narrative medicine and hand therapy: reflecting on case examples

the inter-rater and intra-rater reliabil-ity of PRIME, as well as to establishnormative values for intrinsic musclestrength in children.

Methods: With IRB approval andparental informed consent, typicallydeveloping children in local summerday camps were recruited for thestudy. Four intrinsic muscle groupswere tested in each hand: thumbpalmar abduction (APB), thumb op-position (OP), index finger abduction(first DI) and little finger abduction(hypothenar mm). We calculatedmean, standard deviation, intraclasscorrelation coefficient (ICC) andsmallest detectable difference (SDD)using SPSS software (Chicago, Ill) forinter-rater and intra-rater reliability.Regression analysis was performedfor normative values by age, gender,and hand dominance.

Results: 30 children (15 boys, 15girls), ages 7–16, participated in thestudy. ICCs ranged from 0.85 to 0.94for inter-rater reliability and 0.88–0.98for intra-rater reliability. Bland-Altman plots presented an even dis-tribution across the zero line indicat-ing minimal skew. Normative data ispresented as growth curveswith 10th,50th and 95th percentiles delineatedfor both boys and girls.

Conclusions: PRIME is a reliabletool for the quantification of intrinsichand muscle strength. Age and gen-der specific normative values in typ-ically developing children can serveas a clinical resource for clinicians.

Relevance: Intrinsic hand musclestrength is a clinically important pa-rameter for evaluation of function,surgical decision making and reha-bilitative tracking. There is a need forreliable and reproducible objectivemeasures of pediatric hand strengthin congenital, traumatic, and degen-erative neuromuscular conditions.

OBJECTIVES

1. Introduce intrinsic strengthmeasurements in children asa routine part of clinicalevaluation.

2. Establish reliability of a noveldevice for the specific purposeof measuring intrinsic handmuscle strength.

3. Provide normative values forintrinsic hand muscle strength

in typically developing chil-dren as a clinical resource foraffected populations.

DEVELOPMENTANDIMPLEMENTATION OFAHAND THERAPYEXTENDED SCOPEDIAGNOSTIC CLINICFOR BOTH ELECTIVEAND TRAUMA HANDCONDITIONS TOENHANCE PATIENTCARE

Robyn-Lee Rose, Guy’s & StThomas’ NHS Foundation Trust,United Kingdom

Purpose: A changing and compet-itive healthmarket demands the needto review existing services and de-velop new ways of working in orderto improve and maintain service de-livery. Developing the role of theextended scope practitioner (ESP)and altering patient pathwaysthrough specialist hand units is oneway service delivery can be im-proved to enhance patient care byproviding early access to a specialistopinion and investigations.

Methods: 100 General Practitioner(GP) referrals for carpal tunnelsyndrome (CTS) and firstCarpometacarpal osteoarthritis(CMC OA) were selected to attendan ESP clinic audit led by two special-ist occupational therapists for diag-nosis and implementation of aconservative treatment programme,whichwas confirmed by a consultant.The ESP clinic was audited againstkey performance indicators to evalu-ate ESP effectiveness and improve-ments in the patient pathway.

Results: The ESP can effectivelydiagnose and manage CTS and CMCOA patients without increasing thedemand for surgical opinion or pro-cedures. The ESP is also effective indiagnosing other conditions such asearly-onset Dupuytren’s disease, deQuervain’s disease, ganglions andtrigger finger. The ESP clinic has de-veloped further to include the assess-ment and management of acute wristtrauma to support Accident andEmergency in the identification andmanagement of fractures and liga-ment injuries.

Conclusions: ESP clinics have thepotential to improve the patient path-way by providing earlier access to aspecialist opinion for a diagnosis andmanagement of both trauma andelective hand conditions thereby im-proving service delivery.

Relevance: ESPs are clinical ex-perts who have demonstrated ad-vanced knowledge and skill whocan meet the needs of a changingand competitive health care marketto improve service delivery and en-hance patient care, which is in linewith global health trends.

OBJECTIVES

1. Describe the practical aspectsof developing the ESP interms of implementing a pi-lot study to determine theneed for the role, identifytraining competencies, deter-mine key performance indica-tors and obtaining ratificationfrom clinical governance toorder specialist investigationssuch as nerve conditions,blood tests and MRI scans.

2. Present the results of pilotaudited against the key perfor-mance indicators.

3. Discuss the subsequent devel-opment of the ESP role in as-sessing and managing acutewrist trauma to identify wristfractures and ligament injuriesthat have been missed in theAccident & Emergency depart-ment and the resultant positiveimpact on patient care.

NARRATIVE MEDICINEAND HAND THERAPY:REFLECTING ON CASEEXAMPLES

Cynthia Cooper, ScottsdaleHealthcare, United States ofAmericaPurpose: Evidence-based medi-

cine is the integration of best researchevidence with clinical expertise andpatient values. Incorporating patientvalues into hand therapy is accom-plished through the use of narrativemedicine. Narrative medicine is

October–December 2010 e25

practice that includes professional-ism, empathy, trustworthiness, andreflection. A narrative approach inhand therapy requires the ability toabsorb, interpret, recognize, and bemoved by patients’ stories.

Methods: This paper reviews theliterature on narrative medicine andapplies narrative themes to handtherapy intervention in order to max-imize the integration of patientvalues into clinical care. Case exam-ples will demonstrate how narrativemedicine may look like casual con-versation between the therapist andpatient, but what is occurring is ac-tually quite powerful and poignant.This paper teaches specific commu-nication techniques that elicit per-sonal and meaningful informationfrom the patient. Case examples willshow how both the patient and theprovider participate in the exchange,with the provider listening actively,providing eye contact, reflecting,avoiding interruptions, and askingopen-ended questions. Patients feellistened-to when they have opportu-nities reflect on emotional aspects ofthe upper extremity problem forwhich they were referred. The caseexamples illustrate how use of narra-tive in hand therapy improves theircare.

Results: Narrative medicineteaches us that patients’ stories arenot trivial; that hand therapistsshould treat the patient’s illness ex-perience, not just the disease or im-pairment; and that patients’ medicalhistories represent only a part of theirrelevant stories. Hand therapy caseexamples will portray a scenario foreach of these themes and the narra-tive message of these examples willbe clearly explained.

Conclusions: The medical modeladvocates that therapists maintainobjectivity and professional distance.Hand therapists need to be structure-specific in order to treat diseases andinjuries safely and accurately. But wemaximize hand therapy’s relevanceand meaning to patients by acknowl-edging and incorporating the subjec-tive aspects of their experiences andstories. The practice of narrativemedicine in hand therapy allows pa-tients’ stories to unfold so that theirhand therapy care can incorporatetheir values and thus be more per-sonalized and meaningful to them.

e26 JOURNAL OF HAND THERAPY

Relevance: Narrative medicine ex-emplifies how much richness is illu-minated in the revealing of aparticular detail. When we listen topatients’ stories, we in effect collabo-rate with them to create new lifestories. Use of a narrative approachuncovers details that reflect patientvalues, thereby contributing to thepractice of evidence-based medicinein hand therapy.

OBJECTIVES

1. Define narrative medicine as itapplies to hand therapy.

2. Identify three ways to promotestorytelling in hand therapypatients.

3. Name three open-ended ques-tions to elicit patients’ stories.

INNOVATION INPRACTICE: ONE-STOPCARPAL TUNNELCLINIC

Donna Kennedy, ImperialCollege Healthcare NHS Trust,Cathy Ball, Jagdeep Nanchahal,United Kingdom

Purpose: Carpal tunnel syndrome(CTS) is the most common compres-sion neuropathy and in the UnitedKingdom in 2000, operative treat-ment was undertaken for 31% ofnew cases. In 2008, the NationalHealth Service Improvement Planstated that no patient should waitlonger than 18 weeks from referralto hospital treatment. In response, aOne-Stop Carpal Tunnel Clinic (CTC)was developed to provide timely,quality care.

Methods: The CTC is a treatmentand research clinic, investigating theoutcomes of the management of CTS.Prior to attending, patients receivepatient information sheet and com-plete questionnaires. At the clinic, aSurgeon completes an examinationand provocative tests and HandTherapist completes evaluation andnerve conduction studies. Nerve con-duction studies are performed utilis-ing portable electrodiagnostic device.Assessment findings and nerve studyresults are reviewed, a diagnosismade, and treatment administered

on the day. The CTC is innovative;conducted bi-weekly on Saturdaymornings, accommodating patients’schedules; assessment and treatmentprovided in one appointment, mini-mising visits and delays; treatmentand research clinic; hand therapistswork in extended scope role, performnerve conduction studies

Results: Patient satisfaction withthe CTC is evaluated with a ques-tionnaire with a high degree of satis-faction reported. Clinical outcome isassessed at three months with theBoston Carpal Tunnel Questionnaire(BCTQ), and at one year with theBCTQ, Michigan Hand OutcomesMeasure (MHQ), strength and sensi-bility. The BCTQ is a disease-specificquestionnaire for evaluating symp-tom severity and functional impair-ment (Levine et al 1993). Items arerated on a scale of 1 to 5, with lowerscores implying milder symptomsand less functional impairment. Apaired-samples t-test was conductedto evaluate the impact of treatmenton BCTQ scores. In the surgery group(n 5 43) there was a statisticallysignificant decrease in symptomscores from pre-surgery (M 5 3.10,SD 5 0.98)) to 3 months postsurgery(M 5 1.99, SD 5 0.94, t (42) 5 7.73,p , .0005). There was a large effectsize for symptoms (.587) and a mod-erate effect size (.35) for function. Inthe injection group (n 5 5), there wasa decrease in symptom and functionscores but this did not approach sta-tistical significance.

Conclusions: Results of a patientsatisfaction questionnaire and theBCTQ indicate a high level of patientsatisfaction and excellent clinical out-comes at three months post-surgery.

Relevance: Evidence of the effec-tiveness of hand therapists in ex-tended scope role; Increasedunderstanding of clinical outcomerelative to pretreatment symptom se-verity; Evidence of patient satisfac-tion with innovative service.

OBJECTIVES

1. To report on and increaseawareness of innovation inpractice.

2. To report evidence of handtherapists working in an ex-tended scope fashion, with