Date Presented 03/28/20
Following Dupuytren’s contracture, therapists rely on clinical judgment more often than other forms of evidence, likely due to insufficient evidence. Therapists use diverse assessments based on clients’ needs. Over one-third of therapists may focus on client factors and performance skills in place of occupation-based interventions. This early evidence supports the development and investigation of evaluation and intervention protocols for persons following surgical interventions.
Primary Author and Speaker: Corey McGee
Additional Authors and Speakers: Anne Harmann
PURPOSE: There is limited literature on rehabilitation following fasciectomy (FS), needle aponeurotomy (NA), and collagenase clostridium histolyticum injection (CCH) Dupuytren’s contracture release (Sweet, S., et al., 2014; Elliot, D., 2017). A comprehensive exploration of the practice patterns of rehabilitation therapists following surgical and procedural interventions for Dupuytren’s contracture does not exist.
Study Questions: Q1) Do therapists use occupations/activity as treatment? Q2) What evidence sources do therapists use to inform their clinical practice? Q3) Do therapists use different assessments after FS, NA, and CCH? Q4) Do therapists follow different protocols after FS, NA, and CCH? and Q5) Do therapists prioritize treatment differently after FS, NA, and CCH?
DESIGN: Descriptive electronic survey research. Eligible participants were OTs or PTs, American Society of Hand Therapists (ASHT) members, and had treated clients following FS, NA, or CCH procedures within the last 8 years.
METHOD: Survey Design: Survey created after a literature review and interview of 4 OTs and 1 PT experts. A design expert was consulted for usability reasons, 5 expert therapists piloted survey and provided feedback, and the Qualtrics Survey Engine was used for delivery. Analyses: Used frequency analysis for Questions 1, 2, 3, 4 and a mixed effects linear model for Questions 5.
RESULTS: At the time of abstract submission, analysis completed on 180 surveys, 64 considered complete. 90.6% were female, 95.3% occupational therapists, 70.3% certified hand therapists. Therapists report treating patients following FS (96.9%), NA (56.3%), and CCH (65.6%). Q1: 60.3% use occupations/activity as treatment. Q2: 93.8% use clinical judgement as evidence; 42.2% use colleague opinion. Therapists use various protocols and published texts. Q3: 86.1% reported no difference in assessment use across different procedures. Therapists do not rely on a single assessment. 87.5% assess active range of motion, patient-rated function, pain, and edema. 57.7% use the Disabilities of the Arm Shoulder and Hand Questionnaire. Q4: 67.2% use published protocols after FS, 58.6% use published protocols after NA, 52.2% use publish protocols after CCH. CCH and FS protocols appear to differ least, whereas NA differed most when compared to CCH and FS. Q5. Mean number of visits following FS is 8.0, NA is 5.0 and CCH is 4.6. Therapists treat persons after FS more frequently than NA (p=.001) and CCH (p.<001). Following FS, therapists prioritize manual therapies (p=.005), wound care (p<.007), scar management (p<.007), and ADL training (p<.02) significantly higher than they do following NA and CCH.
CONCLUSION: Q1. Over 1/3 of therapists may focus on client factors and performance skills in place of occupations. Q2. Therapists primarily use clinical judgement likely due to inadequate evidence. Q3. Therapists appear to use diverse assessments based on the clients’ needs, and not the procedure Q4. More published protocols are followed for FS. Likely because it has been standard for years, and results in greater soft tissue trauma. Q5. Intervention priorities differ between FS and NA/CCH with manual therapy, wound care, scar management, and ADL training being priortized.
IMPACT STATEMENT: These preliminary findings provide early evidence to support the development and investigation of evaluation and intervention protocols for persons following surgical interventions. Future related research will include: 1) Use survey data to establish trends in protocols and staged progression of rehabilitation, 2) comparative effectiveness trials for these protocols and 3) Testing the impact of occupation/activity-based approaches.
References
Sweet, S., Blackmore, S. (2014). Surgical and therapy update on the management of Dupuytren’s disease. Journal of Hand Therapy, 27(2), 77-84. doi:10.1016/j.jht.2013.10.006
Elliot D. (2017). Treatment of Dupuytren Disease: Where Are We Now? In: Werker, PMN, Dias, J., Eaton, C., Reichert, B., Wach, W., eds. Dupuytren Disease and Related Diseases - The Cutting Edge. Cham: Springer International Publishing, 231-239. doi:10.1007/978-3-319-32199-8_32
