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Hand and wrist orthoses for adults with Rheumatological conditions

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Presentation on theme: "Hand and wrist orthoses for adults with Rheumatological conditions"— Presentation transcript:

1 Hand and wrist orthoses for adults with Rheumatological conditions
Practice guideline    Royal College of Occupational Therapists Specialist Section - Rheumatology CPD Session: PowerPoint, notes and group activities The slides and information in this CPD session can be used as a template, but can be adapted to reflect local need and priorities. You may want to use some of the slides together with a handout such as the Quick Reference Guide. The overall aim of this resource is to support a continuing professional development session to explore the practice guideline Hand and wrist orthoses for adults with rheumatological conditions (COT 2015). The resource comprises this PowerPoint presentation and notes which can be used for a one-hour facilitated workshop, or for individual self-directed learning. There are some interactive activities which are intended to be used to encourage reflection on current practice and to explore some areas in more detail. Pre-requisite materials: Guideline document: Hand and wrist orthoses for adults with rheumatological conditions: practice guideline for occupational therapists. (COT 2015) Implementation tools i.e. Audit Form. Quick Reference Guide. It is essential that workshop facilitators familiarise themselves with the full guideline document and implementation tools in advance.

2 Learning outcomes On completion of this professional development activity participants will be able to: Describe aspects of the practice guideline recommendations in relation to current practice. Explain the importance of using practice guidelines to inform practice. Demonstrate how to use the RCOT Audit Form to benchmark against the evidence-based recommendations. Slide 3 Practice question Slide 4 Guideline objective Slide 5-6 Methodology and recommendation grading Slide 7 Recommendation areas: Rheumatoid arthritis: orthoses for activity and rest Osteoarthritis: base of thumb orthoses (Activity 1 and 2) Optimising service user outcomes Slides Evidence overview and list of the recommendations Slides Impact of the guideline (Activity 3) Slide 24 Practice guideline resources Information used in the session is taken from the full practice guideline document and the other implementation tools, particularly the audit tool. Activities 1 and 2 can potentially be applied to any of the three recommendation areas. Choose the one that you think would yield as much discussion as possible by the group in order that they may take plenty of ideas away to think about.

3 Practice questions: 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?

4 Key objective 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.

5 Methodology 2. Guideline scope defined involving stakeholders
1. Guideline development group established 5. Critically appraise articles 4. Screen findings 3. Literature search 6. Development of practice guideline recommendations 7. Peer review, stakeholder and service user consultation The College of Occupational Therapists’ guideline development process is rigorous and is Accredited by the National Institute for Health and Care Excellence. Selection of a topic 1. Establish the Guideline Development Group Submit a proposal 2. Define the scope and practice question(s) 3. Literature search 4. Screen findings 5. Appraisal and grading of the evidence 6. Formulate the recommendations Write the guideline 7. Peer review and consultation involving stakeholders (includes occupational therapists as end users) and service users 8. Ratification by the COT Practice Publications Group Publication and Implementation Review – within 5 years. Stakeholder, service user and carer engagement and involvement was fundamental to the development of the guideline. 9. Published by COT 2015 8. Final draft approved by COT Practice Publications Group

6 Evidence-based recommendations
Recommendations are based on the evidence available within 31 critically appraised papers. Each recommendation is assigned: A strength scoring 1 or 2 (Strong or Conditional) A quality grading A, B, C or D (High, Moderate, Low or Very Low) Each relevant article of evidence identified from the search (2004 – 2014) was critically appraised by two members of the guideline development group, and a quality of evidence grading subsequently determined based on that assessment. The quality of evidence grading reflects the typical hierarchy given to study design. For example the highest level (A) reflects consistent results from randomized controlled trials, whilst the lowest (D) includes studies such as case studies or expert opinion. Higher level studies are perceived as being less susceptible to bias. The strength of the recommendation is scored as either strong (1) or conditional (2). This is based on the benefits and risks of the evidence. A strong recommendation indicates that benefits appear to outweigh the risks for the majority of the target group, where as a conditional or suggested recommendation, means that the risks and benefits are more closely balanced or there is more uncertainty. A total of 51.6% of the evidence (31 studies) from which the recommendations were developed was assessed as being high or moderate quality studies. 25.8% of the evidence was graded as high (A), 25.8% as moderate (B), 35.5% as low (C) and 12.9% as very low (D) quality. Four of the eight recommendations are graded as strong. Each recommendation is specific and is based on the appraised evidence. Details about the studies referenced can be found in the evidence tables section (Appendix 5) of the full guideline.

7 Recommendation areas Rheumatoid arthritis: orthoses for activity and rest. Osteoarthritis: base of thumb orthoses. Optimising service user outcomes. The recommendations are based on the synthesis of the best available evidence. It should, therefore, be noted that the guideline is not able to be fully reflective of all the aspects of occupational therapy practice with respect to the prescription of orthoses for adults with rheumatological conditions. Recommendations, based on the evidence, were developed in three key areas: Rheumatoid arthritis: orthoses for activity and rest Osteoarthritis: base of thumb orthoses Optimising service user outcomes: measuring outcomes; orthosis design and wearing regimen, service user experiences

8 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)

9 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)

10 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 dexterity- related 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)

11 Rheumatoid arthritis: orthoses for activity and rest
Functional wrist orthoses It is recommended that a functional wrist orthosis should be prescribed for service users experiencing wrist pain as a result of rheumatoid arthritis. (Haskett et al 2004 [B]; Pagnotta et al 2005 [C]; Ramsey et al 2014 [A]; Thiele et al 2009 [C]; Veehof et al a [B]) 1A Resting/night orthoses 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. (Adams et al 2008 [B]; Silva et al 2008 [A]) 2B Orthoses for swan neck deformity 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. (Spicka et al 2009 [D]; van der Giesen et al 2010 [D]; van der Giesen et al 2009 [C]; Ziljstra et al 2004 [C]) 2C Activity 1 Prior to showing the next slide 12, ‘Osteoarthritis: base of thumb orthoses’ evidence overview, Activity 1 can be carried out. Tell the group that the next section deals with orthoses for thumb base osteoarthritis. Split the group into pairs and ask them to discuss what they think would be covered/recommended in this section. Prompt them to think about their own practice in this area, highlighting examples of their own best practice. Following discussion, ask the pairs to share 1-2 examples with the group; you might want to record on a flipchart the groups’ suggestions to refer back to these ideas when you show the recommendations. On completion of the activity present the overview of evidence (slide 12) and recommendations for thumb base osteoarthritis which are on slides 13 and 14.

12 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)

13 Osteoarthritis: base of thumb orthoses
Orthoses to reduce pain and/or improve function 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. (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 [C]; Moe et al 2009 [A]; Rannou et al 2009 [A]; Sillem et al 2011 [B]; Wajon and Ada [A]; Weiss et al 2004 [C]) 1A Orthoses to improve grip and pinch strength It is suggested that an orthosis can improve the grip/pinch strength for some people with thumb base osteoarthritis. (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]) 2C Activity 2 Once the recommendations have been presented, the questions below can be used to encourage the group to talk about the recommendations in relation to their own suggestions: Do they cover the best practice examples they identified? Why might these not be the same? You may want to refer back to the methodology of creating evidence-based guidelines and how it is based on the published literature - evidence-based practice guidelines support practice, but can only reflect current evidence. It may be important to emphasise that just because their own examples are not covered, this does not necessarily mean they are not best practice. Occupational therapists also need to adhere to other service standards, consider the service user’s perspectives and apply their clinical judgement and reasoning when providing orthotic interventions for adults who have rheumatological conditions. The Audit Form can now be used to further consider the thumb base osteoarthritis recommendations. Ask the pairs/small groups to discuss the recommendations, sharing their current practice in relation to the recommendation and how they would evidence this. If the recommendation is not current practice then they should look at what an action plan might consist of to implement that recommendation.

14 Optimising service user outcomes
Evidence overviews: Measuring outcomes The evidence across the studies indicated that pain and function outcomes can be determined using self-reported measures such as the VAS or NRS for pain, and the DASH or AUSCAN for function. Measures can also be used to objectively determine performance for dexterity, grip and pinch strength. The combination of subjective (self-reported) and objective performance measures can provide reliable, valid and responsive information about the outcomes of orthotic intervention, and contribute to evidence of effectiveness (COT 2015, p33)

15 Optimising service user outcomes contd.
Orthosis design and wearing regimen A wide range of prefabricated orthoses are available commercially; others are custom-made. These may be fabricated from a variety of materials, including thermoplastics, neoprene leather and hybrid combinations. Research studies have compared a number of these orthoses, for both osteoarthritis and rheumatoid arthritis. While some orthoses showed a greater effect on pain reduction, and others were preferred by participants, there is no consistent evidence of a superior orthosis design. Furthermore, the variance of wearing regimen is particularly evident within the evidence. (COT 2015, p34)

16 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) .

17 Optimising service user outcomes
Measuring outcomes 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. (Bani et al 2014 [C]; Bani et al 2013a [C]; Bani et al 2013b [A]; Boudstedt et al [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 [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]) 1A Orthosis design and wearing regimen 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. (Bani et al 2013b [A]; Becker et al 2013 [B]; Haskett et al 2004 [B]; Sillem et al [B]; Thiele et al 2009 [C]; van der Giesen et al 2009 [C]; Wajon and Ada 2005 [A]; Weiss et al 2004 [C]) 2A

18 Optimising service user outcomes
Service user experiences It is recommended that to optimise adherence to wearing a prescribed orthosis, the occupational therapist should discuss with the service user 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. (De Boer et al 2008 [C]; Gooberman-Hill et al 2013 [D]; McKee and Rivard 2004 [D]; Veehof et al 2008b [C]) 1A Activity 3 – can be carried out before moving onto the next slides Divide into groups again and ask them to consider what they think the impact of these guidelines will be for themselves, their service managers, the users of their service, and the commissioners of services. Obtain feedback from the groups before going through the suggested impacts on slides 19–23.

19 Impact of the practice guideline for you: the practitioner
Challenges / affirms your current practice. Provides evidence-based recommendations to inform and support your practice. Raises awareness of benefits and risks and organisational and financial barriers. Provides a vehicle for you to audit and justify your practice.

20 Impact of the practice guideline for managers
Provides evidence of the need for occupational therapy services for adults who have rheumatological conditions. Provides a structure to audit the work of occupational therapists within the service to improve service quality. Provides a vehicle for justifying service provision.

21 Impact of the practice guideline for commissioners
Articulates the need for occupational therapy interventions within services for adults with rheumatological conditions. Provides evidence-based recommendations developed by a NICE Accredited process. Can help educate commissioners to identify learning needs for the workforce. Audit form provides a mechanism to review service delivery in accordance with the evidence. NB: Highlight the significance of the guideline having been developed by the COT Guideline Development process which is NICE Accredited, e.g. COT practice guidelines developed using the NICE Accredited guideline process are clearly visible in search results on NICE Evidence. Guidelines developed via a NICE Accredited process are eligible for consideration as evidence in the development of NICE Quality Standards. Provides robust evidence-based recommendations that can demonstrate to commissioners the benefits of occupational therapy for the community on whose behalf they are commissioning services. Further information at:

22 Impact of practice guideline for service users
The recommendations reinforce the fundamental importance of the service user perspective and desired outcomes. In being adopted by services and occupational therapists, the guideline should improve the consistency and quality of intervention for users of services. Gives assurance that practitioners use the available evidence to support interventions.

23 Service user perspectives
“Try to get the therapist to underline that the outcome might not be clear if only restricted to a two- to four-week 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 am 79 – all my working life I was a draughtsman and the ‘splints’ did help reduce pain” “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” Conclude the session by summarising some of the key areas of discussion and messages from the guideline recommendations. Ask each participant to share a thought about the recommendations and to identify something they are going to do following the session. If applicable, you may also want to identify how as a service you are going to complete and monitor the Audit Form. Finish by reiterating the importance of a practice guideline in informing work with service users, focusing on empowering the service user to fully engage and take responsibility of achieving individual goals.

24 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 Resources are available from the Royal College’s website at:


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