Winter Warmers - Australian Hand Therapy Association
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NEWSLETTER
OF THE
Issue 123, Apr - Jun 2020
Winter Warmers
FEATURES UPDATES
Coronavirus (COVID-19), Telehealth and the Research & From the CEO
Scholarships Subcommittee
2020-21 Course Dates
Distal radius fracture malunion: surgical and therapy decisions
for the older adult Portfolio Reports
Hand Therapy Awareness Week Wrap Up Regional and Remote Grants
ahta.com.au l 1
20/21
Professional Development & Education
Course Dates
Introduction to Hand Therapy
15/22 August 2020, Online
22 March 2021, Adelaide 5 June 2021, Brisbane
18 September 2021, Sydney 20 November 2021, Melbourne
Fundamentals of Hand Therapy
4-6 December 2020, Melbourne
29-31 March 2021, Sydney 6-8 November 2021, Brisbane
Orthotics Immobilisation
17-18 October 2020, Sydney
30-31 January 2021, Gold Coast 16-17 October 2021, Perth
Orthotics Mobilisation
12-13 September 2020, Gold Coast
1-2 May 2021, Sydney 27-28 November 2021, Melbourne
Closed Trauma
23-25 October 2021, Brisbane
26-28 February 2021, Sydney 7-9 August 2021, Gold Coast
Advanced Open Trauma
20-22 November 2020, Sydney
5-7 March 2021, Perth 10-12 September 2021, Melbourne
Assessment & Treatment of Wrist
1/8 August 2020, Online
20-21 March 2021, Brisbane 9-10 October 2021, Sydney
Elbow Arthritis
19-20 June 2021, Brisbane 10-11 July 2021, Melbourne
F O R M O R E I N F O R M A T I O N A N D T O
B O O K Y O U R P L A C E P L E A S E V I S I T
A H TA.C O M.A U
C O U R S E D E TA I L S M AY C H A N G E W I T H O U T P R I O R N O T I C E A N D A R E
S U B J E C T T O M I N I M U M N U M B E R S A N D C O V I D - 1 9 R E S T R I C T I O N S
2 l AHTA NEWSLETTER l APR-JUN 2020
In this issue
PUBLISHED BY FEATURES
11 Coronavirus (COVID-19), Telehealth and the Research &
Scholarships Subcommittee
Australian Hand Therapy
Association Incorporated
13 Distal radius fracture malunion: surgical and therapy
decisions for the older adult
ABN 72 874 453 636 18 Hand Therapy Awareness Week Wrap Up
PO Box 5111 22 Cyclists Palsy - a case study
25
West Busselton WA 6280
Clinical Pearl: Nerve transfers
T: +61 8 9778 9070
E: enquire@ahta.com.au 28 Review: APFSHT Melbourne: March 2020
www.ahta.com.au
29 Research: Library review of the video: Ergonomics tips, tricks
and trivia
EDITOR
Louise Brown
E: communications@ahta.com.au
REGULARS
ADVERTISING SALES
Kate Noller
4 From the Editor
T: 02 8776 1860 5 From the CEO
40
E: Kate.Noller@ahta.com.au
Contact Us
DISCLAIMER
While every effort has been made to REPORTS
ensure the accuracy of information,
the Australian Hand Therapy
31 President
Association Inc. (AHTA) will not 32 Professional Practice
32
accept any responsibility for errors or
omissions or for any consequences Research & Scholarships
arising from reliance on information
published.
33 Knowledge & Resources
34 Memberships & Credentialing
Views expressed are those of the
writers and are not necessarily the 35 Communications
opinions of, or are endorsed by the
AHTA unless otherwise stated.
35 Marketing & Promotions
Copy in this newsletter cannot be
36 States and Territories
reproduced without the written 41 References
authorisation of the AHTA. The AHTA
welcomes contributions but reserves
the right to accept or reject any
material.
ahta.com.au l 3
REGULAR
From the editor
Welcome to the June edition Take care of yourself, while you’re taking care of
others. For enquiries, please don’t hesitate to
of FingerPrint! get in touch via email.
I thank everyone who has contributed to the
newsletter. Multiple case studies have been
received recently and I thank you all for your
time in compiling these so that we can learn
from, and with, each other.
The events of this year have had huge
implications for our professional development
opportunities. I would like to recognise the
education committee, SIG coordinators,
Louise Brown
conference convenors and AHTA office staff
AHTA Communications Officer
who have all had to make difficult decisions and
rapidly adapt. Letters to the editor are welcome and may be emailed
to communications@ahta.com.au. Letters should not be
2020 has been difficult for everyone in varying more than 300 words and must be accompanied by the
therapist’s name (published) and contact information.
degrees, as we navigate these unprecedented
times personally and professionally, as
employees and employers, sole traders, Just for interest’s sake...
colleagues, family and friends. As health The Department of Health has prepared a
professionals, even though we don’t often checklist to assist health professionals in
work with respiratory matters, we are exposed complying with privacy obligation when
to the worries of our clients as well as our providing telehealth services.
own, cumulatively collecting more and more
incremental trauma. There hasn’t been a more More great research by AHTA members...
pertinent time to reach out and ask ‘are you
Karina Lewis has been published in the
okay?’ to someone else, and to yourself.
Journal of Physiotherapy, with her article
The Black Dog Institute has compiled resources “Group education, night splinting and home
specifically for health professionals, across a exercises reduce conversion to surgery
broad range, including mental health, financial for carpal tunnel syndrome: a multicentre
stress, parenting, working from home and randomised trial.” This is particularly timely
a plethora of others. There are other online given the impact on elective surgeries this
resources for mental health support tailored year.
to health professionals, including an app that
Upcoming events
is under construction. Information and links to
resources are available here. We have omitted the upcoming events from
this edition of FingerPrint, hopefully we can
The Department of Health has also collated links advise of new dates for scheduled meetings
to various publicly funded digital and telephone in the next issue.
avenues for help, for anyone experiencing
difficulties. Head To Health provides links to AHTA weekly eNews
trusted resources for anyone trying to improve Our weekly eNews emails are being sent out
their own mental health, or support somebody with vital Association updates. Be sure to
else. check your junk folder if you haven’t been
receiving them and add us to your safe
senders list to ensure you don’t miss out!
4 l AHTA NEWSLETTER l APR-JUN 2020
REGULAR
From the CEO
I am delighted to provide you The Plan seeks to answer five key strategic
questions: Where are we now? Where do we
with some more information want to be? How will we get there? What must
regarding the AHTA Strategic we do? What does success look like?
Plan – Next Phase of Growth Where are we now?
2020 - 2023. During the development of the Plan, some
key strategic issues were identified as either
The development of the Plan involved holding the association back or that should be
consultation and collaboration which took place addressed.
over four phases:
Structure
1. Learning phase
The learning phase involved review of relevant Despite being thirty-five years old, AHTA still
AHTA background information, including Annual functions as a Committee where committee
Reports and Member Surveys. members actively manage ‘portfolios’ and
the staff that come with them. This volunteer
2. Discovery phase led and run model has limits and may not be
The discovery phase involved 14 contributors: sustainable.
eleven active volunteer members and three As the association has grown, significantly in the
staff, who were interviewed for 60-90 minutes. last five years, COM have made decisions that
In addition, two surveys were distributed to address structural changes.
and completed by contributors. These surveys
were: Reviewing the Strategic Plan 2019 Vision, The COM employed a CEO and restructured
Mission and Priorities and Reviewing the existing (nine) Committees. With four new
Strategic Plan 2019 SWOT Analysis. Committees, each set up to address Key Result
Areas of the Association - communication,
3. Strategy-Making phase collaboration, activity and measuring success
The outputs of these interviews and surveys will be more efficient and effective.
were used to develop this plan. The first The COM feel that it is appropriate to
draft was presented at an informal meeting transition from an Incorporated Association in
of the Committee of Management (COM) in Queensland* to a Company structure, regulated
Melbourne on Thursday 13 March 2020. The by the Australian Securities and Investment
first draft was distributed to all 14 contributors Commission (ASIC) with a Board of Directors.
shortly after the meeting for comment.
A Company Limited by Guarantee is a structure
4. Consensus-Building phase that is recommended for organisations that
In the consensus-building phase, comments work nationally or internationally, who require
received from contributors were considered greater legal and financial credibility, and have
and included in the plan or they were discussed larger financial resources. A company limited by
further. guarantee is regulated under ASIC which is
I would like to thank the contributors who
served as members of the Strategic Planning *Incorporated associations: This structure is recommended
Group: Lara Griffiths, Hamish Anderson, Olga for smaller state-based or community organisations which
Alkin, Rosie Koh, Carla Bingham, Dave Parsons, require a simpler legal structure and less demanding regulation.
Louise Brown, Brigette Evans, Elizabeth Giuffre, AHTA can conduct regular business outside Qld because it
Tracey Clark, Andrea Bialocerkowski, Kate is registered as an Australian Registered Body (which while
Noller, Sarah Dixon and Kelly Toner. straightforward to do, means that it has a dual registration and
the need to comply with dual requirements).
ahta.com.au l 5
considered to have a vigilant and quality are an essential stakeholder of the Association
regulatory framework. This means that – they have the potential to become our
companies limited by guarantee may be seen members’ best advocates.
as more serious, trustworthy organisations
that are recognized as credible companies not Widening the circle
only by the public but also by other regulated
organisations such as banks and insurance The AHTA has focussed efforts on providing
companies. This structure does come with services to its members (the inner circle below)
more stringent rules that better safeguard the for 35 years, and rightly so.
organisation.
However, there are likely to be many
To change from an Incorporated Association to a Physiotherapists and Occupational Therapists
Company structure requires a change from the (and students of these disciplines) that have
AHTA’s Own Rules to a Constitution. Members not yet been engaged in the services provided
will be involved in a consultation process, as is by the AHTA (2). Without engagement, these
required and a new Constitution will be voted practitioners will not become members of the
on at an Annual General Meeting. AHTA and the association will therefore not
have an opportunity to influence the practice of
A Voice for Hand Therapy these professionals.
Up until now, with essentially a volunteer The AHTA should also broaden its reach and
workforce, the association has been limited communicate and engage professionals that do
in its capacity to be proactive or vocal on the not fall into circle 1 or 2. Ultimately the AHTA
issues impacting the profession. and its members want other professions to
know about the work of a hand therapist so that
According to the contributors who have been they will refer their patients when their patient
consulted during the development of this plan, requires rehabilitation of the upper limb.
it is time for the AHTA to develop its voice
and to speak up on behalf of hand therapy Finally, the AHTA must also promote its
practitioners on the issues that affect them. members to the wider community so that
patients seek out the services of a hand
Hand therapy also lacks a ‘patient voice’ therapist rather than a GP, or Physiotherapist
because the patient hasn’t yet been considered or Occupational Therapist not trained in hand
as having a role in the association, nor have therapy, when they require rehabilitation of the
they been involved or invited to participate at upper limb.
the association level. Patients of hand therapy
6 l AHTA NEWSLETTER l APR-JUN 2020
The Accredited Hand Therapist Where do we want to be?
On 17th October 2015, the AHTA membership Our VISION is for wide recognition of Hand
voted at an Annual General Meeting to develop Therapy as an area of specialty practice.
and implement the AHT credential as a platform
from which to lobby key stakeholders for Our PURPOSE is to advance the hand therapy
recognition of the specialist scope of practice of profession to improve outcomes for patients
hand therapy, because it is based on assessable and the community.
standards of recognised hand therapy
competencies. At present there is a need to: Key Result Areas
• promote to patients the practice of hand
therapy and the Accredited Hand Therapist 1. 2.
credential;
• more effectively communicate the way that
education is viewed – from “obligation” to
“opportunity for lifelong learning”;
• improve the advantages of being
credentialled;
• gather or conduct research to provide
evidence that the practice of hand therapy
improves patient outcomes.
3. 4.
With more time and continued effort, the
Accredited Hand Therapist credential, which
has been designed to help the AHTA deliver
on its long-held desire to be recognised as its
profession, will become a reality.
ahta.com.au l 7
1. Membership 2. Professional
Practice
Strategic Goal Strategic Goal
To strengthen, support and To advance professional
serve the needs of the practice in hand therapy
members. through best practice: in
education, research and
accreditation.
Strategic Objectives
1. To improve members services. Strategic Objectives
2. To communicate effectively with members.
1. Advance the AHTA’s professional
3. To work with the states and territories to development services.
ensure that the members’ needs are being met
and membership is highly valued. 2. Advance the professional development of
practicing hand therapists.
Specific actions include: 3. Advance the systems and processes that
• Establishing and working as a dedicated underpin the Accredited Hand Therapist (AHT)
committee to deliver improved services and credential.
value to members; 4. Encourage accreditation and reaccreditation
• Designing and leading the implementation of the Accredited Hand Therapist (AHT)
of a membership engagement strategy; credential.
• Providing professional insight to support
the implementation of a marketing and Specific actions include:
communications plan, including Hand
• Establishing and working as a dedicated
Therapy Awareness Week (HTAW);
committee to deliver best practice:
• Developing links to university students and education, research and accreditation for
graduates to engage them in hand therapy practising hand therapists;
and the AHTA.
• Designing and leading the implementation
Specific outcomes include: of a professional practice strategy;
• Providing professional insight to support the
• Improved recognition of hand therapy, implementation of the AHTA’s professional
practitioners in hand therapy and the practice program;
Accredited Hand Therapist (AHT);
• Review the AHTA Course Accreditation
• Improved engagement with key stakeholder
program;
groups;
• Improved positive engagement with and • Assess courses for acceptance into the AHTA
among members; professional practice program or AHTA
• Improved value of membership; Course Accreditation program;
• Improved member satisfaction; • Determine the feasibility and benefit of a
• Increased number of Associate Members pathway to post-graduate studies in hand
becoming Accredited Hand Therapists; therapy;
• Increased patient referrals to a practitioner • Review and maintain the AHTA course
in hand therapy from key stakeholders; program;
• Increased visitation to the AHTA website, • Determine the feasibility and benefits of the
specifically ‘find a hand therapist’ by development of an AHTA Australian text in
patients; hand therapy;
• Increased engagement with undergraduate
• Advance the AHTA mentorship program;
and graduate OT and Physiotherapy
students; • Advance international and professional links
• Improved profile of the AHTA. to learn and share best practice;
8 l AHTA NEWSLETTER l APR-JUN 2020
• Collaborate with the Research and in hand therapy and the Accredited Hand
Scholarships Committee to monitor new Therapist (AHT) credential.
research into hand therapy;
• Collaborate with the Research and Specific actions include:
Scholarships Committee to foster research • Establishing a dedicated group of volunteers
and develop opportunities for research into to deliver on the Committees objectives;
hand therapy in Australia. • Designing and leading the implementation of
Specific outcomes include: an Advocacy Work Plan, where stakeholders
• AHTA course curriculum is underpinned by are identified and prioritised, and strategies
evidence and best practice; are developed;
• Development of position statements and
• Practitioners of hand therapy have submissions that address issues that may
access to quality, affordable professional impact or benefit practitioners of hand
development; therapy to enable nimble and effective
• AHTA members meet the requirements for response;
accreditation and re-accreditation reliably; • Developing a watching brief on issues
• AHTA course presenters are skilled, qualified impacting hand therapists to ensure hand
and highly proficient; therapy and the practicing hand therapist
• Members have the opportunity for receive due consideration.
leadership training and development
to exercise confident leadership within Specific outcomes include:
public and private settings and to deliver a • Formalised relationships with key
sustainable profession; stakeholders;
• Evidence-based standards, protocols and • Increased opportunity for members to be
position statements underpin the AHTA as involved in decisions that affect them;
the peak body;
• Improved member satisfaction – members
• Australia is recognised as a leader in hand feel heard and represented;
therapy research;
• Increased remuneration/compensation for
• Practitioners of hand therapy are recognised the Accredited Hand Therapist (AHT);
through published evidence of improved
patient outcomes; • Increased recognition of hand therapy by
stakeholders;
• Post nominals and the AHT logo are widely
and correctly used. • Increased referral rates of patients requiring
rehabilitation of the upper limb;
• Increased number of patients visiting the
AHTA for information on hand therapy or to
3. Advocacy find a local hand therapist;
• Advanced preparedness to respond to
submission requests from stakeholders;
• Increased recognition of the AHTA as the
Strategic Goal peak body and the ‘voice’ of hand therapy;
To deliver widespread • Improved credibility for following best-
recognition of hand practice healthcare governance – through
therapy, practitioners in the involvement of patients in the
hand therapy and the association decision-making processes.
Accredited Hand
Therapist (AHT) credential.
Strategic Objectives
1. Develop AHTA as the national voice for hand
therapy, practitioners in hand therapy and the
Accredited Hand Therapist (AHT) credential.
2. Advocate for hand therapy, practitioners
ahta.com.au l 9
4. Governance Wrap up and Evaluating success
Baseline data was gathered to enable the AHTA
to measure success over the next three years.
Strategic Goal This baseline data includes: the number of
AHTs, the number of Associate members, the
To deliver best-practice
number of courses provided for members and
governance and build the
the numbers of participants, the number of
capacity and capability of
events provided for members, the reach of the
the AHTA.
Association’s communications through social
Strategic Objectives media, the number of active volunteers, annual
surplus/deficit, annual conference attendees
1. Adopt a policy governance board model and member satisfaction (determined through
2. Increase and diversify revenue streams, in member surveys). We will continue to identify
order to provide improved services to members ways of measuring the success of our efforts
and ensure sustainability of the Association over the next few months.
3. Create pathways to develop future leaders of
the Association. While the contributors have addressed ‘Where
are we now?”, “Where do we want to be?” and
Specific actions include: “How will we get there?”, the intention is to
involve all members over the next two months
• Establishing a dedicated committee, in the development of “What must we do?”.
including skilled independent persons to
This question addresses the activity/the finer
deliver on the objectives of the Committee;
elements of what we will actually do to deliver
• Developing a new organisation structure;
on our strategic objectives. Member volunteers
• Designing and leading the implementation
have been meeting in their newly formed
of a Work Plan where risks are identified
Committees this month to consider their Terms
and opportunities for financial growth
of Reference and formulate a 12-month plan.
prioritised;
We will soon present these to the Membership
• Developing a policy framework and policies;
and provide an opportunity for input to shape
• Transitioning from a Committee of
the direction of the Association.
Management to a Board of Policy
Governance; On behalf of the COM, I invite you to join in and
• Provision of director and board induction participate in the future direction of the AHTA.
and training; The Association exists for you, works for you
• Creating pathways/succession plan to and wants to engage with you.
develop future leaders for the Association.
Specific outcomes include:
• Compliance with legal and other
requirements;
• Improved independent scrutiny;
• Operational efficiency (individuals get on
with their jobs without the need to discuss
issues each time they arise);
• Consistency and predictability throughout
the organisation;
• Quality assurance and improvement;
• Compliance with community and members
expectations; Wendy Rowland
• Mitigation of risks to the association; AHTA Chief Executive Officer
• Increasing capacity and capability;
• Improving long term sustainability.
10 l AHTA NEWSLETTER l APR-JUN 2020FEATURE
FEATURE
Coronavirus (COVID-19),
Telehealth and the Research and
Scholarships Subcommittee
Lauren Miller, PHD
With social distancing and telehealth consultations by Doing something that might
advice to stay at home due hand therapists. be helpful, at a time when
to Coronavirus (COVID-19) everything else felt out of my
presenting significant challenges The Research and Scholarship control brought me some peace
to our traditional face-to-face Subcommittee members were amidst the uncertainty.
model of care, many hand asked to provide a response
therapists have commenced on behalf of the AHTA, and However, I was not alone in my
telehealth consultations in a I volunteered to prepare a desire to do something helpful
bid to provide continuity of draft for the other members at such a stressful time, and
service to patients. Initially, to review. I had never written I certainly was not working
private health insurers were a review paper before, nor alone. The initial request for
not providing a rebate to their imagined I would try to write the response letter led to a
members for these telehealth my first in a weekend - certainly communication trail over 50
consultations. At the end of not at a time when all aspects emails in length, involving all
March when the Coronavirus of life were in a state of the other members of the
pandemic was at its peak in upheaval and my mind felt so Research and Scholarship
Australia, Private Healthcare disquieted. I was extremely well Subcommittee as well as other
Australia (who represents placed to take it on however, members of the Association. I
private health insurers) asked as telehealth consultations would like to thank:
allied health professional had been introduced early • Hamish Anderson (Chair and
associations to provide evidence by my employer as part of AHTA President-Elect),
for their use. our practice’s adaptation to • Andrea Bialocerkowski,
Coronavirus changes, and I • Susan Peters,
Thanks to our new CEO could draw on the previous • Nicola Massy-Westropp,
Wendy Rowland, the AHTA weeks of first-hand experience • Our CEO Wendy Rowland,
was also invited to provide a when reviewing the evidence. • Chair of the Credentialing
brief paper on the evidence Council Tracey Clark, and
of clinical effectiveness of In normal times, I’m usually so • President Lara Griffiths.
telehealth consultations, exhausted by the end of the day
including nomination of areas that I fall asleep trying to get my Due to the combined efforts
of practice where evidence was children to sleep – their energy of all these people, over 40
favourable for hand therapy, boundless, mine finite. But full text articles and references
and any areas of practice these were not normal times relevant to the efficacy of
where the evidence suggested and I didn’t sleep much at all telehealth consultations in hand
telehealth consultations were on the first weekend in April. I therapy were sourced, the initial
not appropriate. On receipt of stayed at home with my family, draft response was written,
the evidence, Private Healthcare read and summarised articles, shared, edited and greatly
Australia were then to distribute and wrote a draft response improved upon (especially
advice to member funds who paper based on the evidence. with input from Hamish
would make individual decisions At the end of the weekend I felt Anderson and Professor Andrea
regarding whether to fund exhausted, but empowered. Bialocerkowski - co-authors),
ahta.com.au l 11FEATURE
and a final response from the alone and gave you some with it, one of the biggest
AHTA was prepared for Private reassurance at a time when hurdles to introducing a change
Healthcare Australia within the you were branching into a new to practice, getting people to try
week. This incredible teamwork model of care delivery with it, has already been addressed.
made me feel so proud to be your patients. It has helped In the future, we may see
part of the AHTA. me to be more confident when telehealth consultations being
offering telehealth consultation woven into the course of a
Many (but not all) private as a viable alternative to face- patient’s hand therapy care. This
health insurers are now to-face appointments in the could occur particularly after
providing a rebate for telehealth current circumstances. Whilst the hands-on requirements of
consultations for Occupational Telehealth consultation is not initial appointments have been
Therapists and Physiotherapists appropriate for the application completed, or perhaps in a
– in no small part thanks to of splints/casts, complex wound hybrid form between face-to-
the “collective influence”, care and sensory testing, there face visits. This of course will be
as our CEO Wendy Rowland are a surprising number of dependent on ongoing funding
described it, of many allied assessments and interventions for telehealth consultations
health professional associations used by hand therapists for from private insurers and other
responding so rapidly with which telehealth consultation compensable schemes after this
evidence – including ours. have been found to be has passed.
comparable to face-to-face, and
As well as being sent to Private crucially, patient satisfaction is Get some sleep and stay safe
Healthcare Australia, we also generally high. everyone.
wanted our response to be
available quickly for members How extensively telehealth The full article published in
to review, and it was published consultation is used beyond the the AHTA eNews (15th April) is
in the AHTA eNews (15th April). Coronavirus pandemic remains available here.
I’m hopeful that the evidence to be seen. As many of us are
contained within our response now gaining quite intensive
paper helped you to feel less (albeit unexpected) experience
12 l AHTA NEWSLETTER l APR-JUN 2020FEATURE
FEATURE
Distal radius fracture malunion:
surgical and therapy decisions
for the older adult
Christine Redmond
Introduction associated with excessive loads to correct the relationship in
Malunion is a complication of across the ulnocarpal joint. length between the radius
a distal radius fracture. The This can lead to symptomatic and ulna and are indicated for
decision whether to correct a degeneration of the triangular malunions without significant
shortened radius is based on fibrocartilage complex (TFCC), articular involvement or
symptoms and radiographic the ulnar head, adjacent carpal carpal malalignment (Aibinder,
assessment of radial length. A bones (lunate and triquetrum), Izadpanah & Elhassan 2018).
case study is presented of an the lunotriquetral interosseous Contraindications for surgery
ulnar shortening osteotomy, ligament (LTIL) (Rajgopal et al. are poor overall health, severe
with a dynamic compression 2015; Sammer & Rizzo 2010) osteoporosis and advanced
plate, to correct a positive and distal radioulnar joint arthrosis (Mulders et al. 2017).
ulnar variance. This surgery is (DRUJ) (Aibinder, Izadpanah & Case series have reported
effective in relieving symptoms Elhassan 2018). advantages and disadvantages
but some patients experience for both procedures.
delayed union or non-union. Ulnar impaction syndrome
LIPUS has been used to (UIS) is diagnosed clinically and DRO is preferred for malunions
stimulate bone healing following supported by findings on X-ray. with positive ulnar variance that
an osteotomy but, based on Patients complain of gradually have dorsal angulations >20
a recent systematic review, it worsening ulnar-sided wrist degrees, or volar angulations
is no longer recommended. A pain, and occasionally swelling of >10 degrees (Hassan et al.
recent, small case series has and loss of wrist movement and 2019). A recent case series has
also raised questions about the forearm rotation. Symptoms reported that DRO procedures
6 to 12-week duration of cast are aggravated by activities that have improved function,
immobilisation that is often require forceful grip, pronation, as measured by the DASH
prescribed. Therapy programs and ulnar deviation. Gripping and PRWE scores, reduced
address immobilisation, forcefully and moving into pain scores and improved
movement and strengthening pronation result in a relative radiographic parameters
and includes decisions lengthening of the ulnar on the (Mulders et al. 2017). On the
on whether supervised radius, to dynamically increase downside, the surgery takes
rehabilitation or a HEP gives the ulnar variance, and increase longer compared to USO as it
best outcome. ulnocarpal load (Owens et al. is more technically challenging
2019; Sammer & Rizzo 2010). to correct both the height and
Literature review angulation of the radial head.
Distal radius fracture is a The surgical management In addition, surgical procedures
common fracture of the upper for UIS involves different such as bone grafting or
extremity, particularly in older procedures to decompress concomitant ulnar osteotomy,
adults, as the result of fall onto the ulnocarpal joint, including are often needed (Aibinder,
the outstretched hand (FOOSH). corrective distal radius Izadpanah & Elhassan 2018).
Radial shortening is a deformity osteotomy (DRO) and ulnar Re-operations for complications
that may occur, which changes shortening osteotomy (USO). are common. Recent series
the radioulnar variance, and is These surgical procedures aim have reported complications
ahta.com.au l 13FEATURE
including implant failure dose, that is proposed to have wrist is usually immobilised in a
(breakage of screws or plates), cellular effects through acoustic below elbow cast (Hassan et al.
extensor tendon irritation or cavitation. It is available on 2019; Rajgopal et al. 2015), but
rupture associated with the Exogen or Osteotron machines. forearm rotation may also be
plate and nonunion. Rates of restricted if a Muenster cast or
complications of 38% (16/48 However, the role of LIPUS hinged elbow orthosis has been
patients) and hardware removal in the management of acute applied, for either DRO or USO
of 45% (10/22 patients) have fractures appears to be (Aibinder, Izadpanah & Elhassan
been reported (Mulders et al. less promising than initially 2018; Sammer & Rizzo 2010).
2017; Rothenfluh, Schweizer & thought. A recent review A simpler, removable wrist
Nagy 2013). of randomized clinical trials orthosis has also been used
concluded that LIPUS is no following DRO (Rothenfluh,
USO is considered for ulnar- longer recommended as an Schweizer & Nagy 2013), which
sided wrist pain after distal adjunct treatment for acute allowed gentle wrist range of
radius malunion with positive fractures. Schandelmaier et motion exercises to be started
ulnar variance and with minimal al. (2017) found that trials at 2 weeks. Otherwise, active
or no angulation. It has been of low risk of bias failed to wrist movement is delayed
shown to improve function, show a benefit with LIPUS for until 6-12 weeks, when the
pain, range of motion, grip pain, function (as assessed plaster cast is removed. In these
strength and radiographic by RTW and days to weight- studies, exercises progressed to
parameters (Aibinder, Izadpanah bearing in tibial fractures) strengthening when radiological
& Elhassan 2018; Hassan et al. and radiographic healing. union was evident.
2019; Rajgopal et al. 2015). USO Benefits were only evident in
procedures have advantages trials with a high risk of bias. A In contrast, a small case review
in that they are usually simpler limitation of this study was that assessed the time to union for
and shorter operations. But, nonunions and osteotomies an early active mobilisation
there are the risks of hardware were under-represented in the protocol for USO. This protocol
irritation, delayed union, literature. The authors felt that limited immobilisation to the
nonunion and of re-fracture similar responses were likely first 2 weeks. Patients started
after removal of hardware. A and concluded that the value to actively move their wrists
systematic review found an of LIPUS was debatable, for after this period, as no further
average rate of delayed union nonunions and osteotomies. immobilisation was applied. All
of 6% and nonunion of 4% fractures united in this small
(Owens et al. 2019). Hardware There is limited evaluation of sample, with a similar median
removal has been reported in post-operative rehabilitation. time to union (14 weeks) and
case reviews at 9-45% (1/11 and The surgical literature tends rate of removal of hardware
34/75 patients) and fracture to give brief descriptions of (19%, 3 patients), as other case
following removal of hardware post-operative rehabilitation series (Blackburn et al. 2019).
at 11% (4/75 patients) (Hassan programs that vary in the extent These results suggest there
et al. 2019; Rajgopal et al. and duration that movement is scope for more rigorous
2015). is restricted. It is common for evaluation of short-term
the wrist to be immobilised immobilisation after osteotomy
Innovative technologies have for 2 weeks after surgery, to with dynamic compression plate
been introduced to address allow for early wound healing. compared to longer-term 6-12
the risk of delayed or nonunion This is often in a plaster back weeks.
after USO. Patients have used slab (Aibinder, Izadpanah &
low intensity pulsed ultrasound Elhassan 2018; Hassan et al. Case study details
(LIPUS) as an adjunct treatment 2019) but a sugar tong splint Mrs J is a 73-year-old widow
for bone healing for the last has also been described for USO who lives alone and sustained
twenty years. The prescribed (Sammer & Rizzo 2010). At the a right FOOSH injury. Her distal
dose is 1.5MHz, 0.03 W cm2 2-week review in outpatients, radius fracture healed but in
pulsed at 1:4 (20%) at 1000Hz this splint is changed and a shortened position. One
and applied for 20 minutes, immobilisation often continues specialist wants to perform an
daily. This is a sub-thermal for a further 6-12 weeks. The ulnar osteotomy with a dynamic
14 l AHTA NEWSLETTER l APR-JUN 2020FEATURE
compression plate and use for 20 minutes a day for weeks removed for gentle wrist and
LIPUS, another specialist wants or months, until healing has elbow movements. The patient
to perform a radial osteotomy. occurred. If a cast is used, a should demonstrate donning
Mrs J wants her daily life window can be created to give and doffing the orthosis and be
independence and to get back access (Poolman et al. 2017). provided with wear and care
to lawn bowls, and go interstate instructions. A sling may have
to her family for Christmas in 3 Early treatment phase been provided for the first 2
months. Early treatment phase following weeks, to reduce swelling and
an osteotomy would occur for protect the arm. This can be
Surgery details the first six weeks or longer, removed after this period, and
The patient decided to have during the period the fracture the hand used for light activities
treatment from the surgeon is uniting. Our aims are to during the day.
recommending an ulnar provide instruction and an
osteotomy with a dynamic understanding of the course of There is a low risk of
compression plate and use rehabilitation, give guidance complications in the early
LIPUS. The osteotomy is on how much rehabilitation phase. Therapists should
performed at the junction of the the patient will need to do check for signs of infection or
middle and third of the ulna. independently, how much emerging CRPS. The advice and
Typically, a transverse or oblique strain can be imposed on written plan of independent
osteotomy is made, and fixation their forearm in their day- exercises may be provided at a
is achieved with a compression to-day activities, and what single session, to be reviewed
plate on the volar surface. complications may occur. when the cast is removed.
The incision is made along the The treatment will vary with Monitoring may be more
subcutaneous border of the the duration and method of frequent, if swelling is excessive
ulna, between the extensor immobilisation. or there are high levels of pain.
carpi ulnaris and the flexor carpi
ulnaris. In ulnar positive wrists, The therapy may be provided Therapists should understand
the ulnar should be shortened at the 2-week review, in adjunctive treatments, such as
to 0 to -2 mm ulnar variance. conjunction with medical LIPUS, to be able to support
review. The back-slab is patient compliance. Daily
The LIPUS treatment is removed and may be replaced treatment can be a burden and
prescribed by the surgeon. by a cast at this appointment. patient adherence to treatment
There is low risk of harm with At the therapy session, an with LIPUS can be low, averaging
LIPUS but the lack of evidence assessment is made of how 43% in a recent high quality
for efficacy should have been Mrs J is managing at home, trial. Adherence has been
discussed with Mrs J, and with preparing meals and other improved by using a therapy
her values and preferences activities, her pain levels, and calendar, which has been
considered, when making the how much support she has incorporated into a more recent
recommendation. It would from family or friends. A visual Exogen model (Pounder, Jones
be interesting to discuss analogue scale (VAS) is a useful & Tanis 2016).
the clinical decision making outcome measure for pain. The
behind this recommendation extent of swelling and the range Middle treatment phase
with the surgeon and of movement of adjacent joints The middle phase would
determine if he/she is aware will be assessed. commence at 6 weeks until
of the current clinical practice signs of radiographic healing
recommendation against using In the early post-operative are evident, at approximately
LIPUS. period, elevating the arm is 12 weeks. Union is assessed
recommended for swelling, as clinically, by pain-free palpation
The treatment involves the well as gentle digital movement and from bony trabeculae
patient placing the ultrasound and tendon glides four to six bridging the osteotomy site. Our
probe on the skin at the site times a day, for managing pain aims at the middle treatment
of the fracture, fastening it in and stiffness. If the back slab phase stage are to regain full
place and activating a small was replaced by an above pain free active movement,
hand held unit. Treatment is elbow orthosis, this may be restore function and provide
ahta.com.au l 15FEATURE
support for Mrs J to maintain that returning to light ADLs repetition or progression
independent daily life. More and exercising with movement to have these additional
broadly, it’s important to reduce will reduce the likelihood of benefits. To improve muscle
the risk of another fall and pain persisting and swelling strength, exercises should
emphasise the value of good thickening into scar tissue that be specific, performed at 60-
nutrition and sleep for healing. causes joint stiffness. 70% of 1-repetition maximum
and progressed at 2-10% to
Auditing our own outcomes Aids can be provided to challenge the neuromuscular
is good practice, particularly help the patient manage system (Bruder et al. 2017).
in cases where treatments symptoms. An off-the-shelf or If AROM of the wrist and/or
have low evidence for efficacy. a fabricated removable wrist forearm has plateaued before
Pain levels can be reviewed orthosis may be provided for functional range has been
with the VAS. Using a patient- support and protection as achieved, dynamic or static
rated outcome measure, such needed by the patient, with progressive orthoses should be
as the PRWE or the Patient advice on modifying activities. considered to promote tissue
Specific Functional Scale, can A compression glove may remodelling, based on TERT
demonstrate the value of be appropriate if swelling is (total end range time).
therapy. A full evaluation of unresolved.
active movement will include Mrs J wants to return to lawn
the shoulder, elbow, forearm Patients are assessed for bowls, which is a motivating
supination and pronation, radiographic union at medical goal to work towards. Her
wrist, thumb opposition and review. The main complications exercises should address the
composite finger flexion. at this phase are delayed specific mobility, strength and
Sensory disturbances may be healing and persistent pain. endurance needed for this.
present, as the incision site A lawn bowl weighs about
is close to the dorsal sensory Late treatment phase 1 kg and it needs to be held
branches of the ulnar nerve, so This phase starts from when comfortably, so it doesn’t slip
an assessment of sensation may bony union is present, at out of the hand and drop onto
also be indicated. approximately 12 weeks. The the grass. The bowling action
Given the limited evidence aims of our treatment in this has controlled momentum and
to guide good practice in this phase are to regain strength and the aim is to repeat the action
phase, therapists will need to support Mrs J in returning to full consistently. The forearm is
draw on clinical experience, function, including participation supinated during the backswing,
patient preferences and in lawn bowls. The home controlled release and follow
evidence from other upper exercise program is periodically through. The elbow flexors work
limb fractures when deciding reviewed and upgraded to concentrically and eccentrically
if supervised rehabilitation reflect this. Grip strength can be during this action, with the
or a home exercise program added as an outcome measure. wrist controlled through a
will give a better outcome. Discharge is planned around small arc of motion. Exercises
Instructing the patient, having achieving goals or plateauing can progressively load and
them demonstrate the ROM progress. train these actions. Simple
exercises and providing a equipment can be used. For
written plan would be the We can take some lessons example, a hammer can be used
minimum standard for a home learned from a systematic as a weight to stretch the DRUJ
exercise program. Supervised review of rehabilitation after and strengthen the forearm
rehabilitation, possibly distal radius fracture and apply muscles. The exercise can be
weekly appointments, may them to an USO. Exercise had progressed by gripping the
be considered for patients to short-term benefit for pain handle further from the head,
meet specific goals, in addition and activity levels after cast which lengthens the lever.
to patients who are at risk removal. But, exercise had no
of poorer outcomes. Home benefit in the medium term on Complications at this stage that
exercises would be continued participation or activity levels. It require revision surgery include
between review appointments. is possible that current exercise non-union (diagnosed at ≥6
Explaining to patients that prescription is insufficient in months), removal of hardware
are anxious about movement, terms of duration, intensity, and re-fracture after hardware is
16 l AHTA NEWSLETTER l APR-JUN 2020FEATURE
removed. Removal of hardware for improving function, good assessment and clinical
usually occurs at one to two grip strength and pain. It reasoning when designing
years. Plates, which can often also has risks for delayed their therapy program.
be palpated under the skin, are healing or developing a non- This program can initially
more likely to cause irritation united fracture. LIPUS was address oedema control,
if they are placed on the ulnar recommended as a home pain management strategies
border of the ulna, rather than treatment for bone healing. and use of orthotic devices.
on the volar surface, or have a But, in contrast to Guidance is given to re-engage
higher profile (Sammer & Rizzo manufacturer’s claims, LIPUS in ADLs. Regaining movement
2010). has not proven to be effective is the focus when the period
as an adjunctive treatment for of immobilisation in a cast is
Conclusions bone healing. completed, usually at 6-12
This case study reviewed Evidence for the efficacy of weeks and progressed to
literature on treating supervised rehabilitation strengthening when there is
symptomatic positive ulnar versus a home exercise evidence of bony union.
variance from distal radius program following USO
shortening with USO. This is also lacking. Therefore, References
operation had good results therapists need to rely on
ahta.com.au l 17FEATURE 18 l AHTA NEWSLETTER l APR-JUN 2020
Hand Therapy Awareness Week committee had the unenviable We would like to acknowledge
(HTAW) is an annual event task of determining the winner the other nominees for the
designed to raise the profile ofof our HTAW competition from Local Legend award:
hand therapy in the community all the amazing entries received Victoria Allbrook, WA
and amongst referrers and is from across Australia. After Carmel Bain, WA
proudly supported by the AHTA. much debate, they couldn’t Lisa Browne, WA
look past the nomination from a Laura Carter, QLD
HTAW brings the benefits of gorgeous little girl named Verity, David Coles, QLD
the hand therapy profession to who at 5 years old had some Julia Condon, QLD
new audiences – demonstrating amazing results under the care Kate Connor, NT
the advantages of prevention of Nicholas Criticos from Action Nicola Cook, NSW
and treatment procedures for Rehab. Congratulations on your Nicholas Criticos, VIC
patients who have been affected award Nick, you are our Local Stacey Cross, QLD
by an accident or trauma and in Legend for 2020! Helen Fitzgerald, WA
educating the public to prevent Joy Hanna, QLD
injury and dysfunction. Joanne Hetherington, QLD
Mia Mackellar-Basset, NSW
The event ran from 1-7 June Amy Mangoin, NSW
2020, and this year we were Beth McNeish, VIC
asking you to nominate a Local Lauren Miller, QLD
Legend. This therapist was Nick will receive $500 worth of Charlotte Nash, SA
someone that has solved a Performance Health product, Tammy Robert, NSW
unique problem very creatively, which was kindly donated Alana Saggese, SA
or had been faced with a by Performance Health to Bethanie Trevenen, WA
particularly complex trauma celebrate HTAW. Verity receives
case requiring a lot of work and an Apple iPad and cover valued Congratulations to all of our
skill, or are just a consistently at up to $700! We look forward nominees and thanks to all of
wonderful person, caring for to bringing you some photos our members for your support
their patients each day. from the prize presentation of HTAW 2020.
The AHTA Marketing sub- soon.
ahta.com.au l 19FEATURE 20 l AHTA NEWSLETTER l APR-JUN 2020
Helping Hands - Townsville, Flex Out Physiotherapy - Albury
Ingham and AYR and Woden
Our HTAW t-shirts were designed by Lauren Squires We had an excellent week at Flex Out
of Almost Anatomical. We wanted something Physiotherapy celebrating our wonderful team of
unisex, fun and eye catching - and we think we hand therapists.
nailed it! We love to dress up, but we also had a Our hand therapists planned a full week of
great time decorating our rooms, as well as using activities including free live education sessions
our social media accounts to spread education (COVID style), social media campaigns, express
about hand therapy. hand workouts, mindfulness colouring, a hand
The icing on the cake had to be the coincidental photography competition, a special morning tea
receipt of the latest edition of Rehabilitation of and even a casting workshop, which was a great
the Hand and Upper Extremity - for Cassandra experience for the rest of our team.
especially, who is up to her 4th edition of this Our hands really are so valuable, that’s why we
book! HTAW is our favourite week of the year! think it is so important to share the message about
how it is so critical to take care of them.
What is a hand therapist?
The nominations for our
Local Legend competition
gave us some great
insight into just what our
patients and colleagues
are saying about us.
We created this word
cloud so you can see the
words frequently used
to describe our hand
therapists.
ahta.com.au l 21FEATURE
FEATURE
Cyclists Palsy - a case study
Kristy Pritchard
Mountain bikers are generally a reported one or more overuse (FDM, AbDM, ODM)
stoic and resilient bunch. They injuries with 31% of these • Weakness in finger
race hard, they train hard, they being overuse related hand abduction and adduction
bounce hard, except for my pain (Schwellnus & Dorman, (interossei)
dear husband. This report will 2014). Factors contributing to • Weakness to the thumb in
describe the events that took overuse hand and wrist pain the direction of adduction.
place following the Reef to Reef are many and varied and can be (AddPoll)Ulnar claw by MCP
4 day stage race. summarised in Table 1. extension and PIP flexion
(lumbricals 3 and 4).
Following the race he was “Cyclists Palsy”, otherwise
elated, yet told me he was known as ulnar nerve Happy with my diagnosis, I
“never doing that again”. In the neuropathy, is a condition advised that he should refrain
morning, he reported that he that can arise following direct from cycling until symptoms
was finding it difficult to use pressure on the ulnar nerve resolved and reassured him that
both hands and he had noticed from the handlebars, while the nerve was likely just a little
a mild clawing to the ring and the nerve is in a stretched bruised and swollen, however
little fingers. He could correct position from wrist extension. shouldn’t lead to long term
the claw with effort however Specifically, the ulnar nerve deficit.
on passive relaxation of the passes through Guyon’s Canal
hand, it fell back to the ulnar which is a tunnel bordered by A few days later, he reported
claw posture. Being the caring the pisiform and the hook of the clawing to be less
diligent spouse that I am, I hamate. Presentation can be pronounced, however he had
immediately leapt into action variable depending on which noticed a weak pinch and was
for a rapid assessment and branch of the ulnar nerve experiencing difficulty doing up
diagnosed him with “cyclist’s is involved and can include buttons and opening bottles.
palsy”, as that sounded like the the following (Brubacher & He displayed a positive Jeanne’s
logical conclusion. Leversedge, 2017): sign (Skirven et al, 2011), where
• Pain the MCP joint hyperextends
Cycling injuries that affect • Paraesthesia in the ulnar in a thumb to index finger
the upper limb can be broken ring finger and palmar little pinch. I decided to test for
into acute injury, such as that finger Froment’s sign (Skirven et al,
following a crash, or an overuse • Weakness to the little finger 2011), which was positive. On
injury. In a survey of 518 in the direction of flexion, attempt to hold a flat sheet of
recreational cyclists, 85% abduction and opposition. paper in a lateral pinch grasp,
Table 1. the paper out easily. I concluded
Individual Variables Environmental Equipment that my diagnosis of ulnar nerve
Variables Variables neuropathy was still correct as
adductor pollicis could supply
Inadequate training Constant vibration High saddle a lot of power to this pinch
Gripped hand posture Rough ground Down tilted saddle posture.
Over extended wrist Downhill increases Low handlebars
position pressure on the hands Within the week I was getting
Insufficient core muscles Uphill increases the grip High pressure tires
a little exasperated by the
force
constant running commentary.
He reported that his thumbs
General fatigue Skinny tyres
were now the main issue in
22 l AHTA NEWSLETTER l APR-JUN 2020FEATURE
I pulled that he could not the abductor pollicis brevis Figure 1. Displaying correct and
manipulate freely during fine muscle would provide useful incorrect riding position
motor tasks. I would usually data for functional impairment,
expect a mild neuropathy to however, it is difficult to get a
resolve within two weeks. This reliable objective measure of
particular case was strange in this. They suggest measuring
that it actually appeared to be a standard hand grip strength
worsening over that first week. using a dynamometer.
On closer inspection, the ulnar
digit strength and the clawing When observed to attempt a
did seem to have resolved and tip to tip pinch, he was able to
the weakness was now more reach the tip of the index finger
profound in the thenars. but not generate significant
power and he couldn’t hold the
This would be more consistent correct posture of slight flexion
with a median nerve at the IPJ and MCPJ of the
entrapment at the wrist such thumb. Functionally, he could
as carpal tunnel syndrome. not open toothpaste lids and
Carpal tunnel syndrome is squeezing eye dropper bottles
the most common peripheral required two hands. As the
nerve entrapment syndrome weeks ticked by, he wondered
worldwide. It occurs when the if he would ever be the same
median nerve is compressed again and I could only be helpful
at the level of the wrist where by saying it’s a waiting game.
it passes through the carpal
tunnel. The carpal tunnel is Further discussions highlighted
formed by the wrist bones a possible postural component
dorsally and the transverse to the issue. Excessive fatigue To pass the time, the research
carpal ligament volarly. and inadequate training and online shopping began
Symptoms again can vary coupled with weak core in earnest as all bikers seem
depending on which nerve muscles lead to a ‘chest down’ to be addicted to buying new
branches are compressed. position with thoracic flexion, gadgets. He is determined not
Pain is a common symptom cervical extension, shoulder to have this issue again and
but not always present and flexion, elbow flexion and the bike now sports a few new
in more severe cases the pain wrist extension, the habitual modifications.
can spread proximally into resting posture for hours on
the arm (Padua et al., 2016). end (See Figure 1). Smith et al So What Can be Done?
Sensory abnormalities such as (2008) reported a significantly
tingling or numbness usually greater number of cyclists with Prevention of overuse related
occur in the median nerve positive ulnar nerve neuropathy hand and wrist pain in cyclists is
distribution of the palmar also had positive provocative multifactorial:
radial three digits however testing for thoracic outlet • Gear – let’s face it, this is
it is often reported to be the syndrome. This logically makes most likely the only change
‘entire palm’. My husband did sense with the forward posture to be made in many cases
not have any sensory symptoms required of cycling usually with willingly
or any pain and his Phalen’s cervical spine extension and • Ergonomics and posture on
manoeuvre where the wrist is thoracic spine flexion. My bike the bike
held flexed for 1 minute was riding husband has in the past • Training load control
negative. He did have a positive sustained a fractured right • Adjustments made whilst
Tinel’s sign when percussed clavicle which I speculated could cycling to alternate grip,
over the carpal tunnel for be also a risk factor for double hand and wrist position
pain that was temporary in crush syndrome. • Off the bike hand exercises
nature. Luca Padua et al (2016) and core stability
reported that the strength of
ahta.com.au l 23You can also read
