An occupation-based intervention in patients with hand-related disorders grouped using the sense of coherence scale-A randomized controlled trial.

STUDY DESIGN: A nonblinded randomized controlled trial. INTRODUCTION: Occupation-based interventions are superior to physical exercise-based interventions in patients with activity limitations. However, only a few studies have examined the effect in patients with hand-related disorders. Patients recover heterogeneously, which could be due to personal factors, such as sense of coherence (SOC). PURPOSE OF THE STUDY: To investigate the effectiveness of an occupation-based intervention for patients with hand-related disorders and whether SOC can give an indication of the expected effects. METHODS: A total of 504 patients were stratified into three SOC groups and then randomized to either an occupation-based intervention, including physical exercises (OBI) or a physical exercise-based occupation-focused intervention. The primary outcome, functioning, was measured using the Disability of the Arm, Shoulder and Hand questionnaire. Primary endpoint was at three months. Patients were followed up for a year. RESULTS: No significant difference was found in primary outcome analysis. Nevertheless, patients receiving OBI had a statistically significant and greater change in satisfaction with their occupational performance at one, two, and three months follow-up. Patients with a weak SOC had worse functioning and lower health-related quality of life than those in the other groups, at all times. CONCLUSIONS: OBI as delivered in this study was not superior to physical exercise-based occupation-focused intervention in this patient group. However, in taking a client-centered approach, we recommend that OBI be based on individual needs, given that patients had a statistically greater change in score regarding satisfaction with their occupational performance. It is evident that patients with a weaker SOC have a lower level of functioning. This knowledge should inform clinical practice.

Client-centred practice from the perspective of Danish patients with hand-related disorders.

PURPOSE: The objectives of this study were to investigate perceptions of client-centred practice among Danish patients with hand-related disorders engaged in rehabilitation at outpatient clinics, and to decide on domains to serve as a conceptual foundation for item generation in the development of a new, standardized questionnaire to evaluate the experience of client-centredness among patients with hand-related disorders. METHOD: Focus group interviews were held with 25 patients with hand-related disorders from six outpatient hand clinics in Denmark. Deductive content analysis was used to decide on domains for item generation. RESULTS: Patients found that information was paramount in understanding their situation and to feel empowered and motivated. They attached importance to participation in decision making so that rehabilitation was considered meaningful. Moreover, they thought rehabilitation should be individualized by taking their life situations and personalities into account. Six domains were found to be central to client-centred practice: patient participation in decision making, client-centred education, evaluation of outcomes from patient's perspective, emotional support, cooperation and coordination, and enabling occupation. CONCLUSIONS: The domains can be used in the further development of a Danish questionnaire to evaluate the experiences of client-centredness among patients engaged in rehabilitation at outpatient clinics for hand-related disorders. Implications for rehabilitation Patients with hand-related disorders wish for rehabilitation to be tailored to individual needs. The patient's life situation and personality, including coping ability, are important factors to consider in rehabilitation planning, interventions, and evaluations. Patients with hand-related disorders attach importance to information and require health professionals' support to manage their activities of everyday life. Patients with hand-related disorders ask for participation and shared decision making in rehabilitation planning.

Test-retest reliability of Antonovsky's 13-item sense of coherence scale in patients with hand-related disorders.

PURPOSE: To report on the distribution and test-retest reliability of Antonovsky's 13-item Sense of Coherence (SOC-13) Scale in patients with hand-related disorders (HRD). Links between the SOC-13 score and factors such as age, number of days between date of injury and start of rehabilitation, gender and educational level were explored. METHOD: Survey with test-retest, using self-administered questionnaire. SOC-13 was completed before starting rehabilitation at an outpatient clinic after 14 days and three months. Adult patients with HRD were included. RESULTS: A total of 170 participants completed the SOC-13 at baseline (median SOC 71, range 30-91). The Intra-class Correlation Coefficient between baseline and 14 days was 0.84 (n = 151), and baseline and three months was 0.79 (n = 113). Weak correlations were found between SOC and age rs = 0.17, p < 0.03. No correlation was found between SOC and number of days since injury rs = 0.01, p > 0.92. No difference was found in SOC score related to gender or educational level. CONCLUSIONS: The SOC-13 scale showed reliability for patients with HRD. There was a weak connection between age and SOC without clinical relevance. SOC-13 has the potential to be a powerful tool to measure the ICF component personal factors, which could have an impact on patients' rehabilitation outcomes. Implications for rehabilitation Antonovsky's SOC-13 scale showed test-retest reliability for patients with hand-related disorders. The SOC-13 scale could be a suitable tool to help measure personal factors.

Health-related quality of life 5 years after carpal tunnel release among patients with diabetes: a prospective study with matched controls.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy encountered in diabetes. The short-term improvement after carpal tunnel release has previously been demonstrated not to differ between patients with and without diabetes, despite a marked impairment in health-related quality of life (HRQL) among the former. In this study, we compare HRQL 5 years after carpal tunnel release between these two groups of patients. METHODS: In a prospective series, 35 patients with diabetes and CTS were matched with 31 control patients with idiopathic CTS but no diabetes. At the 5-year follow-up patients completed the Medical Outcomes Short-Form 36 (SF-36) and Antonovsky's sense of coherence (SOC) questionnaire. Differences in changes over time were compared between patients with and without diabetes using mixed model analysis. RESULTS: Although patients with diabetes reported a significant decrease in physical functioning (p =0.004) as compared to patients without diabetes, postoperative improvement was maintained in the physical domains, role physical and bodily pain. A more pronounced decline in the mental health domain, social function (p =0.03), was demonstrated among patients with diabetes. There was no evidence of any difference in SOC between the patient groups. CONCLUSION: Patients with diabetes retained their improvement in physical domains sensitive to changes after carpal tunnel release in the long-term, despite a decline in other domains of both physical and mental HRQL. This differed from patients without diabetes. Differences in SOC could not explain the sharper decline in these domains among patients with diabetes.

Linguistic validation and cultural adaptation of an English version of the evaluation of daily activity questionnaire in rheumatoid arthritis.

BACKGROUND: To linguistically validate and culturally adapt the Evaluation of Daily Activity Questionnaire (EDAQ) for use in rheumatoid arthritis (RA) from Swedish to British English. The EDAQ is a patient reported outcome measure of daily activity ability. It includes 11 activity domains (Eating and Drinking; Personal Care; Dressing; Bathing; Cooking; Moving Indoors; House Cleaning; Laundry; Moving and Transfers; Communication; Moving Outdoors) and was developed for use in rheumatoid arthritis (RA). METHODS: The EDAQ was translated from Swedish to English using standard methods. Activity diaries, cognitive debriefing interviews and focus groups were completed with people with RA to: generate new culturally applicable items; identify important items in the Swedish version to retain in the English version; and develop the English EDAQ based on their views of content and layout. Content validity was established by linking the EDAQ to the International Classification of Functioning RA Core Set. RESULTS: The English EDAQ translation was harmonized with the Swedish version to ensure equivalence of meaning. Sixty-one people with RA participated. 156 activities were identified from 31 activity diaries and included in a draft English EDAQ. Following interviews (n = 20) and four focus groups, 138 activities were retained and three additional domains added (Gardening/Household Maintenance; Caring; and Leisure/Social Activities). Most ICF RA Core Set activities are in the EDAQ. CONCLUSIONS: The English EDAQ is a detailed self-report measure of ability in RA with good content validity.

Carpal tunnel release in patients with diabetes: a 5-year follow-up with matched controls.

PURPOSE: To compare clinical outcomes 5 years after carpal tunnel release among patients with and without diabetes. METHODS: In a prospective consecutive series, 35 patients with diabetes (median age, 54 y; 15 type 1 and 20 type 2 diabetes) with carpal tunnel syndrome were age- and sex-matched with 31 control patients without diabetes (median age, 51 y) with idiopathic carpal tunnel syndrome. Exclusion criteria were other nerve entrapment, cervical radiculopathy, inflammatory joint disease, thyroid disorder, previous wrist fracture, and long-term exposure to vibrating tools. Participants were examined independently at baseline, 1 year, and 5 years after surgery for sensory function (Semmes-Weinstein), motor function (abductor pollicis brevis muscle strength and grip strength), cold intolerance, and completion of the Boston Carpal Tunnel Questionnaire symptom severity and functional status score. RESULTS: Five years after surgery, the overall attendance rate for clinical examinations and completion of the Boston Carpal Tunnel Questionnaire were 86% and 95%, respectively. Between 1 and 5 years after surgery, there was a tendency toward a decrease in sensory function but an increase in motor function, with no statistically significant difference between groups. Cold intolerance demonstrated long-term significant improvement for patients with diabetes. The improvement in symptom severity and functional status score, as well as the large effect size, were maintained at 5 years in both patient groups. CONCLUSIONS: Long-term improvement in patients with diabetes remained after carpal tunnel release to the same extent as for patients without diabetes. Furthermore, improvement in cold intolerance in patients with diabetes suggests the potential for the long-term regeneration of small nerve fibers. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

Costs and outcome for serious hand and arm injuries during the first year after trauma - a prospective study.

BACKGROUND: To study costs and outcome for serious hand and arm injuries during the first year after the trauma. METHODS: In patients with a Hand Injury Severity Score (HISS) > 50, DASH and EQ-5D scores as well as factors related to costs within the health care sector, costs due to lost production and total costs were evaluated. Cox-regression analysis stratifying for mechanism of injury was used to analyse return to work. RESULTS: The majority of the 45 included patients (median 42 years 16-64) were men with severe (n = 9) or major (n = 36) injuries with different type of injuries (amputations n = 13; complex injuries n = 18; major nerve injuries/full house n = 13; burn injury n = 1). DASH and EQ-5D decreased and increased, respectively, significantly over time during one year. Total costs (+34%) and costs of lost production were highest for persons injured at work. Factors associated with higher health care costs were age >50 years (+52%), injury at work (+40%) and partial labour market activity (+66%). Costs of lost production had a significant role in total costs of injury. Patients with major injuries had longer duration of sick leave. Patients with severe injuries were more likely to return to work [(RR 3.76 (95% CI 1.38-10.22) from Cox regression, controlling for age, gender and presence of nerve injury]. CONCLUSIONS: Despite the fact that work environments have constantly improved over the last decades, we found that hand injuries at work were most costly both in terms of health care and costs of lost production, although the severity, i.e. HISS, did not differ from injuries occurring at home or during leisure.

Return to work after a serious hand injury.

OBJECTIVES: This paper explores factors important for return to work (RTW) in people who have sustained a serious hand injury. PARTICIPANTS: Forty people aged 19-64, with a severe or major hand injury were recruited consecutively during 2005-2007. METHODS: A self-administered and study specific questionnaire, including demographic data and standardised questionnaires for function, disability, daily occupations, health, quality of life, sense of coherence and several open questions was sent out by mail twelve months after injury. Open questions regarding RTW were also included. RESULTS: The results showed that 27 people had returned to work within twelve months and 13 had not. Factors related to RTW and general work motivations were divided into individual factors, and factors related to the work environment and rehabilitation. The most prominent differences between the groups were individual factors, such as higher perceived disability, reduced hand function, and dissatisfaction with daily occupations resulting in a lower physical quality of life. The no RTW group had also more ward days (inpatient care) and lower sense of coherence. CONCLUSIONS: These findings support the idea that the RTW process can be more dependent on the person's own ability and motivation than on the severity of the hand injury. Suggestions for intervention and further studies are presented in the discussion.

Activity limitations before and after surgical carpal tunnel release among patients with and without diabetes.

OBJECTIVES: To evaluate activity limitations before and after carpal tunnel release among patients with and without diabetes, to explore differences between genders and the influence of grip strength on activity limitations. DESIGN: Prospective case-control study. PATIENTS: Thirty-three patients with diabetes and carpal tunnel syndrome (CTS) were age and gender matched with 30 patients without diabetes having idiopathic CTS. METHODS: Activity limitations were assessed pre-operatively, 3 and 12 months after surgery, with the self-administered Evaluation of Daily Activities Questionnaire (EDAQ) containing 102 activity items in 11 dimensions and 3 additional male-activity-oriented dimensions including 22 items. RESULTS: For all dimensions the mean score was higher for patients with diabetes compared with patients without diabetes. This indicates a more pronounced activity limitation for patients with diabetes. However, no statistical differences between the two groups could be demonstrated. In general, females have significantly higher activity limitation scores than males. CONCLUSION: CTS creates a broad variety of activity limitations for affected patients. After carpal tunnel release a significant alleviation of these limitations occurs within the first 3 months. Activity limitations seem not to be related to diabetes, but were more pronounced in women than in men, probably due to reduced grip strength.

Outcome and clinical changes in patients 3, 6, 12 months after a severe or major hand injury--can sense of coherence be an indicator for rehabilitation focus?

BACKGROUND: Our objective was to explore outcome and clinical changes in hand function, satisfaction in daily occupations, sleep disturbances, health and quality of life in consecutive patients after a severe or major hand injury. Our objective was also to investigate possible differences between groups according to severity of injury, presence of peripheral nerve injury and the patients' sense of coherence. METHODS: A postal questionnaire, including demographic data, disabilities of the arm, shoulder and hand (DASH), QoL (SF-36), EuroQol (EQ-5D VAS), hand function (VAS), satisfaction in daily occupation (SDO), was sent out 3, 6 and 12 months after injury to 45 consecutive patients with a severe or major hand injury. Sense of coherence (SOC) was evaluated at 6 months. For the descriptive study, non-parametric tests were used since almost all results were measured with ordinal scales, the study sample was small, and most variables not normally distributed. RESULTS: Almost all self-assessed aspects of hand function, satisfaction in daily occupations, health (DASH), and physical QoL (SF-36) improved statistically for the whole group over time. Large clinical improvement was seen for physical QoL and health, while a low or no improvement was observed for mental QoL, and cold sensitivity. Few differences were found between participants with a severe or major of hand injury or with or without a major nerve injury. No significant differences in demographic data were observed between participants with high or low SOC, but participants with low SOC showed significantly lower satisfaction in daily occupations, higher DASH scores, lower mental QoL, more sleep disturbances, and bodily pain. Correlation was found between SOC, and QoL, health and satisfaction in daily occupations. CONCLUSIONS: SOC had a significant influence on patients with a severe or major traumatic hand injury. Patients with lower SOC would probably benefit from extra support and help to master their daily life, indicating that sense of coherence is an indicator for future rehabilitation focus.

Coping strategies in daily occupations 3 months after a severe or major hand injury.

Coping strategies used in performing daily occupations 3 months after a severe or major hand injury were explored. A semi-structured interview was performed with 13 participants with hand injuries based on Hand Injury Severity Scoring System and analysed using content analysis. Six groups of strategies were identified: 'Changing performance of daily occupations', 'Actively processing trauma experience', 'Changing occupational patterns', 'Receiving assistance', 'Using emotional strategies' and 'Keeping up a social network'. The problem- and emotional-solving strategies identified in this study can be used to support other patients early in rehabilitation. Patients with few coping strategies should be recognized. Information and practical handouts to patients, therapists and relatives should stimulate and help patients with hand problems enabling in meaningful occupations and preventing unnecessary stress. Furthermore, social support should be encouraged and family should be actively involved in rehabilitation. To insure trustworthiness, member checks were used on four randomly selected participants, but could possibly be used with all participants. Further research is needed in a longitudinal study to explore which coping strategies or adaptation patients use to perform daily occupations at a later stage.

Clinical outcomes of surgical release among diabetic patients with carpal tunnel syndrome: prospective follow-up with matched controls.

PURPOSE: To compare the clinical outcome after carpal tunnel release in diabetic and nondiabetic patients. METHODS: We evaluated a prospective, consecutive series of 35 diabetic patients (median age, 54 years; 15 with type 1 and 20 with type 2 diabetes) with carpal tunnel syndrome, who were age- and gender-matched with 31 nondiabetic patients (median age, 51 years) having idiopathic carpal tunnel syndrome. Exclusion criteria were other focal nerve entrapments, cervical radiculopathy, inflammatory joint disease, renal failure, thyroid disorders, previous wrist fracture, and long-term exposure to vibrating tools. Participants were examined independently at baseline (preoperatively) and 6, 12, and 52 weeks after surgery, including evaluating sensory function (Semmes-Weinstein), motor function (abductor pollicis brevis muscle strength and grip strength), pillar pain, cold intolerance, and patient satisfaction. RESULTS: The number of patients with normal sensory function (pulp of index finger) increased notably in both patient groups from baseline (diabetic patients, 7 of 35; nondiabetic patients, 10 of 31) compared with the 52-week follow-up (diabetic patients, 25 of 35; nondiabetic patients, 24 of 31). Grip strength decreased temporarily at 6 weeks but recovered completely after 12 weeks. At the 52-week follow-up, mean grip strength (95% confidence interval) had improved significantly in both patient groups (diabetic patients: 3.0 kg [-0.3 to 6.2], nondiabetic patients: 3.4 kg [0.2 to 6.6]). Pillar pain correlated significantly with grip strength at the 6-week follow-up (r(s) = -0.41 to -0.54 [p < .05]). The number of patients reporting cold intolerance decreased over time (diabetic patients, 22 of 35 to 19 of 35; nondiabetic patients, 18 of 31 to 8 of 31), but decreased markedly less for the diabetic patients. Level of patient satisfaction was equal between groups. Comparing type 1 and type 2 diabetic patients, no important difference was noted on any test variables. CONCLUSIONS: Patients with diabetes have the same beneficial outcome after carpal tunnel release as nondiabetic patients. Only cold intolerance demonstrated a lesser extent of relief for diabetic patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

Hand disorders, hand function, and activities of daily living in elderly men with type 2 diabetes.

AIMS/HYPOTHESIS: This study aimed to examine hand disorders, symptoms, overall hand function, activities of daily living (ADLs), and life satisfaction in elderly men with type 2 diabetes mellitus (DM), impaired glucose tolerance (IGT), and normal glucose tolerance (NGT). METHODS: Subjects were interviewed and evaluated with a battery of clinical and laboratory tests, including hand assessment, and a questionnaire. RESULTS: HbA1c differed between groups (highest in DM, especially in long-term DM). Limited joint motion (LJM), for example, prayer sign and Dupuytren's contracture, was most common in individuals with DM, followed by individuals with IGT, as compared to those with NGT. Vibrotactile sense was impaired symmetrically in the index and little fingers in DM. However, there were no differences for sensibility, dexterity, grip strength, and cold intolerance between groups. Individuals with long-term (>15 years) DM were more affected regarding sensibility and ADL than individuals with short-term DM, who had more sleep disturbances. ADL difficulties were less among IGT subjects. Vibrotactile sense showed correlations with Semmes-Weinstein monofilament test and static two-point discrimination. CONCLUSIONS/INTERPRETATION: Dupuytren's contracture and impaired vibrotactile sense in finger pulps occurred in patients with DM but not in those with IGT, although LJM occurred in both IGT and DM patients. A longer duration of DM was associated with more severe neuropathy and ADL difficulties. Life satisfaction was high, and hand disorders did not have a significant impact on ADL.

Hand injuries and cold sensitivity: reliability and validity of cold sensitivity questionnaires.

PURPOSE: Sensitivity to cold is a common consequence of hand injuries and other conditions, and this phenomenon has a profound effect on health-related quality of life and upper-extremity disability. The aim of the present study was to examine the reliability and validity of the Swedish version of the Cold Sensitivity Severity (CSS) scale and Cold Intolerance Symptom Severity (CISS) questionnaire and the reliability of the Potential Work Exposure Scale in a group of patients with traumatic hand-injury or vibration-induced problems. METHOD: We translated the self-administered questionnaires into Swedish and performed tests of reliability and validity. The questionnaire was sent to 159 patients with hand injuries. RESULTS: Validity and internal-consistency results are based on a sample of 122. Test - retest results are based on a sample of 100. Good construct validity was demonstrated via correlation statistics. There were high correlations for both the CSS scale and CISS questionnaire scores with single questions concerning cold sensitivity, with the Disability of the Arm, Shoulder and Hand scale, and with the bodily-pain subscale of the SF-36 questionnaire. Reliability (both internal consistency and test - retest) was excellent. CONCLUSIONS: We conclude that the Swedish versions of the CSS scale and CISS questionnaire are reliable, and that this study provides evidence of the validity of the scales. The Potential Work Exposure Scale is reliable method of assessing exposure in the workplace.

Quality of life in Swedish workers exposed to hand-arm vibration.

The objective of the present study was to analyse whether differences existed among workers exposed to hand-arm vibration (HAV) with regard to quality of life (QoL) issues. One hundred and eight male workers from a heavy manufacturing plant, with and without HAV symptoms, and workers referred to a hand surgery department with severe HAV symptoms participated in the study. The participants attended a clinical interview, were given a physical examination of the hands and administered the Göteborg Quality of Life instrument and the Evaluation of Daily Activity Questionnaire (EDAQ). Results indicated that workers referred to a hand surgery department with more severe HAV symptoms described a lower quality of life, defined here as lower subjective well-being, more symptoms of ill-health and difficulties with activities of daily living (ADL), than workers with no HAV symptoms. Workers from a heavy manufacturing plant with HAV symptoms experienced more difficulties with ADL, especially while working outdoors in cold weather, than workers with no HAV symptoms. Limitations of the present study include the use of a subjective scale to describe HAV symptoms. Further research is recommended on a larger sample of workers at risk for HAV symptoms to develop preventative ergonomic strategies.

Behavioural treatment of post-traumatic and vibration-induced digital cold sensitivity.

Cold sensitivity is a common problem after all types of hand injuries. The aim of the present study was to assess possible effects of treatment by Pavlovian conditioning, a behavioural treatment method for digital cold sensitivity where whole body cold exposure becomes associated with warm hands. Eighteen hand-injured patients and nine patients with vibration-induced problems in their hands completed the treatment. Questionnaires and questions, assessment of perception of touch/pressure and skin temperatures after cold provocation, was made before and after the completed period of treatment and after 6 and 12 months. The results indicated subjective improvement in the hand-injured group in contrast to a lack of response in the vibration group. An increased digital skin temperature after treatment was noted for the vibration-exposed group only, which however did not persist at 6 and 12 months' follow-up.