Department of Occupational Therapy

Patient Adherence and Outcomes After Hand Therapy Home Program:

A Retrospective Pilot Study

Occupational Therapy DepartmentResearch Synthesis Project

April 7, 2011

Primary Student Investigators:

Sarah Reynolds, MOTS

Stiev Bobell, MOTS

Maelyn Legaspi, MOTS

Bhupinder Kaur, MOTS

Nadine Raymond, MOTS

Faculty & Principal Investigators:

Donna Breger Stanton, MA, OTR/L, CHT, FAOTA

Rolando Lazaro, PT, PhD, DPT, GCS

Research Team

Introduction

Emphasis on effective and efficient health care delivery

Statement of the Problem

Adherence to home exercise programs may help balance rising health care costs.

Hypothesis

The rate of adherence of persons undergoing hand therapy post wrist

fracture to their prescribed home program is less than 75%

Literature Review

Wrist Fractures

• Most common upper extremity skeletal injury (Larsen & Lauritsen, 1993)

• Commonly occurs as one (Mehta & Bain, 1999)

• Severe symptoms subside within two months (MacDermid et al., 2003)

• Minimal pain and disability remain after six months (MacDermid et al., 2003)

Treatment: Wrist Fractures

• Wide range of treatment and modality options (Maciel et al., 2004; Michlovitz, LaStayo, Alzner, & et al., 2001)

• Conservative management of wrist fractures (Maciel et al., 2004)

–Home exercise programs –Reduces healthcare costs

Home Programs May Include

• Splinting• Patient education• Functional Training• Resistive exercises• Compressive wraps• Retrograde massage• Tendon gliding exercises• Active and passive range-of-motion

exercises(Maciel et al., 2004; Michlovitz, LaStayo, Alzner, et al., 2001)

The Cost of Healthcare

0%10%20%30%40%50%60%70%80%90%

100%

1960 2007 2035 (projected)

U.S. Healthcare Spending as % of GDP(CBO, 2007)

The Rise of Healthcare Costs

$0$2,000$4,000$6,000$8,000

$10,000$12,000$14,000$16,000$18,000$20,000

1999 2009Cost of Avg Annual Family Health Insurance Policy

(CBO, 2007)

Cost Effectiveness of Home-Based Care

• Home-based care vs. hospital care• Oxygen therapy for COPD patients• 1 year of home therapy < 1 day of

hospital (Dunne, 2000)

• 3-month home-care protocol • patients with heart failure • 37% cost savings (Naylor et al., 2004)

Adherence to Home Program

• Limited research

• Improved health outcomes for wrist fractures (Lyngcoln, Taylor, Pizzari & Bakus, 2005)

• Maximizing home adherence 1. Decrease health care costs 2. Improve patient outcomes

Rate of adherence is affected by:

•Nature of injury/diagnosis

•Patients' preference of other treatments

•Patients' perception of aesthetics of adaptive equipment

•Patients' perception of inconvenience to family

(Wielandt and Strong, 2000)

Methodology

Study Design/Procedure

• Retrospective study• Analyze information that was compiled in the

past

• Procedure • IRB approval• Data received from two clinics from the San

Francisco east bay area • Files were de-identified and coded• Review of patient charts

Patient Selection

• Diagnosis of wrist fracture • distal radius or distal ulnar fx

• Currently undergoing a prescribed home program.

Inclusion Criteria • Patients s/p wrist fractures who

underwent hand therapy• may include post surgical cases,• may include treated with casting, external

fixator, or other orthosis for immobilization

• Adult men and women, 18 years or older

• Able to participate in a home program for a minimum of one week.

Exclusion Criteria

• Did not participate in a home education program

• Demonstrated inability to follow directions, per clinician report

Instrumentation

• Data Collection Summary Form (DCSF)• Included potential information that may be

generated from the data• Type of home program• Pre and post evaluation • Range of motion• Edema• Level of pain• Interventions applied

Data Collection Summary Form (DCSF)

Data Management and Analysis

Generated descriptive statistics: • Gender• Age • Hand dominance and hand injured• Time post injury• Length of treatment • Type of home program• Frequency of home program• Number of home exercises

Data Management and Analysis

• Clinical documentation was reviewed• Data was transcribed to spreadsheets

Rate of adherence to the prescribed home program was calculated by:

# of treatment sessions patient was noted to be adherent / # of potential treatment sessions

Results

Demographic Data

Prescribed Interventions for HEP

Prescribed Home Programs

Num

ber o

f Hom

e pr

ogra

ms

pres

crib

ed

Rate of Adherence in Pilot Sample

Mean Rate of adherence: 73.5%

Rate

of A

dher

ence

Patient Number

Statistical Analysis

• Wilcoxon Signed Rank Test

• Pearson Chi Square Test

• Pearson Product Correlation

The Wilcoxon Signed Rank Test ResultsMovements Measured

Initial Evaluation(Pretest)

Mean

Discharge (Posttest)

Means

Mean Posttest-

Mean Pretest(Difference)

Wilcoxon Signed

Ranked Test Score

Total Active MotionFlexion/

Extension

73.42 114.13 41.17 0.018*

Total Active Motion

Pronation/Supination

103.33 154.5 47.33 0.028*

Total Active MotionRadial

Deviation/Ulnar Deviation

20 36.67 27.33 .180

Significant at .05

Pearson’s Chi-Square Test

significant at .05

Adherence and … Pearson Chi-Square Value

Sex .776

Hand Injured .509

Pearson’s Product Correlation

Adherence rate and…Pearson Correlation

Coefficient

Number of exercises .002

Time post surgery .028

Duration of hand therapy .449

0.7 or higher show a significant correlation

Number of Home Programs and Adherence

Patients 1, 7 & 10

Patients 3 & 9

Patient 5

Patient 2 Patient 6

Patient 8

Patient 4

Discussion

Data revealed no correlation between adherence & objective measures

Data did reveal significant improvement in TAM of wrist Flexion/Extension &

Pronation/ Supination

Overall Results

Limitations to the Study

• Small sample size (n=10)• Inconsistency in chart documentation• Initial Evaluations w/ pre-measures had no follow-up or

post-measures• Unable to determine degree to which patient performed

HEP• Notes did not specify adherence to entire program or

individual exercises• No consistent protocol for recording or measuring

progress • No clinical documentation recorded of HEP technique or

graded improvement

Questions

• How does one differentiate between progress resulting from therapy within the Clinic and progress resulting from the combination of HEP & therapy within the Clinic?

• How does one differentiate adherence if patient does not perform the entire prescribed number of exercises on a daily basis?

• If multiple exercises are prescribed, will rate of adherence diminish?

Discussion/ Ideas to Explore

• Pilot study to explore factors that affect rate of adherence to a HEP

• Explore alternative methods to measure adherence to a HEP as may affect outcomes

• Example: • Control Group with Clinical Therapy only

vs. • Experimental group w/ Clinical Therapy & HEP and

HEP Tracking Form/ Calendar

Ideas for future study

Study Number Exercises HEP vs. Rate of Adherence1. Is patient adherent to entire program? 2. Use Tracking form 3. Calendar w/ tally mark system to track number exercises

completed per day4. Ensure clear and consistent documentation of HEP by

the patient – instructions in advance5. Weekly measures done at the Therapy Clinic evaluating

HEP technique and progress

Summary/Suggestions Future prospective studies to analyze:1. Weekly clinical measures taken to account for ability

to performed HEP 2. Progress in exercises with respect to Days adherent

to HEP3. Number of exercises prescribed in HEP and level or

grade of Adherence 4. Currently, patient records do not specify the degree

to which prescribed home exercises were performed.

ReferencesAlbazazz, R., Wong, Y., & Homer-Vanniasinkam, S. (2009). Complex regional pain syndrome: a

review. Annals of Vascular Surgery, 22(2), 297-306.

Breger-Stanton, D. E., Lazaro, R., & MacDermid, J. C. (2009). A systematic review of the effectiveness of contrast baths. Journal of Hand Therapy, 16, 343-346.

Congressional Budget Office. (2007). The long-term outlook for health care spending. Retrieved from http://www.cbo.gov/ftpdocs/87xx/doc8758/intro.shtml.

Dunne, P. J., (2000). The demographics and economics of long-term oxygen therapy. Respiratory Care, 45(2), 223-228.

Hardage, J., Peel, C., Morris, D., Graham, C., Brown, C., Foushee, R., & Braswell, J. (2007). Adherence to Exercise Scale for Older Patients (AESOP): A Measure for Predicting Exercise Adherence in Older Adults after Discharge from Home Health Physical Therapy. Journal of Geriatric Physical Therapy, 30(2), 69-78.

Jacobs, K., & McCormack, G. L. (2011). The occupational therapy manager, 5th ed.(pp.) Bethesda, MD: American Occupational Therapy Association NEEDS CLEANING? WHAT PAGE?CHAPTER??

Larsen, C. F., & Lauritsen J. (1993). Epidemiology of acute wrist trauma. International Journal of Epidemiology, 22(5), 911-916.

ReferencesLehmann, J. F., & DeLateur, B. J. (1990). Therapeutic heat. In J. F. Lehmann (Ed.), Therapeutic heat

and cold, 4th Ed. (p. 451). Baltimore, Md: Williams & Wilkins.

Lehmann, J. F., & DeLateur, B. J. (1990). Cryotherapy. In J. F. Lehmann (Ed.), Therapeutic heat and cold, 4th Ed. (pp. 590-628). Baltimore, Md: Williams and Wilkins.

Lehmann, J. F. & DeLateur, B. J. (1990). Application of heat and cold in the clinical setting. In J. F. Lehmann, (Ed.), Therapeutic heat and cold, 4th Ed. (pp. 633-644). Baltimore, Md: Williams & Wilkins.

Lucado, A. M., & Li, Z. (2009). Static progressive splinting to improve wrist stiffness after distal radius fracture: A prospective, case series study. Physiotherapy Theory and Practice, 25(4), 297-309.

Lyngcoln, A., Taylor, N., Pizzari, T., & Baskus, K. (2005). The relationship between adherence to hand therapy and short-term outcome after distal radius fracture. Journal of Hand Therapy, 18(1), 2-8.

MacDermid, J. C., & Stratford, P. (2004). Applying evidence on outcome measures to hand therapy. Journal of Hand Therapy, 17, 165 -173.

Maciel, J. S., Taylor, N. F., & McIlveen, C. (2005). A randomised clinical trial of activity-focused physiotherapy on patients with distal radius fractures. Orthopaedic and Trauma Surgery, 125(8), 515-520.

ReferencesMorris, N. S. (2000). Distal radius fracture in adults: Self-reported physical functioning, role

functioning, and meaning of injury. Orthopaedic Nursing, 19(4), 37-48.

Naylor, M .D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatric Society, 52(5), 675-684.

Portney, L. G., & Watkins, M. P. (2009). Exploratory research: Observational designs. In (Portnoy & Watkins, eds) Foundations of Clinical Research, Applications to Practice 3rd ed. (p. 278). Upper Saddle River, NJ:Prentice Hall.

Schneiders, A. G., Zusman, M., & Singer, K. P. (1998). Exercise therapy compliance in acute low back pain patients. Manual Therapy. 3(3), 147-152.

Taylor, E., & Humphrey, R. (1991). Survey of physical agent modality use. American Journal of Occupational Therapy, 45, 924-931.

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