such as removing the wrapper off a sucker to encourage bilateral hand use. Putty was used to encourage light passive extension for the ring finger, gripping/squeezing/ pulling once incisions were healed, and functional ADL simulation was used as well (e.g. zippers, strings, buttons, silverware). The children did so well using their hands once the wrist was restored to a neutral position, little “therapy” was

necessary–living life was their treatment. Verbal communication was, to say the least, interesting! I do not speak French, and Morey knew little to no English, which left me to do a lot of hand motions and demonstrating. Surprisingly, he responded well despite being in what I can only imagine to be a strange place and scary situation.

Professionally

I went into the area of hand therapy because I enjoy the challenge and the opportunity to continuously learn. The complexity of the hand, the surgical repairs and the challenge of helping my patients achieve their goals are what make me love my job. I enjoy keeping up with the new procedures, and I have the perfect environment to do so while working so closely with surgeons. As an individual, I challenge myself mentally and physically via forms of exercise, training for races, following the ASHT discussion forums and reading journals. I attempt to bring these qualities into the work environment and push my patients to their best, challenging them to obtain maximum results from their injuries. Working for The Hand Center of Southwestern Ohio has allowed me access to patients and diagnoses that are complex and rare. We have the amputations, boney reconstructions, crush injuries with complications and now we’ve added the

uniqueness of injuries that occur to those in underdeveloped countries without ever leaving our clinic. A future goal is to travel abroad and perform hand therapy in underprivileged areas, aiming to help make their lives better in whatever way I can.

Social Media at the Annual Meeting

You told us networking with fellow therapists is one of the most valuable benefits of attending ASHT’s Annual Meeting. Take your interactions to another level this year with three new, easy-to-use social networking tools. Web Badges

Pinterest

Twitter

Show your support for the 2012 ASHT Annual Meeting by sharing these web badges on Facebook or Twitter. Visit http://www. ashtannualmeeting.com and click the “share” buttons. If you’d like a .JPG of the web badges, please e-mail ASHT@asht.org.

Pinterest is a “virtual pinboard” that allows users to organize and share images, ideas, projects and more. ASHT has created a board for the 35th Annual Meeting where you can browse products, services and innovations available this year in San Diego.

Follow ASHT’s Twitter feed @HandTherapyASHT.

#ASHT2012 Use this hashtag to keep up with the latest on the 35th Annual Meeting in San Diego.

New to Twitter? Hashtags – marked with a # – are a way for users to categorize messages. Users typically mark relevant keywords and phrases (no spaces) in their tweets so they will display more easily in Twitter’s search results. Clicking on a hashtag in any message will show you other tweets marked with that keyword.

At the Meeting Have a question for fellow attendees? Want to share how great that workshop was? Looking for a lunch buddy? Whatever your message, when you send a tweet about the meeting, include “#ASHT2012” anywhere in the body to connect with other attendees in the “Twittersphere.”

New “pins” are being added weekly, so check back often! Visit the ASHT 35th Annual Meeting Pinterest board at http://pinterest.com/ handtherapyasht.


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Volume 19 Issue 3

www.asht.org • ASHT Times

Incorporating Mirror Box Therapy into Hand Therapy Practice by Tara Packham, MSc, OT Reg. (Ont) Hamilton Health Sciences/McMaster University Hamilton, Ontario, Canada

M

irror box therapy (also known as mirror visual feedback) is an application of motor imagery where the image of an unaffected limb is viewed in a mirror strategically positioned to create the sensory illusion that the person is viewing their affected limb. The idea was pioneered by Ramachandran for persons experiencing phantom limb pain after amputation1, and it has since been used with stroke, complex regional pain syndrome (CRPS) and other hand and nerve injuries2-6. It would appear to be a hot topic at recent conferences. The strength of the evidence ranges from descriptive case studies to small, randomized controlled trials, and it has been described in systematic reviews7-9 as indicating a trend towards support for utilization with post-stroke and CRPS, with limited evidence for other hand conditions. So why, when and how might a hand therapist incorporate this technique into their practice?

Indications for use

Post- sStroke Review of the literature suggests mirror therapy (MT) has been studied for persons at a variety of temporal and functional stages of motor recovery3,10. It may be contraindicated for those with premorbid or associated cognitive or visual impairments, including neglect and apraxia.3 CRPS Most of the studies using MT with this population have applied it as part of one component of a graded motor imagery program11-13 and use laterality and motor imagery activities as the initial steps. However, others have reported small case series of MT14,15 with positive results using MT alone. It is worth noting that those who benefited from MT were described as having early CRPS14 and CRPS II.15 In my clinical experience using this modality, I have also found the use of additional motor imagery components is not necessarily required when MT is used early in the syndrome (less than three months since the development of symptoms). However, I always use the client’s initial response to gauge the need

for a more comprehensive program.

I use these instructions with my clients:

Other Hand Injuries/Surgeries While there is little formal research evidence for application of MT to other populations, there remain several theoretical arguments for its use. This technique has been shown to be useful for phantom limb pain, and three of the papers describing the use of MT with hand injuries also include populations where there is an element of deafferentation.4-6 Simply put, when the patient has lost the sensory feedback from their hand because of nerve injury (amputation being the most extreme form of this), MT may provide a useful surrogate. The second (and related) argument is for those cases where sensory feedback exists but does not match the cortical expectations of the motor prediction patterns underpinning normal movement.16,17 The so-called sensorimotor incongruence may be the result of nerve injury, pain, stiffness, edema or immobilization, and MT may help to correct the mismatch and facilitate movement.

1. Place affected arm inside box with mirror facing unaffected arm. Make sure the box is comfortably positioned in front of you where you can see the reflection of your unaffected arm clearly in the mirror.

Instructions for use

Review of the literature demonstrates an overall lack of consistency and detail in program implementation. Therapists new to the concept are directed to Priganc and Stralka’s detailed description of graded motor imagery17 and McCabe’s excellent summary of applications in clinical practice16 for more detail. General guidelines include daily practice, working in a comfortable seated position and removing all jewelry from the hand that will be seen in the mirror. Most authors suggest the patient perform a series of arm, hand and finger postures in front of mirror with unaffected hand and attempt to “mirror” with affected hand. Exercises are tailored to patient abilities and graded as appropriate. In my clinical experience, the biggest key to success is careful patient education, taking the time to explain what you are trying to do and why you think it might help them. I will usually have the person start for short periods of 3-5 minutes and increase time to 10-15 minutes as tolerated.

2. Start by concentrating on the reflected image in the mirror. Try to imagine that what you are seeing is actually your other hand. This may take a minute or two, but sometimes happens quite quickly. 3. Keeping your affected hand relaxed, start by gently doing the exercises your therapist has selected with you only with the unaffected hand. Try to focus on the image in the mirror while you do the movements. 4. Now repeat the same exercises, but this time, try to do them with both hands at the same time. Again, focus on the image in the mirror while you do the movements. Do not do anything with your affected hand that produces pain. Stop if you become tired or experience any feelings of nausea or dizziness. If the person does not experience the sensory illusion at step two, then we do not progress any further. I may try again at a different time of day or in a completely quiet or private area of the clinic to see if there was some distraction factor. Do not underestimate the power of this technique to create a response in the central nervous system–there are several studies that document the impact of creating an artificial sensorimotor incongruence even in healthy volunteers.18,19 Sometimes clients will have a strong sensory or emotional reaction even at this point–nausea, dizziness, tears, even transient pain in the unaffected limb. If a negative response is elicited at any point, we move back to the previous step, which may mean laterality and motor imagery rather than using the mirror box. On a practical note, I use a purpose-made box of melamine for easy cleaning, open at


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both ends, 12” high by 14” wide and 16” long–this allows for lots of room to move within the box. I also have an extra unit for short-term loan to patients to get them started, and then will encourage them to make one for home use with a sturdy cardboard box and a 12” square sticky-back mirror tile from the hardware store.

Progressing Therapy

If the person tolerates the mirror box, work on gradually increasing the length of use to 10-15 minute periods, as well as the number of times used daily. The amount of stimulation or challenge to the sensory system can also gradually be increased by varying the location where MT is performed, lighting, noise or other distractions. The person can also move from exercise to activity, adding tools or other objects to the experience. Other forms of sensory stimulation can also be added to MT, and this may increase the effectiveness of the program.20 Consider adding sensory stimulation by touching different textures like smooth/rough, warm/ cold, hard/soft and/or furry.

Incorporating into overall treatment plan

The foundational framework of hand therapy is traditionally biomechanical; most treatment protocols arise from this perspective. However, when our clients are not following the expected course of recovery, hand therapists are skilled at incorporating components of other approaches (like cognitive-behavioral or exercise physiology). MT is yet another addition to the therapists’ toolkit. Consider using it when there is fear of movement, reports of dysthesias, deafferentation or difficulty in consistently recruiting the desired muscles or movement patterns. Start with short periods of use in the clinic to monitor response before adding a home program. Continue to use as long as the symptoms persist, progressing the program as tolerated. Be sure to incorporate measurement tools to objectively monitor progress and outcomes to further inform your practice and advance the evidence for this modality.

www.asht.org • ASHT Times

References and resources:

1. Ramachandran VS, Roger-Ramachandran D. Synaesthesia in phantom limbs induced with mirrors. Proc Biol Sci. 1996; 263: 377-86. 2. Altschuler E, Hu J. Mirror therapy in a patient with a fractured wrist and no active wrist extension. Scand J Plast Reconstr Surg Hand Surg. 2008, 42:110-11. 3. Yavuzer G, Selles R, Sezer N, Sütbeyaz S, Bussmann JB, Köseog˘lu F, Atay MB, Stam HJ. Mirror therapy improves hand function in subacute stroke: A randomized controlled trial. Arch Phys Med Rehabil. 2008; 89:393-8. 4. Bjorkman A, Waites A, Rosen B, Lundborg G, and Larsson E. Cortical sensory and motor response in a patient whose hand has been replanted: One year follow-up with functional magnetic resonance imaging. Scand J Plast Reconstr Surg Hand Surg. 2007, 41: 70-6. 5. Rosen B, Lundborg G. Training with a mirror in rehabilitation of the hand Scand J Plast Reconstr Surg Hand Surg. 2005, 39: 104-8. 6. Sumitani M, Miyauchi S, McCabe CS, Shibata M, Maeda L, Saitoh Y, Tashiro T, Mashimo T. Mirror visual feedback alleviates deafferentation pain, depending on qualitative aspects of the pain: a preliminary report. Rheumatology. 2008; 47:1038–43. 7. Ezendam D, Bongers RM, Jannink MJA. Systematic review of the effectiveness of mirror therapy in upper extremity function. Disabil Rehabil, 2009; 31(26): 2135–49. 8. Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT. The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature. Int J Rehabil Res. 2011, 34:1–13. 9. Thieme H, Mehrholz J, Pohl M, et al. Mirror therapy for improving motor function after stroke. Cochrane Database Syst Rev. 2012 Mar 14;3:CD008449. (Review) PMID: 22419334 10. Dohle C, Pullen J, Nakaten A, Kust J, Rietz C, Karbe H. Mirror therapy promotes recovery from severe hemiparesis: a randomized controlled trial. Neurorehabil Neural Repair. 2009, 23:209–17. 11. Moseley GL. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain. 2004, 108:192–98. 12. Moseley GL. Is successful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomized clinical trial. Pain. 2005, 114:54 61.

13. Moseley GL (2006). Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology. 2006, 67:2129–34. 14. McCabe CS, Haigh RC, Ring EFJ, Halligan PW, Wall PD, Blake DR. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology, 2003, 42:97–101. 15. Selles RW, Schreuders TAR, Stam HJ. (2008) Mirror therapy in patients with causalgia (CRPSII) following peripheral nerve injury: 2 cases. J Rehabil Med 2008; 40: 312–14. 16. McCabe, CS. Mirror Visual Feedback: a practical approach. J Hand Ther. 2011, 24:170-9. 17. Priganc VW, Stralka SW. Graded Motor Imagery. J Hand Ther. 2011, 24:164-9. 18. Fukumura K, Sugawara K. (2007). Influence of mirror therapy on human motor cortex. Intern J Neuroscience, 2007; 117:1039–48. 19. McCabe CS, Haigh RC, Halligan PW, Blake DR. Simulating sensory-motor incongruence in healthy volunteers: implications for a cortical model of rheumatology pain. Rheumatology. 2005; 44:509–16. 20. Moseley, GL, Wiech, K. The effect of tactile discrimination training is enhanced when patients watch the reflected image of their unaffected limb during training. Pain. 2009, 144:314–319.


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Volume 19 Issue 3

www.asht.org • ASHT Times

Member Highlight Mike Szekeres, OTR, CHT

W

here did you get your degree?

I obtained my OT degree at the University of Western Ontario. I recently found out that I will be heading back there full time for one year to pursue my PhD in Rehabilitation Science with a focus on Physical Therapy.

Where do you work, and what is a typical caseload?

I currently work in two settings. I spend four days per week working as a staff hand therapist at the Hand and Upper Limb Centre. This center has a unique blend of plastic and orthopedic surgeons that work under a hand surgery model and a mix of OT and PT that work under a hand therapy model. Together, we see more visits per year than any other center in Canada. I also am one of the owners of Hand Therapy Canada. This organization was originally started to initiate a national Hand Therapy Conference for Canada as there was nothing happening north of the border for a national conference. This company has evolved into a successful private practice providing hand therapy to clients from across Soutwestern Ontario and a location in the Ottawa area.

Name two or three people involved in your professional development. I am very lucky to work at the Hand and Upper Limb Centre with many excellent people. Joy MacDermid has been an excellent mentor for me. She has given me many opportunities for development within the profession, and she has guided me with developing research questions. She has also been influential in my decision to pursue my PhD. Dr. Graham King and Dr. Bing Gan have also been excellent friends and mentors who have included me in several publications and presentations over the years.

Do you have any special interests in the field of hand therapy? Any specific research and/or hand therapy related projects?

My research interest currently lies in the area of using superficial heat to pre-condition tissues prior to stretching. My most recent publication was as a co-author of a text book chapter on flexor tendon rehabilitation. Other previous publications and teaching have focused on the biomechanical analysis of orthotic use and rehabilitation after elbow trauma and instability. I have written several hand therapy related websites, and I am working on developing an iPhone app for home exercise programs and a FileMaker database for using the iPad for online documentation.

How long have you been a CHT? I attained my CHT four years ago.

What has been your involvement in special projects with ASHT?

leaders for the society and the profession. My most recent project was as a member of the website development task force. We just recently launched the new site and will continue to meet to refine the project and make access to the member community within the site a valuable resource for members.

In 2009 I was vice-chair of the education council, and, in 2010, I was the Director of the Education Division for ASHT. This was a great experience for me, and it was worth the time and effort it took to run the various projects associated with the Education Division. The education council was composed of an excellent group of people that are continuing to move up the ranks and become true

What do you like to do in your spare time?

My life outside the hand therapy world includes family time with my wife Tammy and our three girls who are eight, five and four years old. I like to play baseball in the summer and hockey in the winter.

Thanks to Our Donors!

ASHT VISION

2012

We recognize the following members who donated to ASHT restricted funds between June 1, 2012 and September 1, 2012. SUPPORTERS (Donations of $20 or more) John E Austin, OTR/L, CHT

Daniel S. Bash, MS, OTR/L, CHT

Timothy M Mullen, PhD, OTR, CHT

Mark Bagg

Lydia A Hohman, OTR/L, CHT

Gary S. Solomon, MBA, MS, OTR/L, CHT

ASHT has three restricted funds:

Gifts to the Annual Meeting Sessions Fund help ASHT continue the quality programs hand therapists need.

The Vision Fund is dedicated to the support of ASHT’s strategic initiatives in Governmental Affairs, Advocacy, Education and Research.

Rebecca L. Von Der Heyde, PhD, OTR/L, CHT

Donations to the Awards and Scholarship Fund help promote or recognize professional development.

To support ASHT with a donation, please visit www.asht.org/about/donate.


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Volume 19 Issue 3

www.asht.org • ASHT Times

Viewpoint W hat advice would you give to a therapist about to take the CHT Exam? “Meet regularly with a few other therapists who will be taking the exam. Organize your meetings for topics and questions to be answered. Review previous exam questions. Review procedures and protocols for various hand surgeries. Know your peripheral nerves and treatment.” Hilda B Hodtes OTR/L, CHT Santa Cruz, Calif.

“After 20 years of being a CHT, I still believe the most important thing to study, review, memorize and, most importantly, understand, is anatomy.” Kim Granhaug, OTR, CHT

“Get involved in a study group, and have an agenda for each meeting. To minimize distractions, focus a bit of time each day to spend a half-hour to an hour reading with nothing else going on around you. Go to the review course, and meet others. If the right person comes along, it can be infectious and make studying so much less stressful. It is all about taking the time to study, and I truly believe six months is not enough.” Deb Hartenstein, MS, OTR/L, CHT Vermont

“Set up a study schedule months in advance, and keep to the timeline. Study with reliable and motivated colleagues. Utilize your final weeks prior to the exam to review what you know, rather than cram final material. Get a good night’s sleep the night before the exam. During the exam, select answers based on readings from reputable sources, rather than purely clinical experience. Monitor the clock to ensure you answer all your questions in the allotted time frame.”

“Relax and make sure you remember how tissues heal. You can apply that knowledge to any condition/ surgery and help decide what the best treatment option might be.”

Mo Herman, MA, OTR/L, CHT Torrance, Calif.

K. Macy Schepis, OTR/L CHT

“Give yourself a year to prepare. When reading and studying, I took all of my notes on index cards so I could transport them easily to study and test myself throughout the day. Also, start your studying with the brachial plexus and take the time to memorize each nerve root, nerve and muscles in the order of innervation. Writing this information out at the test center in the first few minutes before starting testing was extremely valuable for me.” Cynthia Weinberger, OT/L, CHT Windsor, Vt./Newport, N.H.

“Pace yourself! Try and review, read or learn something new every day before your exam. Give yourself plenty of time. It is worth the effort!” Katherine Greg, MS, OTR, CHT

Ildiko Paulovits, OTR,CHT West Orange, N.J.

“Know the anatomy forwards and backward. Origin, insertion, innervation and action. Once you have that, the rest is much easier.”

“Organize your studying in the same way that the books are organized. Each book usually starts with anatomy, wound healing, evaluation and then progresses to specific diagnosis. Write any pertinent information on an index card and keep them with you. (I wish I had bought stock in index cards!) I had them at work, in my purse, in my car and at home. Any spare moment was spent reviewing the index cards.” Terri Narehood, OTR/L, CHT Pittsburgh, Pa.

“Plan for the exam one year ahead. Read Rehabilitation of the Hand and Upper Extremity cover to cover. As you read, incorporate your new learning into patient treatments, which will improve as a result of your study.” Debbie Ahearn, MA/OTR/L, CHT Eugene, Ore.


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Volume 19 Issue 3

“Make a structured study schedule and hold yourself accountable for completing it! Create a topic per week (i.e. shoulder, fractures, tendon transfers, etc.) to review. and then review all information on that topic and take notes on important concepts. Follow this up with some type of practice test. Make sure to schedule some ‘crunch time’ to review everything prior to taking the test. I found this extremely helpful, and, at the end, I had some really great information sheets on each topic that I still pull out now.” Sara Schroeder, MS, OTR/L, CHT Philadelphia, Pa.

“I took the first exam in 1992. I studied hard. It made me a more knowledgeable therapist, and it was one of the best things I ever did in my career. I believe the same will be true for all the future CHTs.” Louisa Affleck, OTR, CHT

“I used the Rehabilitation of the Hand and Upper Extremity, Hand Rehabilitation: A Quick Reference Guide and Review and the ASHT CHT Test Prep to better understand anatomy, diagnoses and treatment approaches. But your best critical thinking preparation comes from your own hand patient experience. The test requires you to utilize both types of information.” Paul Anderson OTD, OTR/L, CHT Medford, Ore.

“Find supportive MDs to discuss questions. I attended the medical schools UE ortho rounds once a week for a year. You will learn so much, and the future MDs will know who you are and what a CHTs is!” Jem Hopkins, MS, OTR/L, CHT

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“Learn one new thing a day, every day. Emphasize anatomy and tissue healing concepts. If you know the anatomy and physiology of tissue healing, you can figure out the answers to the CHT exam questions, and, more importantly, the treatments needed for your patients.” Stacy Hite, PT, DPT, MS, CHT Charlottesville, Va.

“Take the prep class offered by ASHT. The study guide was wonderful and helped me prioritize what to study.” Colleen Schmitz, OTRL CHT Cary, N.C.

“Take a couple of days off from work before the test. Use the first day to review your weak areas. Take the second day off from studying and relax, de-stress. Don’t go into test day stressed and unrested. I had to take my test in another town. I reserved a room in a hotel for two days. The second day I did a little sightseeing, had a nice dinner and went to bed early.” Kim Masker, MSOT, CHT Bristol TN/VA

“Soak up all the knowledge, and get as much “hands-on” training as you can from watching hand surgeries, cadaver labs to CEU courses. The best yet is working with a CHT. A study group can help too, especially if you formulate questions to ask in multiple choice form. Practice test taking skills (again) if you are not a good test taker.” Karen Griggs OTR, CHT Kingwood Texas

“Get yourself a study partner or get in with a study group with other individuals who are also preparing for the hand therapy exam. You will be able to review materials together, share ideas and help each other when you come across a stumbling block. Also, don’t wait until the last minute to start studying! There is a lot of material to cover and you need to know it like the back of your hand in order to pass the exam!” Kimberly Hartman, OTR/L, Woodbridge, VA.

“Know the anatomy of the UE inside and out; know your kinesiology and biomechanics of each joint. As you treat a diagnosis in the clinic, go back and read up on it, then you can associate a diagnosis with a face — easier than just reading [Rehabilitation of the Hand and Upper Extremity] cover to cover. Observe surgery. Follow the hand surgeons in clinic. Know the anatomy can’t be understated!” Brenda Pedersen, MS, OTR/L, CHT West Des Moines, Iowa

“I bought earplugs. It enabled me to focus better without any outside distractions I also wrote out the brachial plexus to refer back to before I answered my first question. It seemed to give me the ability to settle into the exam.” Ylisa Young OT/L CHT Hollywood, Florida

“Be very familiar with your anatomy. If you are versed in anatomy and tissue healing rates, you can problem solve through most anything.” Daniel Acker, OTR, CHT


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Volume 19 Issue 3

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Chapter News California During its January Board of Directors meeting, the chapter hosted guest speaker Marleene Steele, COTA, and developed its skills through three continuing education meetings. Chapter president Margaret Phillips formed the new Past President’s Advisory Committee to give recognition and utilizing the past expertise and skills of past president’s for board and association activities. They participated in our March conference. The two-day conference, “The Elbow: The Unforgiving Joint,” was held in March and attended by approximately 100 people. The conference featured international speakers, including Shrikant Chinchalka, and keynote speaker Dr. Jeff Budoff. The chapter has plans for at least four more continuing education meetings this year, in addition to participating in the ASHT Annual Meeting in San Diego in October. In honor of Healthy Hands Week, the California chapter purchased week-long ads on public radio during prime morning times to promote public knowledge about healthy hands and the benefit of seeing a Certified Hand Therapist. ASHT-CA also hosted a dinner for therapists, guests and physicians with guest speakers Diane Coker and Pam Silverman. Using multiple e-mailings, the chapter encouraged facilities and private practices to send thank you letters to physicians and patients, serve refreshments, etc. during Healthy Hands Week and listed the information available through asht.org for therapists to organize activities appropriate for their settings. California members participated in a Scleroderma Walk for Life event with a booth. Two therapists demonstrated splints and used information handouts to give participants information on how hand therapy can help sustain hand function skills.

MICHIGAN A quote by an unknown author, “Hand therapists grow in the soil of experience with the fertilization of example, the moisture of desire and the sunshine of satisfaction,” has been the framework of the activities the Michigan Chapter of ASHT this quarter. The chapter has assisted in the growth and the fertilization of new and old therapists by hosting a conference this past June on joint mobilization. The well-attended course was presented by Paul LaStayo and Ken Flowers. The chapter has also just finished planning a fall conference entitled “Dynamic Stability for the Painful Thumb: It is More Than an Orthosis.” Virginia O’Brien, OTD, OTR/L, CHT and Jan Albrecht, OTR/L, will present November 2-3, 2012, at the Bay Pointe Inn Lakefront Resort, Shelbyville, Mich. Attendance is limited to 40 individuals. Please contact Rasa Poorman, OTR/L, CHT, at (248) 5434886 for more information. The Michigan chapter has begun a letter-writing campaign regarding the state’s deregulation of occupational therapy.

TEXAS Each year, a Texas Chapter of ASHT member is awarded the Shining Star award for outstanding leadership and commitment to the profession. This year, Sheila Heflin, OTR, CHT, of Corpus Christi received the honor. Heflin was born in New Mexico and graduated from Texas Women’s University in 1986. She moved to Corpus Christi in 1987 and went to work for Memorial Hospital Outpatient Burn Center with her mentor, Gene Constantine, OTR. Heflin went into private practice (Heflin Hands) for two years and moved to another private practice, Hand Therapy Services, where she has been since 1994 and currently manages the Hand Therapy Department. Heflin became a CHT in 1997. Her colleagues know her best for her love of her profession and ability to mentor. She served as Education Coordinator for the Texas Chapter of ASHT in both 2001 and 2010. Heflin loves spending time with her family, fishing and the beach. The Texas Chapter of ASHT thanks Heflin for her dedication to the profession and her shining example as a leader.

WISCONSIN The Wisconsin Chapter of ASHT sadly announces the retirement of newsletter editor Vickie Alba, OTR, CHT, secretary Cathy Selzer, OTR, CHT and student liaison, Katie Schuh, OTR, from the WI-ASHT Board of Directors. They have served the organization with a depth of commitment that has been deeply appreciated and their presence on the board will be missed.  Alba and Selzer have served in various capacities for many years and have truly been the backbone of this organization. They have promised, though, to still be active in WI-ASHT, and the chapter looks forward to many more years of experiences together. The Wisconsin chapter is pleased to announce that current vice president Carmen Aponte, OTR, CHT will also be serving as secretary, and Misty Carriveau, OTR, CHT, will be the new Hand It to Me newsletter editor. Fue Moua, OTR, will serve as the new student liaison. The Wisconsin Chapter of ASHT thanks everyone who dedicates their time and talents.


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Volume 19 Issue 3

www.asht.org • ASHT Times

How You Can Influence the Legislative and Regulatory Process Tim Mullen, PhD, OTR/L, CHT

W

hen you first thought about becoming an occupational or physical therapist, it’s unlikely you considered legislation and regulation of the professions. When you graduated and entered the work force, you probably still weren’t thinking about the impact of the legislative and regulatory process. Now that your professional career is under way, you have undoubtedly come to realize that the reality of today’s reimbursement lies squarely on the shoulders of the legislation and regulatory process. What can be performed, what can be billed, what must be documented and what may be reimbursed are now at the forefront of your business. If you understand the process, the legislative and regulatory process does not have to be a spectator sport. Elected officials represent their constituents people like you who vote for them. These politicians are often looking for expertise and constituency opinion on a variety of issues. Occupational and physical therapists can provide constructive input that may significantly influence policy decisions. The process is consistent and proper. Remember the Schoolhouse Rock animated video “I’m Just a Bill” that used to air during Saturday morning cartoons? (http://www.youtube. com/watch?v=tyeJ55o3El0). At each phase of any proposed bill, politicians are looking for input. You can influence members of the House, members of the Senate and even the President. The first step in influencing the process is for you to stay abreast of the issues that may impact hand therapy. AOTA, APTA and ASHT all monitor these issues. Their respective websites are filled with information, often accompanied by the organization’s opinion or a call to action. ASHT’s Legislative Committee also alerts members by eblast when action is required to effect legislative change and may even provide sample letters for you to personalize.

Once an issue is identified, it is time for you to act. You can identify your state representative or senator and obtain contact information using a simple search tool located on ASHT’s website (http://www.asht.org/practice/legislativereimbursement-resources). Remember to address elected officials with the respect due to the office. Your state representative and senator are looking to you to share your professional expertise and tell them what position you think they should take and why. They want examples of how a decision will affect other voters. Politicians often maintain offices in their home state as well as in Washington DC. They have office hours at both locations and welcome visitors by appointment. Sometimes you may be more persuasive presenting your case face-to-face than in a letter. While you may not be able to meet with the actual politician at your appointment, you will be able to visit with their staff aides who specialize in health care issues. The aides will then convey your ideas and opinions to the elected official. AOTA and APTA also sponsor annual legislative visits, often known as ‘Capitol Hill Days’. This can be another nice way to get face time with your elected officials and identify yourself as an expert in the field who is willing to facilitate their understanding of issues affecting hand therapy. Time and again, the legislative actions of individuals or grass roots efforts have been extremely effective in promoting change – helping protect your right to perform wound care, your ability to make orthotic devices or your right to utilize modalities. Your efforts can also help prevent barriers to the services you are trained to provide. These outcomes were achieved because of the efforts of people like you. Stay informed. Get involved. It is the best way to secure your future practice. If you have any questions, do not hesitate to e-mail legislation_reimbursement@ asht.org. We have a team of committed volunteer leaders ready to assist you.

Reimbursement Committee Update for ASHT Times The ASHT Reimbursement Committee is a new committee formed from ASHT’s Legislative and Reimbursement Division. Since its inception last year, this committee has been focusing its attention on reimbursement issues, exploring potential solutions and developing resources for the ASHT members. This year the committee has been focusing its attention on updating the FAQ section on the ASHT site. We are also expanding the available information and resources available for PQRS, CCI edits and ABN utilization. In addition, we continue to monitor the listserv and group site for reimbursement issues and answer reimbursement-related questions emailed to ASHT.

The RC also is researching and exploring the Alternative Payment System, a potential solution to the current timed/untimed code documentation and payment system. The APS was introduced and presented by APTA and ASHT was invited to provide comment. The RC is currently reviewing this document for potential discussion with APTA.

The Reimbursement Committee would like to effectively address all issues across all disciplines. We are actively seeking PT/CHT members to volunteer for this committee! We are looking for leaders with a strong background managing reimbursement related issues. Submit you resume to ASHT for consideration, and help provide representation for our PT members!


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Volume 19 Issue 3

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The Scratch Collapse Test by Lorna Canavan Kahn, PT, CHT

T

he following essay is a synopsis of an instructional course taught by the author, Dr. S. Mackinnon and Dr. G. Gontre, at the January 2012 AAHS/ASPN meeting in Las Vegas. The examination of a patient with a peripheral neuropathy typically includes a variety of clinical tests followed by electro-diagnostic studies. Given that the sensitivity and specificity of these clinical tests may vary from 30 to 100 percent1, it comes down to the experience of the examiner to weigh the results of the various tests and come to a diagnostic conclusion. There is now a test that can be added to the clinical evaluation, which may enhance the diagnostic conclusion. It is referred to as the “scratch collapse test.” The test is performed with a touch or “scratch” to a suspected nerve injury site followed by a pseudo strength test. When injury or irritation is present, the involved limb will be unable to maintain strength and “collapses” to the force of the tester. Within seconds after the test, the pre-test or normal strength returns. One of the advantages of this test is that it is difficult for the patient to feign results—most are surprised and confused by the result. The scratch collapse test is not new, but it has gained popularity and respect in the last 10 years with the publication of several papers supporting its usefulness. It has been shown to be reproducible, accurate, highly sensitive and easy to perform.2 In spite of this, a clear explanation of its mechanism remains elusive. The SCT is believed to be a “gross manifestation of the cutaneous silent period.” In the human limb there are inhibitory motor reflexes triggered by very painful stimuli to the hand. The cutaneous silent period is believed to be an evolutionary protective reflex that prepares the human extremity for movement away from the offending object. The term “silent” refers to the absence of muscle activity as demonstrated on EMG when this reflex is studied.3 There are several similarities between the cutaneous silent period (CSP) and the scratch collapse test (SCT). Both the CSP and SCT are resistant to habituation, and

both are able to override voluntary muscle contraction. The pattern of withdrawal in both is consistent with a pattern of protection often compared with an evolutionary survival reflex. Finally, the brief loss of motor control occurs following noxious stimuli. It should be noted that with CSP, the stimulus is perceptibly painful, whereas the stimulus in the SCT is not. Although the patient will not necessarily report pain where they are touched, this site is thought to be an area of subclinical nerve irritation. These areas of nerve irritation are believed to correlate to areas with higher concentration of Substance P. Substance P is a neurotransmitter that can influence neural activity by carrying information directly to the cells and tissues. Unlike our traditional understanding of neurotransmitters, they are no longer believed to exist only within the synapse. “[N]eurons can have receptors on membranes throughout their cell bodies and dendrites. This is particularly true for the substance P receptor, which exists all over the cell body of its neurons.”4 It has been shown that Substance P is present and involved in inflammation and neuropathic pain. An increased presence of Substance P in central and peripheral nerve endings of sensory neurons has been demonstrated following inflammatory conditions and after nerve injury.5 These areas of injury and inflammation with suspected elevated Substance P levels appear to correlate with the areas that cause a positive response when they are stimulated or scratched. This gives the examiner a predictor to the specific area of nerve irritation. No preparation or tools are required for performance of the SCT. It is best to have the patient seated forward in their chair, directly in front of the examiner. The subject’s elbows should be flexed to 90 degrees and held at their sides with forearms in neutral rotation. The examiner performs a pretest pseudo muscle strength test by placing his hands on the dorsal aspect of the patient’s forearms and applying an inward force (as if testing bilateral external shoulder rotation strength). Instruction is given to counter this force with just enough strength to “balance” the resistance (not an arm wrestle or MMT).

Next, a finger swipe or “scratch” is applied to the uninvolved side in an area corresponding to the suspected compression on the involved side. For example, if you suspect compression at the right carpal tunnel you would start with a scratch to the left volar wrist. The pseudo-strength test is repeated immediately following the scratch. Assuming the patient has no active nerve compression on the uninvolved side the result should be the same as the pre-test. Next, a finger swipe is applied to the suspected area of compression on the involved side, once again followed by the strength test. When neuropathy or nerve irritation is present the involved arm will typically collapse or give way, unable to maintain the starting position. In this situation the test is considered positive.


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In patients whose level of pain limits tolerance of light touch, an alternate stimulus is used. In such cases of allodynia the nociceptors may respond to stimuli that would not normally be interpreted as painful or noxious. Blowing on the suspected area instead of scratching will often suffice to elicit a “collapse” response. Conversely, in areas where the suspected compression or nerve irritation is deep to the skin, as in the median nerve below the pronator teres muscle, deeper pressure with the finger swipe may be needed to elicit a positive response. Recently, a patient presented in the Peripheral Nerve Clinic for a second opinion following a carpal tunnel release. The patient reported that his symptoms of hand pain/paresthesias were unchanged, if not worse 2 months post operatively. During the evaluation it was noted that he had a short, well-healed scar in the palm. A scratch collapse test to the proximal

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median nerve compression site in the forearm was negative as was the same test to the carpal tunnel scar. When the area just distal to the scar was tested, the arm collapsed to inward force, indicative of a positive result. From this information the surgeon surmised that the distal portion of the carpal tunnel was not fully released and further surgery may be needed to fully decompress the median nerve . The scratch collapse test is a useful tool for peripheral nerve evaluation. When combined with current clinical evaluation tools an enhanced clinical picture may emerge. Not only can it reinforce the suspected diagnosis, it may aid in injury localization in a way that other tools cannot. The reproducibility, simplicity and high sensitivity of the scratch collapse test make it a welcome addition to the clinical evaluation “toolbox.”

References:

J Hand Ther 1991; 4:169-6 JHS vol 33A, November 2008 “Scratch Collapse Test for Evaluation of Carpal and Cubital Tunnel Syndrome.” Christine J. Cheng, MD, MPH, Brendan Mackinnon-Patterson, MPH, John L. Beck, MD, Susan E. Mackinnon, Md. Leis, A , Stokic,DS, Fuhr,P, Kofler, M, et al . Nociceptive fingertip stimulation inhibits synergistic motoneuron pools in the human upper limb. Neurology 2000;55:1305-1309 XXIInd Congress of the Collegium Internationale Neuro-Psychopharmacologicum Day 4 - July 12, 2000 Substance P Research in Psychiatry TA Kramer, MD. Understanding Substance P Ozturk N, Erin N, Tuzuner S. Changes in tissue Substance P Levels in Patients With Carpal Tunnel Syndrome. Neurosurgery, December 2010, V 67

Q and A

How much information should researchers provide regarding the assessors of the outcomes and the intervention provided in a study? By Kris Valdes OTD, OTR/L, CHT

T

he researchers should describe the training and expertise of the intervention providers. Did the providers have the expertise to perform specific tests? Did they require any special training to provide the intervention? This is important information to know in order to determine if the assessors were qualified to perform the assessment. Sometimes studies will indicate the researchers testing methods and results were compared to ensure all subjects’ outcomes were tested in the same manner no matter what assessor measured their results. This is called inter-rater reliability. The interrater reliability, inter-rater agreement or concordance is the degree of agreement among raters. It gives a score of how much homogeneity, or consensus, there is in the

ratings given by assessors. A common way of performing reliability testing is to use the intra-class correlation coefficient (ICC). There are several types of this and one is defined as, “the proportion of variance of an observation due to between-subject variability in the true scores.” The range of the ICC may be between 0.0 and 1.0 (an early definition of ICC could be between −1 and +1). The ICC will be high when there is little variation between the scores given to each item by the raters, i.e. if all raters give the same, or similar, scores to each of the items. The intervention should also be clearly described and specified. The more precise, specific and detailed the description of the intervention provided, the higher the probability is that the experiment can be

replicated in the future. If the researcher simply reported that the intervention included hand therapy, we would have no idea how often the subject received hand therapy, what particular exercises or modalities were part of the intervention or how long the subject received the intervention. It would be more useful to know details such as duration of the intervention, exercises or techniques in the intervention and how long each therapy session lasted. When trying to analyze interventions to determine their effectiveness or compare one study’s findings to another, precise description of the instructions and the interventions received by the subjects are critical.


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Volume 19 Issue 3

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TechnoTips by John E. Austin, OTR/L, CHT

EMR Software

O

ver the past decade, computer technologies have changed dramatically, and many of us would have trouble going back to the days before we had our laptops, smartphones, tablets and fast Internet speeds. As we continue the discussion I started in the last ASHT Times, we’ll be looking at the various components of EMR/EHR technologies. Current EMR systems are designed to utilize these enhanced capabilities to provide significant advantages for daily practice. Before making any decision regarding EMR/EHR software, there are important questions you need to answer to properly evaluate systems to find the correct fit for your practice. A firm understanding of your practice needs and the options available are critical to a successful EMR/EHR implementation. This article contains a short list of considerations that may help you outline your search parameters.

What is the size of the practice?

Software options exist for large or small practices. For multiple office practices, consider if client information will need to be shared between locations. Can staff information, document templates and billing be managed from a central location? For smaller practices, buying a system with options/services you can’t use will be more expensive than your needs require.

Do you want integrated billing, practice management and documentation? Some EMR/EHR software will only offer a suite of products that include practice management, billing and documentation, while others allow you to combine separate modules to meet your practice needs.

Will you require integration with portable systems? The latest versions of some EMR/EHR software are designed to work with tablets and smartphone technology. Other systems can be made to work with these portable devices, but the interface is often cumbersome.

Would your practice be better served by SAAS (Software as a Service) or web-based EMR?

For smaller practices, SAAS- or “cloud”based systems may be a more cost-effective way to implement an EMR/EHR system. However, site-specific customization is not typically allowed, although the software is generally quite comprehensive.

Does the system allow for easy quality reporting?

Data-mining, the term used for being able to retrieve relevant information, is an important part of gathering data for productivity, outcomes, referral levels, etc. Some systems do not have “live” data, which results in difficulty performing queries on your data. Systems with automatic reporting functions, query functions and benchmarking will make the best choices if your practice has productivity or governmental reports to track.

Do you need integrated scheduling?

Electronic scheduling systems are again often provided as separate modules with additional cost. These systems can be useful in coordinating patient schedules and equipment usage across multiple sites. Additionally, these most often require more consistency in collection of registration data.

Does the system have a managed care module?

Does your practice work with managed care contracts? Systems are available that integrate managed care capabilities into the software and others offer modular components. Look for systems that can handle capitated payments and generate reporting that will allow you to assess the financial impact of the contracts.

What report generator does the system use? EMR/EHR systems generally have several “canned” reports available, and you will need to evaluate their usefulness based on the needs of your practice. Others utilize proprietary report generators that do not allow for easy customization and often charge to make site specific reports. Generally, the simplest form of report generation uses an existing program like Microsoft® Word and links data to a template and allows for easier customization.

Before making any decision regarding EMR/EHR software, there are important questions you need to answer to properly evaluate systems to find the correct fit for your practice.


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The table below offers an example of software options that are currently on the market:

Company Mediserve

So)ware Product Medilinks ‐ Inpt

Mediserve Mediserve

Medilinks ‐ Hosp Based Outpt ARgo Therapy ‐ Private Prac;ce

Clinicient Op;mus EMR

Year  Established Documenta;on Inpt PT, OT, Respitory 1986

Scheduling Module Billing Yes Yes (op;onal)

Interfaces EPIC, MediTech, Cerner,  Mekesson, Siemens + others

Cloud  Compu;ng  Mobile  Op;on PlaBorm

1986 1986

Outpt PT, OT, Rehab Outpt PT, OT Private Prac;ce

Yes Yes

Yes Yes

1998

Outpt PT, OT, Speech

Yes

Yes

Long term care OT, PT, Speech  No in conjunc;on with Electronic  Health Record and billing from  Op;mus

Yes

Only to Op;mus eChart

2000

PT, OT

Yes (integrated)

Yes  (integrated)

HL‐7 compliant

unknown

Yes 

Yes

HL‐7 compliant format, Excel

No

No

Op;mus EMR

Yes Yes

Yes

Hands on Technology

Theraoffice

SourceMedical

TherapySource

Cedaron

Connect

OT, PT, SLP, Hand Therapy

Yes (op;onal)

Charge  Capture

McKesson, GE Centricity (IDX),  Yes Siemens (SMS), Cerner, plus  ADT and other document  repositories

Yes

Online EMR

Online EMR

OT, SLP, PT

Yes (op;onal)

Charge  Capture

Yes

Yes

The Rehab  Documenta;on  Company, Inc.

ReDoc

OT, PT, SLP

Yes

1999 1982

1995

What I want you to take away from this article is the need to carefully consider your practice needs and future planning in an effort to “right size” an EMR/EHR option for your clinic.

Training and support?

Understand the levels of support and training offered with the system you are evaluating. Will future upgrades be included, or will additional fees be required? If you are working with a cloudbased system, are updates included? When will updates be performed – in a way that will not interfere with daily activities?

Does the system provide adequate security to meet the needs of the practice and HIPAA?

Are HIPAA security requirements met by the system? Does the system provide adequate security for patient information, financials, personnel files, etc., and can additional levels of security be applied as your practice grows?

Microso) Office and HL‐7

What I want you to take away from this article is the need to carefully consider your practice needs and future planning in an effort to “right size” an EMR/EHR option for your clinic. These are the more critical considerations that will give you guidance in selecting a good robust system that will meet your needs and provide an appropriate ROI. As always, TechnoTips is written to inform interested individuals about new and relevant technology. The author of TechnoTips and/or ASHT does not recommend or endorse any of the specific products mentioned. If you have any questions or comments concerning TechnoTips, you can write to me at Hand2@aol.com. Until next time…


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Volume 19 Issue 3

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Division Updates

Education

For more information, visit: http://www. asht.org/education/upcoming-events/handsorthotics-workshop

ASHT Webinars

ASHT webinars are an opportunity to learn more about a specific area of hand therapy, pose questions to our experienced therapist instructors and participate in a learning experience from the comfort of your home computer. “Excellent webinar last night - good to be able to apply evidence based principals to exercise programs for shoulder conditioning and be able to explain it to the patient. The webinars are definitely are great learning tool. Thank you.” -Sue Clark, OTR/L To participate in a webinar, register online at: http://www.asht.org/education/webinars

Hand Therapy Review Course September 21-23 - Union Memorial Hospital, Baltimore, Md.

Whether participants Hand Therapy are looking to review Review Course the fundamentals of hand therapy or preparing for the CHT Exam, these courses examine common upper extremity diagnoses, evaluation and treatment, as well as relevant evidence in the literature. Courses for 2013 will be held in advance of the May and November CHT exams. “After participating in the Hand Therapy Review Course, I now feel confident to take the test in November. It helped give me the guidelines to study.” - Jamie Jackson

Hands on Orthotics Now scheduling for 2013

The Hands on Orthotics program is bringing orthosis fabrication lab courses to clinics around the country. You You—the the host facility—works in conjunction with the Education Division Director to select six to eight orthoses to help best meet the clinical education needs of participants. This creates a dynamic, “hands-on” experience. If your facility is interested in a customdesigned orthotics course, please contact education@asht.org for more information. Fees are based on course length and content (minimum 10 registrants).

ASHT Test Prep for the CHT Exam Book

The CHT Test Prep Book is undergoing extensive revision and is expected to be released in 2012.

Practice

With the help of volunteer writers, the Practice Division is producing printable, diagnosis-specific patient education handouts for the ASHT website. The resources are currently in a revision phase. Check the ASHT website for more information soon.

Practice Standards Commission

The commission launched its Practice Productivity Survey in July to get a census of how many patients do hand therapists treat in a week, how many initial evaluations are performed in a week, how many orthotics are fabricated in a week, how many add ons/walk-ins are seen in a week, etc. The results of the survey will be presented at the 2012 Annual Meeting in San Diego. The commission is also revision the position paper on modalities to bring it up to date with the changes that have taken place within the OT academic curriculum.

Business Practice Committee

The committee recently performed a survey of the ASHT membership to determine what resources it should produce in relation to business management of a practice. Volunteers are creating resources on operational management, financial management and marketing based on the survey results. The committee is also working on updating the Marketing Toolbox on the ASHT website — an excellent source of ideas and downloads for therapists wishing to market to referral sources and the public.

International Committee

The International Committee is working to bring more international therapists into the association, specifically by coordinating efforts with IFSHT. The committee is also expanding U.S. therapist involvement in the international community through international conferences and outreach medical missions to underdeveloped nations.

The new International Ambassador Program at this year’s annual meeting will pair international attendees and U.S. therapists to help orient them to the meeting, as well as for social and networking opportunities. The committee is also looking to provide educational opportunities to international members not attending the conference through electronic media. Additionally, the International Committee is hoping to start a “sister clinic” program in which U.S. clinics can pair up with an international clinic through the Internet to promote the formal and informal exchange of knowledge. The committee is also developing a networking system that helps therapists donate items to underdeveloped countries.

Research Journal Club

The goal of the Journal Club Chat is to facilitate critical appraisal of research design and clinical implications using a free, monthly, online chat. Please check the Journal Club Chat page for upcoming schedule information, articles of the month and the monthly access links. Monday, September 24, 9 p.m. EST “A Randomized Clinical Controlled Study Comparing the Effect of Modified Manual Edema Mobilization Treatment with Traditional Edema Technique in Patients with a Fracture of the Distal Radius” - JHT, Vol 24, Issue 3, July 2011 Presented by Beverly Bass, OTD, OTR/L, CLT “I really enjoyed the hour, and plan to (try to!) do them each month now. I work alone in a rural setting, so it is really a fun way to connect with current practice and other therapists. Another added benefit is that it’s a snap to sign up, and it’s free to ASHT members. Thanks for making it happen!” Rebecca Norton, OTR, CHT A full calendar of chats and information on how to access the Journal Club Chat can be found online at http://www.asht.org/ research/journal-club.

Annual Meeting 2012

The Research Division is looking forward to outstanding scientific sessions, poster presentations and instructional courses Continued on next page


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Volume 19 Issue 3

Division Updates Continued from previous page pertaining to research and evidence-based practice at the annual meeting this year. Division volunteers contributed to a rigorous review process that identified 18 papers and 39 posters accepted for presentation. Excellence in research design and execution will be acknowledged through the Best Scientific Paper and Outstanding Scientific Poster Awards. For more information visit: http://www.asht.org/research/researchresources. For details on attending the annual meeting visit: http://www.ashtannualmeeting.com/

Research Surveys

As a service to members of ASHT, the Research Division reviews and distributes member surveys to assist in creating evidence-based research. Once a survey has been reviewed and approved by the division, they are then distributed to assist member researchers in gathering the data needed to completing their research. If you are interested in learning more, contact the Director of Education and Research at asht@asht.org with “Research” as the subject.

Clinical Assessment Recommendations

Online formatting of the updated Clinical Assessment Recommendations text is currently in progress. Research Division volunteers and chapter authors have worked diligently under the guidance of editor Joy MacDermid to create and edit the new edition of this important reference. Stay tuned to the ASHT website for further details.

www.asht.org • ASHT Times

New CHTs Kristin E. Allen Corinne L. Allsopp Amy R. Anderson Claire H. Apple Priya Bakshi Elizabeth M. Barnaby Cindy Becker Sandra N. Beeler Amber D. Berg Lynn C. Bollinger Kristin H. Booher Phillip D. Bradley Mary Lenora Brasher Carissa l. Braun Andrea N. Britten Joselyn G. Cafun Karen B. Carmosino Kimberly A. Christensen Jennifer S. Ciotti Susan J. Clark Carol L. Cleveland Dominic S Cuchara Katie L. Curran Nicole L de Carteret Laura Jo A. De Falco Nikki DeMatteo Brian W. Donnelly Kerry A. Ebert Yvette A. Elias Jennifer Q. Farrar Melanie L. Forbes Kimberly M. Ford Peter J Franzone Cynthia A. Frazer Lianne K. Froemming Melissa L. Fry Tyrell J. Funkhouser

Paul Gatenby Koskie R. Gibson Cory J. Gilbert Mark S. Goren Brian T. Gregg Julie Fernandes Daniel W. Grolemund Komal C. Gulati Jennifer S Hamilton Cynthia L. Hayden* Caroline M. Hayes Amy D Heathfield Megan L. Henry Christine M. Herrington* Teresa M. Hnatowicz Heather K. Hopkins Alva E. Howard Melanie L. Jackson Jessica M. Jaeger Corynn W. James Sherry A. Jankuski Camerion B. Judge Kimberly N. Kelshian Dru Krischer Hanre le Roux Kirsten A. Lebo-Talusan Paul A. LeGardeur Charles Justin Lewis Meghan R. Little Miranda M. Materi Catherine E. McCutcheon Elise B. McGarva Cody B. Metropoulos Kristen E. Mitchell Kelly K. Moore Bridget L. Neubauer Leith Nicholson

Kimberlee J. O’Donald Trisha R. Ostrander Jennifer L Palmer Sejal Parikh Michael J. Parkinson Kristie M Patterson Susheel Mohan Pawtey Cory R. Pelkey Marlene Barbari Perez Sue E. Pollock Jane E. Richards Raphael D. Rios Colleen C. Ruebsamen Cheryl Y. Sailer Logan A. Sharma Kimberly M. Shurtleff Denise M. Simoneau Amy E. Sinclair Barbara L. Spraggins Ralph A. Strahler Maria L. Triana Pam E Van Atta Aaron C. Varney Christine K. Vue Vicki A. S. Webb Trisha A Whittaker Kari E B Wiese Sara L. Wilde Wen-Yau Yen JoAnn E. Zander Michele C. Beecher Carl T Brater Renee D. Ferraraccio Cassandra M. Lawless Glenn M. Lofy Lisa K. Walker


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Volume 19 Issue 3

www.asht.org • ASHT Times

Thanks to our 2012 Annual Meeting Sponsors for their generous support of ASHT*

*Sponsoring companies at time of print

Association


It’s All Happening at www.ASHT.org Member Discounts / Networking / Continuing Education Keynote Address Balancing the Art and Science of Clinical Practice Phillip S. Sizer, Jr., PT, PhD, OCS, FAAOMPT Invited Presidential Lecturer Part 1: The Anatomy and Biomechanics of Carpal Instabilities Part 2: Variable Anatomy of the Wrist and How it Helps in Understanding the ‘Dart Thrower’s’ Motion Steven Viegas, MD AAHS Sponsored Lecture How the Wide Awake Approach is Changing Hand Surgery and Therapy Don Lalonde, MD International Speaker Advantages and Disadvantages of Technology in Hand Rehabilitation Yafi Levanon, OT, PhD (Israel)

Latest Research / Legislative Updates / Practice Resources / Publications

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Online Community / Discussion Forums / Career Center / Referrals Members tell us our greatest value lies in bringing hand therapists together to solve problems, brainstorm innovations, benefit from professional development opportunities and learn from each other. Sign up for our professional development programs, pose questions through our forums, share experiences and connect with your peers at www.ASHT.org.

American Society of Hand Therapists • 15000 Commerce Pkwy, Suite C • Mount Laurel, NJ 08054 www.asht.org • 856-380-6856 • 856-439-0525 (fax) • ASHT@asht.org


ASHT Times Q3 2012