Training Appalachian, Hospital-based Occupational Therapists on the Use of Standardized, Occupation-based Outcome Measures and Treatment Concepts for Traumatic Upper Extremity Injuries: A Pilot Program

Executive Summary Background. Traumatic injuries to the upper extremity, such as crush injuries, tendon lacerations, burns, and amputations, are common and may result in missed work, decreased independence in activities of daily living, and decreased the quality of life. In urban areas, traumatic upper extremity injuries are often treated by a Certified Hand Therapist (CHT), who is an occupational or physical therapist with specialized training who has passed a national certification examination. In the Appalachian region of Kentucky, people with traumatic hand injuries are most likely to be treated in a hospital-based outpatient orthopedic setting that is primarily staffed with physical therapists who may have limited knowledge or skills in the treatment of upper extremity dysfunction. The entire region has only one known CHT, and there have been few referrals to occupational therapy. Less than half of all traumatic upper extremity injuries in this region received rehabilitation at all. Purpose. The purpose of the pilot study was to determine the current knowledge base of hospital-based occupational therapists about basic science and occupational performance skills necessary for the evaluation and treatment of traumatic upper extremity injuries. The pilot study identified if an educational program improved the therapists’ knowledge and use of functional outcome tools within a 90 day treatment period for the treatment of acute traumatic hand injuries. Theoretical Framework. The adult learning theory, Andragogy, developed by Malcolm Knowles (Knowles, 1985), emphasized self-directed learning and informal adult education. This applies well to healthcare professionals who have a need for continuing education in maintaining professional competence so was used as a guiding framework for this project. Methods. This project used a pretest/posttest research design. The participants (n=3) took a pretest and participated in an eight-hour educational program covering basic science, occupational performance treatment concepts and the utilization of standardized functional outcome tools for acute upper extremity injuries. Three standardized outcome measures typically used in hand rehabilitation were covered: The Canadian Occupational Performance Measure (COPM), the Quick Disability of the Arm, Hand, and Shoulder (QDASH), and the Global Rating of Change (Groc). Following the education session, the participants administered the three outcome tools to all patients with acute hand injuries at initial evaluation and discharge (COPM and QDASH), and fourth visit and discharge (GROC). The occupational therapy practitioners then participated in a post-test at 90 days after initial training. Results. All three therapists improved in their knowledge about the evaluation and treatment of traumatic UE injuries from pretest to posttest. The pretest indicated the therapists had minimal knowledge of the three standardized outcome measures. Only one of them indicated using two of the assessments (COPM and QDASH), and the other two reported no use of any of the assessments. All three therapists reported using all three tools after the education. At the end of 90 days, all three therapists demonstrated average COPM scores with clinically significant improvement. Two of the three therapists (Therapists 1 and 3) showed clinically acceptable QDASH scores. Because a score of 20 or less is considered good improvement per industry standard, Therapist 2 did not demonstrate good patient outcomes using the QDASH. The GROC findings revealed that Therapists 1 and 2 were able to demonstrate good patient outcomes. Therapist 3 showed that by the fourth visit, patients had actually gotten worse after occupational therapy care; however, by discharge patients had improved. Conclusions. The pilot study was limited in scope with a small sample size and patient population. The participants demonstrated a positive change in test scores and use of functional outcome measures, indicating an improved ability to treat patients with traumatic hand injuries.This pilot study will be a useful model for improving the knowledge base of occupational therapists working in the Appalachian region of Kentucky to ultimately improve the outcomes of patients with acute upper extremity injuries