Non-Surgical Management of Distal Radius Fracture: A Case Study in Hand Therapy

1. Practice placement Case study presentation distal radius (DRF) fracture (#)Hand therapy department Year 2 OCT214 10529913

2. Hand therapy – non surgical management of hand disorders & physical injuries using physical methods. Motivate patient to independently exercise/ restoration of hand function. Work with MDT. Use of the Occupational therapy process [1]. Scar management. Placement setting/Role of the Occupational therapist Advice on ADLs, assist with emotional/ psychological support. Holistic, client centered practice [2][3]. [4] Return patient to meaningful participation their daily activities.  Patient appointments, clinics, group therapy sessions. Various referrals. [1] (Creek, 2003), [2] (Parker, 2011), [3] (IFSHT, 2010), [4] (Islandhandtherapy.com, 2017).

3. Person 'Betty‘ [1][2] Spiritual – 59 year old woman, divorced, admin/photographer Affective – unable to type at work, not able to drive, cannot participate in photography, low confidence, mildly anxious  Physical – right DRF (Colles’ #), stiffness in IF, MCP & radial/ulnar joint, reduced function of the wrist (limited AROM), ?Osteopenic. Occupation Self-care - showering, cooking Productivity – admin assistant Leisure - photography Environment Cultural - Western culture  Social - Roles; employed, friend, patient.              - Forms; cooking, housework, photographer.  Institutional - needing to return to work asap/not take anymore time off  Physical –difficulty using computer at work and operating her SLR camera.  Canadian Model of Occupational Therapy and Engagement Information gathering 'Betty' Occupational therapy process Is important in a physical setting to be aware of the psychological impact of a hand injury [2]. The model allowed me to keep this focus in my assessment and treatment and to give a client centered approach [1]. [1] (Polatajiko, Townsend and Craik, 2007), [2] (BAHT, 2013)

4. Incidence and prevalence • DRF are one of the most common types of fractures [1]. • DRF of the upper extremities are relatively common accounting for approximately 17% of all fractures in patients visiting A & E [2]. • Adults who suffer DRF are at increased risk of further osteoporosis related fractures and represent a high-risk group in whom therapies are available to reduce the risk [3]. • Over 20 types of fracture classification of the distal radius [4]. Causes [4] • Low-energy • High–energy Signs and symptoms [4] [5] • A broken wrist usually causes immediate pain, tenderness, bruising, and swelling. • Deformed/change of sensation in the wrist (secondary to nerve compression). Treatment [4] • Non-surgical/surgical • Followed by rehabilitation/therapy input Impact of condition on occupational engagement • Reduced ROM and strength, limiting performance. Although immobilization can facilitate healing it can affect tendon gliding ability and tenacity after just two weeks [4]. • There is a significant correlation between grip function and feeling of capability, confidence and usefulness affecting occupational performance through different stage of recovery. This highlights the importance of having a bio-psychosocial approach in practice [6]. • Early control of swelling and pain, as well as, early active motion, is of paramount importance in eliminating and preventing dysfunction [4]. [7] [7] [7] Epidemiology – DRF [7] [1] (Nellans, Kowalski, and Chung, 2012), [2] (Jung et al., 2016), [3] (Thompson, Taylor, and Dawson, 2004), [4] (Hove, Lindau, and Holmer, 2014), [5] (Skirven, Osterman, and Fedorczyk, 2011), [6] (Porter, 2013) [7] (Orthoinfo.aaos.org, 2016) [7]

5. All these polices have guided assessment/ treatment with case study.  Policies and Legislations All these help the service work towards clinical governance [12]. [1] (COT, 2015a), [2] (HCPC, 2016), [3] (NICE, 2015), [4] (Compston and Rosen, 2009), [5] (Padegimas and Osei, 2013), [6] (Hove, Lindau, and Holmer, 2014), [7] (NICE, 2014), [8] (MHRA, 2013), [9] (BAHT, 2013), [10] (XXX, 2015), [11] (XXX, 2016), [12] (McSherry and Pearce, 2011)

6. All occupational therapists should be measuring and recording outcomes [13]. [9] Clinical assessments: Goniometry used to measure the total amount of available motion at a specific joint. Goniometry can be used to measure both active and passive range of motion [1]. Goniometer enables the therapist to record AROM for a patient, enabling patient progress to be monitored. Dynamometer A quantitative and objective measure of isometric muscular strength of the hand and forearm, enables measureable outcomes to be recorded through assessments [2]. Functional assessments: Patient reported outcome measures (PROMs)[3] - result in a renewed focus on client centred care and holistic evaluation [4]. • QDASH self-report questionnaire designed to measure physical function and symptoms in patients with any or several musculoskeletal disorders of the upper limb [5]. It has the ability to detect clinically meaningful change in status, an outcome measure with longitude validity [6]. • Oxford Pain scoring to assess function and pain [7]. [10] Outcome and outcome measures [11] [12] [1] (Dutton, 2012), [2] (Skirven, Osterman, and Fedorczyk, 2011), [3] (COT, 2010), [4] (Cooper, 2013), [5] (Kennedy et al., 2011), [6] (Whalley and Adams, 2009), [7] (Brook, Connell and Pickering, 2011), [8] (Porter, 2013), [9] (Anon, 2016), [10] (Topendsports.com, 2016), [11] (Measure and Health, 2016), [12] (Amazon.com, 2016), [13] (COT, 2015b). The results highlight the importance of using a combination of functional assessment and questionnaires in order to address complexity, acquiring a more complete picture of limitations following a DRF [8].

7. Assessment and frames of reference Verbal consent from patient gained throughout assessment and intervention. Occupational therapy process [1] (Supyk-Mellson and McKenna, 2010).

8. Client centred approach [1]. SMART Aims and objectives • OT process influenced by patient aim [1] (Parker, 2011).

9. Remedial approach [4]. Intervention, approaches and implementation • Each intervention used addresses the affective and physical aspects of the Canadian Model of Occupational Therapy and Engagement (CMOP-e) model that has been used to guide the OT process as although its remedial based the interventions are linked to occupation and reengagement with function and occupation, enhancing mood. [1] (MHRA, 2013), [2] (Lannin and Novak, 2010), [3] (Hove, Lindau, and Holmer, 2014), [4] (Curtin, 2010).

10. Contextualisation into everyday activities. • ‘Betty’s’ Hand Class Programme • Warm up • Water and ball • 10 minutes to warm hand up. • Powerweb • Colour graded webs for flexion and extension, finger strength and dexterity exercises. • Finger dexterity and power needed for typing and pressing camera buttons. • Span game • To encourage pronation/supination. • Required for holding and positioning camera. • CPM (continuous passive movement) Machine • Controlled flex./ext. and pro./sup. • Required to get camera out of case. • Table top exercises • Moving paper/cloth etc. in radial and ulnar deviation. • Required for taking lens off/refocusing camera. Intervention links to aspects of the model as it address both the physical and psychosocial aspects. [4] • Although the therapist sets the hand therapy programme, client centred approach as patient can chose which exercises to do/lead their own rehabilitation Patient asked to complete QDASH outcome measure at beginning and end of attendance – evaluates the patient experience and assessment of their perceived functional ability [1]. Group intervention – Hand class • Specific exercises focused around enabling patient to achieve her aims and objectives of increased range of movement and function in order to be able to reengage with chosen occupations. Occupational therapy process All activities can be graded • Patient not only had significant improvement with her ROM but the group changed her attitude towards her injury and recovery, appeared to be less anxious and became compliant with her home exercises. All leading to improved outcomes [2]. [3] [1] (Whalley and Adams, 2009), [2] (Bamford and Walker, 2010), [3] (Exerciser  , 2016), [4](Kokaspeles.lv, 2017). .

11. Pre-intervention End of intervention Right hand Goniometry Wrist Flex/Ext 26/16 RD/UD 6/16 Pro/Sup 90/20 Dynamometer Right – flicker Left – 14kg Functional assessment:- QDASH – 63.63 OxfordPain scoring - 7/10  Right hand GoniometryWrist Flex/Ext 36/24 DynamometerRight - 2kg Left – 20kg Functional assessment:- QDASH– 35 ‘Everything takes longer’ Oxford Pain scoring - 5/10 Outcomes of interventions Is ‘Betty’ better???  Occupational therapy process

12. At this current time the case study therapeutic input still continues. • The patient will be regularly reviewed to determine how long she needs to attend hand class. • Following a distal radius # rehabilitation can take 6-12 months to optimise outcomes [1] [2]. • End of intervention End of intervention, discharge • Highlight further implications associated with/after obtaining a DRF to patient • prevention of falling is better than cure [1]. • NICE guidelines for Osteoporosis [3] – If the fracture is thought to be a fragility fracture, guidelines recommend FRAX [4] the WHO fracture risk assessment tool predicts an individual’s risk of fracture, providing general clinical guidance for treatment decisions. • Secondary osteoarthritis typically develops after a DRF, follow NICE guidelines for diagnosis of Osteoarthritis [5] and treat/advise accordingly. • Patient safety advice/education on discharge/risk factors Occupational therapy process [1] (Hove, Lindau, and Holmer, 2014), [2] Porter, 2013), [3] ] (NICE, 2015), [4] (Kanis et al., 2008), [5] ] (NICE, 2014).

13. Was I client centred? • Led by patient • Took into consideration patient’s wants and needs when considering intervention and desired outcomes. • If there anything you would have done or could have done differently to improve patient outcomes? • Asked patient to complete home exercises sheet to monitor frequency of completion – ‘Betty’ clearly said she had not been completing exercises at home. • Why did use CMOP-e? • Enables positive collaborative approach [1] [2]. • Focuses on occupational performance, need and engagement [1] [2]. • CMOP-E arguably emphasizes the importance of the person more than PEOP model [3]. • Although may not be suitable for clients with cognitive dysfunction [1]. • Why did I pick the case study? • Patient and injury/occupational disruption typical to placement setting. Case study review Occupational therapy process [1] (Clarke, 2003), [2] (Fawcett, 2007), [3] (Wong and Fisher, 2015).

14. Evaluation of placement

15. Amazon.com. (2016). Oxford Handbook of Pain Management (Oxford Medical Handbooks): 9780199298143: Medicine & Health Science Books @ Amazon.com. [online] Available at: https://www.amazon.com/Oxford-Handbook-Management-Medical-Handbooks/dp/0199298149 (Accessed 11 December 2016). • Anon, (2016). [online] Available at: https://www.researchgate.net/figure/233737120_fig4_Fig-4-Wrist-extension-and-flexion-ROM-measured-with-goniometer-from-ulnar-side (Accessed 11 December 2016). • Bamford, R. and Walker, D. (2010). ‘A qualitative investigation into the rehabilitation experience of patients following wrist fracture’, Hand Therapy, 15(3), pp. 54–61. doi: 10.1258/ht.2010.010013. • British Association of Hand Therapy (BAHT) (2013). Hand therapy audit guidelines for clinical practice. [Online] Available at: http://www.hand-therapy.co.uk/ (Accessed 10 December 2016). • Brook, P., Connell, J. and Pickering, T. (2011). Oxford handbook of pain management. Oxford ; New York, NY : Oxford University Press. • Clarke, C. (2003). ‘Clinical Application of the Canadian Model of Occupational Performance in a Forensic Rehabilitation Hostel’.The British Journal of Occupational Therapy, 66(4), pp. 171-174. doi: 10.1177/030802260306600407. • College of Occupational Therapists [COT], (2010). The importance of outcome measures. [Online] Available at: http://www.slideshare.net/baotcot/the-importance-ofmeasuringoutcomes (Accessed 4 December 2016). • College of Occupational Therapists (COT) (2011). Professional standards for occupational therapy [Online] Available at: https://www.cot.co.uk/standards-ethics/capability-competence-and-lifelong-learning (Accessed 25 November 2016). • College of Occupational Therapists (COT) (2015a). Code of ethics and professional conduct. London: COT. • College of Occupational Therapists (COT) (2015b). Measuring Outcomes [Online] Available at: file:///C:/Users/cdone/Downloads/Research-Briefing-Measuring-Outcomes-Nov2015.pdf (Accessed 25 November 2016). • Compston, J. E. and Rosen, C. J. (2009). Fast facts: Osteoporosis (6thEdn.) United Kingdom: Health Press. • Cooper, C. (2013).Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity. 2nd edn. Philadelphia, PA, United States: Mosby. References

16. Creek, J. (2003). Occupational therapy defined as a complex intervention. COT: London. [Onlne]. At https://www.cot.co.uk/publication/publications/occupational-therapy-defined-complex-intervention (Accessed 4 January 2017). • Curtin, M, (2010). ‘Enabling skills and strategies’ in: Curtin, M. (Ed.), Molineux, M. (Ed.), Supyk-Mellson, J. (Ed.) Occupational Therapy and Physical Dysfunction Enabling Occupational Therapy (6thEdn.) Edinburgh: ChurchillLivingstone/Elsevier. pp. 111-125. • Dutton, M. (2012).Dutton’s Orthopaedic examination evaluation and intervention (3rd edn.) New York: McGraw Hill Medical. • Exerciser  , F. (2016). Finger Fitness Power Web Jr. Hand Exerciser. [online] Musician's Friend. Available at: http://www.musiciansfriend.com/accessories/finger-fitness-power-web-jr.-hand-exerciser (Accessed 11 Dec. 2016). • Fawcett, A. (2007).Principles of assessment and outcome measurement for occupational therapists and physiotherapists. Chichester, England: John Wiley & Sons. • Handoll, H. and Elliot, J. (2015). Rehabilitation for distal radial fractures in adults [Online] Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003324.pub3/full (Accessed 4 December 2016). • Healthcare Professionals Council (HCPC) (2016). Standards of conduct, performance and ethics [Online] Available at: http://www.hcpc-uk.org/publications/standards/index.asp?id=38 (Accessed 4 December 2016). • Hove, L.M., Lindau, T. and Holmer, P. (eds.) (2014).Distal radius fractures: Current concepts. Germany: Springer-Verlag Berlin and Heidelberg GmbH & Co. K. • International Federation of Societies for Hand Therapy (IFSHT) (2010). IFSHT Hand therapy practice profile [Online] Available at: http://www.hand-therapy.co.uk/index.php?option=com_content&view=article&id=123&Itemid=104 (Accessed 5 January 2017). • Islandhandtherapy.com. (2017). Island Hand Therapy Clinic: Hand Therapy, Occupational Therapy and Physiotherapy in Victoria British Columbia. [online] Available at: http://www.islandhandtherapy.com/ [Accessed 6 Jan. 2017]. • Jung, H.J., Park, H.Y., Kim, J.S., Yoon, J.-O. and Jeon, I.-H. (2016). ‘Bone mineral density and prevalence of osteoporosis in Postmenopausal Korean women with low-energy distal radius fractures’, Journal of Korean Medical Science, 31(6), p. 972. doi: 10.3346/jkms.2016.31.6.972. • Kanis, J., Johnell, O., Oden, A., Johansson, H. and McCloskey, E. (2008). FRAX™ and the assessment of fracture probability in men and women from the UK. Osteoporosis International, 19(4), pp.385-397. • Kennedy, C. A., Beaton, D. E., Solway, S., McConnell, S., and Bombardier, C. (2011). The DASH outcome measure user’s manual. (3rd ed.) Toronto: Institute for Work & Health. References

17. Kokaspeles.lv. (2017). Handmade Wooden Toys: The tower of Hanoi. [online] Available at: http://kokaspeles.lv/en/categories/logics/the-tower-of-hanoi (Accessed 4 January 2017). • Lannin, N. and Novak, I. (2010). ‘Orthotics for occupational outcomes’ in: Curtin, M. (Ed.), Molineux, M. (Ed.), Supyk-Mellson, J. (Ed.) Occupational Therapy and Physical Dysfunction Enabling Occupational Therapy (6thEdn.) Edinburgh: ChurchillLivingstone/Elsevier. pp. 507-526. • McSherry, R. and Pearce, P. (2011). Clinical Governance. 1st ed. Hoboken: John Wiley & Sons. • Measure, D. and Health, I. (2016). DASH Outcome Measure on the App Store. [online] App Store. Available at: https://itunes.apple.com/us/app/dash-outcome-measure/id656696682?mt=8 (Accessed 11 December 2016). • Medicines and Healthcare products Regulatory Agency (MHRA) (2013). Custom made medical devices [Online] Available at: https://www.gov.uk/government/publications/custom-made-medical-devices (Accessed 4 December 2016). • National Institution of Care Excellence (NICE) (2014). Osteoarthritis: Care and management [Online] Available at: https://www.nice.org.uk/guidance/cg177/chapter/1-recommendations (Accessed 4 December 2016). • National Institution of Care Excellence (NICE) (2015). Osteoporosis: assessing the risk of fragility fracture [Online] Available at: https://www.nice.org.uk/researchrecommendation/frax-and-qfracture-in-adults-with-secondary-causes-of-osteoporosis-what-is-the-utility-of-frax-and-qfracture-in-detecting-risk-of-fragility-fracture-in-adults-with-secondary-causes-of-osteoporosis (Accessed 4 December 2016). • Nellans, K.W., Kowalski, E. and Chung, K.C. (2012). ‘The Epidemiology of distal radius fractures’, Hand Clinics, 28(2), pp. 113–125. doi: 10.1016/j.hcl.2012.02.001. • Orthoinfo.aaos.org. (2016). Distal Radius Fractures (Broken Wrist)-OrthoInfo - AAOS. [online] Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00412 (Accessed 11 Dec. 2016). • Padegimas, E.M. and Osei, D.A. (2013). ‘Evaluation and treatment of osetoporotic distal radius fracture in the elderly patient’, Current Reviews in Musculoskeletal Medicine, 6(1), pp. 41–46. doi: 10.1007/s12178-012-9153-8. References

18. Parker, D. M. (2011). ‘The client centred frame of reference’ in Duncan, E.A.S., (ed.) Foundations for practice in occupational therapy. Bookshelf [Online]. Available at: https://bookshelf.vitalsource.com/#/books/9780702046612/cfi/6/6[;vnd.vst.idref=B978-0-7020-3232-5.00026-8]!/4/2[B978-0-7020-3232-5.00026-8] (Accessed 4 December 2016). • Polatajiko, H. J., Townsend, E. A. and Craik, J. (2007). Canadian Model of Occupational Performance and Engagement (CMOP-E) in Townsend, E. A. and Polatajiko, H. J. (Eds.) Enabling occupation II: Advancing and occupational therapy vision of health, wellbeing & justice through occupation. Ottawa, ON: CAOT Publications ACE. Pp. 22-36. • Porter, S. (2013). ‘Occupational performance and grip function following distal radius fracture: A longitudinal study over a six-month period’, Hand Therapy, 18(4), pp. 118–128. doi: 10.1177/1758998313512280. • Skirven, T.M., Osterman, L.A. and Fedorczyk, J. (2011).Rehabilitation of the hand and upper extremity, 2-Volume set: Expert consult: Online and print. 6th edn. Philadelphia, PA: Elsevier Science Health Science div. • Supyk-Mellson, J. and McKenna, J. (2010). ‘Understanding models of practice’ ’ in: Curtin, M. (Ed.), Molineux, M. (Ed.), Supyk-Mellson, J. (Ed.) Occupational Therapy and Physical Dysfunction Enabling Occupational Therapy (6thEdn.) Edinburgh: ChurchillLivingstone/Elsevier. pp. 67-79. • Thompson, P.W., Taylor, J. and Dawson, A. (2004). ‘The annual incidence and seasonal variation of fractures of the distal radius in men and women over 25 years in Dorset, UK’, Injury, 35(5), pp. 462–466. doi: 10.1016/s0020-1383(03)00117-7. • Topendsports.com. (2016).About Handgrip Dynamometers. [online] Available at: http://www.topendsports.com/testing/products/grip-dynamometer/ (Accessed 11 Dec. 2016). • Whalley, K. and Adams, J. (2009). ‘The longitudinal validity of the quick and full version of the disability of the arm shoulder and hand questionnaire in musculoskeletal hand outpatients’, Hand Therapy, 14(1), pp. 22–25. doi: 10.1258/ht.2009.009003. • Wong, S. and Fisher, G. (2015). Comparing and Using Occupation-Focused Models. Occupational Therapy In Health Care, 29(3), pp.297-315. • XXX (2015). Infection Prevention & Control Policy. [Online] Available at: https://xxxxxxxxxxxxxx/a-z/infection-control/infection-control-documents/?opentab=1 (Accessed 10 December 2016). • XXX (2016). Consent for Examination or Treatment Policy. [Online] Available at: https://xxxxxxxxxxxxxx/easysiteweb/getresource.axd?assetid=3077&type=0&servicetype=1 (Accessed 10 December 2016). References

19. Any questions??