Wrist and hand orthoses for adults with rheumatological conditions Katie McAlarey and Ruth Squire June 2016 [email protected] [email protected] www.COT.org.uk

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Outline of Session         

Set own learning outcomes Why do we need practice guidelines ? Guideline development process Scope of the guidelines Results and recommendations of the guidelines Limitations Areas for future development Challenges in changing practice Facilitating the implementation of guideline-research into practice www.COT.org.uk

SETTING LEARNING OUTCOMES FOR THE SESSION www.COT.org.uk

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Setting your own learning outcomes • Turn to your neighbour and write down 2 or 3 things that you want to learn today • Share with the group • You have 5 minutes to complete this task www.COT.org.uk

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WHY DO WE NEED PRACTICE GUIDELINES? www.COT.org.uk

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Why do we need practice guidelines? •

Evidence based practice

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Assist with professional reasoning

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Audit of service provision

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Improving quality of care

(COT,2011) www.COT.org.uk

Current practice – reflection (audience) • In your small groups discuss the following: • What splints do you currently provide and why? • Who pays for the splints? • You have 10 - 15 minutes to carry out this task www.COT.org.uk

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GUIDELINE DEVELOPMENT PROCESS

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Practice questions: •

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Is there evidence to support the use of hand and wrist orthoses as an intervention for adults living with rheumatological conditions? Is there any evidence of harm arising from the use of an orthosis that practitioners should be aware of?

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Methodology 1. Guideline development group established

5. Critically appraise articles

6. Development of practice guideline recommendations

9. Published by COT 2015 COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

2. Guideline scope defined involving stakeholders

4. Screen findings

3. Literature search

7. Peer review, stakeholder and service user consultation

8. Final draft approved by COT Practice Publications Group www.COT.org.uk

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SCOPE OF THE GUIDELINES

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Scope of guideline To provide evidence-based recommendations that inform the practice of occupational therapists working with adults over 16 years of age who have rheumatological conditions, and who may benefit from a custom-made or prefabricated hand or wrist orthosis. It addresses occupational therapy intervention at any point during a service user’s journey along the rheumatology care pathway. COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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Literature search outcomes Total search results n= 2,069

Abstracts included n= 665

Full articles included n= 175

Evidence included n= 31 www.COT.org.uk

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Making sense of the evidence • Scoring system : 1 (strong) or 2 (conditional) • Quality of evidence : A (high quality) to D (low quality)

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RESULTS AND LIMITATIONS

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Results and Recommendations – 3 main themes 1) Rheumatoid arthritis: • orthosis for activity and rest

2) Osteoarthritis: • Base of thumb orthoses

3) Optimising service user outcomes

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1) Rheumatoid arthritis • Functional wrist braces • Night resting orthoses • Swan Neck deformity orthoses

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Rheumatoid arthritis: orthoses for activity and rest Functional wrist orthoses 1. It is recommended that a functional wrist orthosis should be prescribed for service users experiencing wrist pain as a result of rheumatoid arthritis.

1A

(Haskett et al 2004 [B]; Pagnotta et al 2005 [C]; Ramsey et al 2014 [A]; Thiele et al 2009 [C]; Veehof et al 2008a [B])

Resting/night orthoses 2. It is suggested that where a night or resting orthosis is being considered as potentially beneficial to reduce symptoms for a service user with rheumatoid arthritis, both subjective and objective measures are used for the monitoring and review of effectiveness.

2B

(Adams et al 2008 [B]; Silva et al 2008 [A])

Orthoses for swan neck deformity 3. It is suggested, when considering an orthosis for swan neck deformity, that a potential positive effect on dexterity should be balanced by possible adverse effects such as pressure and paraesthesia.

2C

(Spicka et al 2009 [D]; van der Giesen et al 2010 [D]; van der Giesen et al 2009 [C]; Ziljstra et al 2004 [C]) COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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Rheumatoid arthritis: orthoses for activity and rest Evidence overviews: Functional wrist orthoses The evidence is strong with respect to the reduction of pain, as particularly evidenced by the systematic review undertaken by Ramsey et al (2014). A decrease in pain was a consistent outcome across studies, as measured using visual analogue scales. The reduction of symptoms, such as pain, is also a key motivator for adherence to wearing an orthosis.

Risks associated with wearing a functional wrist orthosis were not specifically reported in the studies, but a potential negative impact on dexterity was highlighted. (COT 2015, p23) COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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Rheumatoid arthritis contd… Resting/night orthoses The effectiveness of a resting or night-positioning orthosis is not definitive. A positive impact on hand pain, grip and pinch strength, upper limb function and functional status was reported for participants with a mean of 9–10 years’ disease duration, although the benefits beyond three months were not researched. Participants with early rheumatoid arthritis did not, however, obtain the same improvement in outcomes as determined by objective measures, although where the orthosis was used there was perceived effectiveness by participants. The evidence reviewed does not enable a specific recommendation to be made with respect to the prescription of a resting or night-positioning orthosis for service users with rheumatoid arthritis. (COT 2015, p24) COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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Rheumatoid arthritis contd… Orthoses for swan neck deformity Some evidence exists to support prescription of an orthosis to improve dexterity where correctable swan neck deformity exists for people with rheumatoid arthritis. Impact on other dimensions, such as dexterityrelated pain and function, is weaker. Inherent with the use of silver ring splints or Oval-8® ring orthoses is the potential for some adverse side effects, and the range of both positive and negative factors influencing choice should be considered as part of the orthotic prescription process. The recipients of an orthosis for swan neck deformity need to be carefully selected, as factors such as long-standing deformity may mean an orthosis is not tolerated. (COT 2015, p26) COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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2) Osteoarthritis • Thumb based orthoses for reduction of pain and improvement in function • Orthosis to improve grip and pinch strength

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Osteoarthritis: base of thumb orthoses Orthoses to reduce pain and/or improve function 4. It is recommended that an orthosis should be prescribed for service users experiencing pain and/or functional difficulties with activities of daily living as a result of thumb base osteoarthritis.

1A

(Bani et al 2014 [C]; Bani et al 2013a [C]; Bani et al 2013b [A]; Becker et al 2013 [B]; Boudstedt et al 2009 [C]; Egan and Brousseau 2007 [B]; Gomes Carreira et al 2010 [B]; Hermann et al 2014 [B]; Kjeken et al 2011a [A]; Kjeken et al 2011b [A]; Maddali-Bongi et al 2014 [C]; Moe et al 2009 [A]; Rannou et al 2009 [A]; Sillem et al 2011 [B]; Wajon and Ada 2005 [A]; Weiss et al 2004 [C])

Orthoses to improve grip and pinch strength

5. It is suggested that an orthosis can improve the grip/pinch strength for some people with thumb base osteoarthritis.

2C

(Bani et al 2014 [C]; Bani et al 2013a [C]; Bani et al 2013b [A]; Becker et al 2013 [B]; Hermann et al 2014 [B]; Maddali-Bongi et al 2014 [C]; Sillem et al 2011 [B]; Wajon and Ada 2005 [A]; Weiss et al 2004 [C])

COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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Osteoarthritis: base of thumb orthoses Evidence overview: The evidence that orthoses have an impact on pain has been consistent in terms of direction of the outcomes, with an improvement being reported in 94% of the studies described (50% of those being statistically significant). One study identified no change in pain. The impact of an orthosis on function was considered in 11 studies, 5 (45%) of which were statistically significant in favour of an improvement in function, with one identifying no change. Risks or adverse outcomes associated with these orthoses were rarely referred to in the studies. Changes in grip and pinch strength outcomes have been less consistent, with one study identifying a decrease in grip, and statistical significance being rare for both measures. (COT 2015, p31) COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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3) Optimising service user outcomes • Outcome measures to evaluate effectiveness of orthoses • Orthosis design / wearing regime to maximise occupational performance

• Engage service users in discussion re potential benefits/limitations www.COT.org.uk

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Service user perspectives “Try to get the therapist to underline that the outcome might not be clear if only restricted to a two- to fourweek review…. I know from personal experience that it has taken even four to six weeks to get the full benefit of the splints”

“I found out that there are not only beige wrist splints but black as well… if there is no extra cost incurred, could we have a little choice?”

“I suspect I am no different to many service users in wanting to know what are the potential benefits and potential risks of any intervention to me personally… strengthening or highlighting the perceived benefit of the recommendation to the user is fundamental in achieving compliance” www.COT.org.uk

“I am 79 – all my working life I was a draughtsman and the ‘splints’ did help reduce pain”

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Optimising service user outcomes Measuring outcomes 6. It is recommended that validated, standardised assessment and outcome measures are used pre- and post-provision of an orthosis to monitor progress and evaluate effectiveness.

1A

(Bani et al 2014 [C]; Bani et al 2013a [C]; Bani et al 2013b [A]; Boudstedt et al 2009 [C]; De Boer et al 2008 [C]; Gomes-Carreira et al 2010 [B]; Haskett et al 2004 [B]; Kjeken et al 2011a [A]; Pagnotta et al 2005 [C]; Rannou et al 2009 [A]; Sillem et al 2011 [B]; Silva et al 2008 [A]; van der Giesen et al 2009 [C]; Veehof et al 2008a [B]; Wajon and Ada 2005 [A]; Weiss et al 2004 [C]; Ziljstra et al 2004 [C])

Orthosis design and wearing regimen 7. It is suggested that given the inconsistent evidence of a superior orthosis fabrication/design, or wearing regimen, the orthosis selected should maximise occupational performance and service user choice.

2A

(Bani et al 2013b [A]; Becker et al 2013 [B]; Haskett et al 2004 [B]; Sillem et al 2011 [B]; Thiele et al 2009 [C]; van der Giesen et al 2009 [C]; Wajon and Ada 2005 [A]; Weiss et al 2004 [C])

COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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Optimising service user outcomes Measuring outcomes 8. It is recommended that to optimise adherence to wearing a prescribed orthosis, the occupational therapist should discuss with the service user the potential benefits and limitations; practicalities of use and comfort; provide the opportunity to try on orthoses prior to issue; and routinely arrange follow-up review of the intervention.

1C

(de Boer et al 2008 [C]; Gooberman-Hill et al 2013 [D]; McKee and Rivard 2004 [D]; Veehof et al 2008b [C])

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Optimising service user outcomes contd. Service user experiences Service user perspectives, when taken into account, can have the potential to enhance wearing of an orthosis in practice and, as such, can improve the outcomes sought by the individual. Views expressed included the importance of the support provided by the orthosis, its comfort and appearance, and ease of use, with ‘perceived need’ being a key driver for adherence of wearing. The range of potential issues influencing wearing of an orthosis implies that follow-up review of an orthosis is necessary to enable these to be addressed. Orthoses that are worn are more likely to result in effective outcomes

for service users and, by association, more efficient use of occupational therapy service resources. (COT 2015, p36) . COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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Limitations of the guidelines • Limited evidence available in areas such as splinting for deformities , CTS secondary to a rheumatological condition and long term outcomes • Study designs varied and therefore not easily comparable • Splint designs /descriptions variable • Potential harmful effects not always identified • Wearing regimes , instructions and compliance not always described www.COT.org.uk

AREAS FOR FUTURE DEVELOPMENT

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Areas for Future Development • Economic evaluation • Outcomes and effectiveness

• Evidence facts sheet for targeting commissioners https://www.cot.co.uk/occupational-therapy-evidence-fact-sheets.

• Service users perspectives (See page 46 ) www.COT.org.uk

Areas for future research • Economic evaluation – cost effectiveness of splints? • Outcomes and effectiveness – across range of conditions and splint types • Service user perspectives - health benefits, psychological impact and desired outcomes www.COT.org.uk

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CHALLENGES IN CHANGING PRACTICE

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Challenges in changing practice • In small groups discuss the potential barriers to using these guidelines in practice • Consider ways in which you can implement the guidelines • Share 2 points with the group • You have 15 minutes to carry out this task www.COT.org.uk

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FACILITATING IMPLEMENTATION OF THE GUIDELINES www.COT.org.uk

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Changing Practice and Implementation • Share and discuss the practice guidelines with colleagues/managers • Audit current practice using COT audit tool • Implement changes if required • Feedback on the guidelines to COT SS Rheumatology • Get involved in future development of practice guidelines www.COT.org.uk

Interview with practitioner – Katie • Can you describe your service for us? • What sort of splints are you currently prescribing? • How have you tried to change practice in light of the new guidance? • What were some of the challenges you faced? • What top tips can you suggest to others ? www.COT.org.uk

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Changing your practice – take home actions • Consider how you can audit your service against the guidelines • What are the challenges/barriers for your service? • Who will you share the audit results with? • What assessments are you using or could you be using? • Service user information www.COT.org.uk

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Sharing guidelines • • • • •

COT website plus OT news COT conference – Workshop Harrogate 2016 COTSSR launch event – watch this space Meetings like this ! Any other suggestions?

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Practice guideline resources • College of Occupational Therapists (2015) Hand and wrist orthoses for adults with rheumatological conditions: practice guideline for occupational therapists. London: COT. • Audit tool • Quick Reference Guide • Feedback form • Guideline tips ( https://www.cot.co.uk/publication/z-listing/hand-andwrist-orthoses-adults-rheumatological-conditions-practice-guideline-o). Resources are available from the College’s website include a pre-prepared powerpoint presentation see: http://www.cot.co.uk/library-publications/cot-publications/practiceguidelines. COT Implementation Toolkit/CPD Session © 2015 College of Occupational Therapists

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FINALLY

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Revisiting learning outcomes • Have you achieved your learning outcomes for today? • Does anyone have any further questions/comments ?

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