A Brief Review
Karin BOER-VREEKE,
BScOT, ECHT, CSTP© , EFSHT President- Elected
”SELF-MANAGEMENT IN ADULTS AFTER DISTAL RADIUS FRACTURE: A MIXED METHODS EXPLORATION”
Brocha Z. STERN, MOT, OTR, CHT. Submitted in Partial Fulfilment of the Requirements for the Degree of Doctor of Philosophy in the Steinhardt School of Culture, Education, and Human Development, New York University (NY), USA, 2020
Being a hand-therapist and CSTP, I treat a lot of patients. One of my questions during the first interview is always, “what do you expect from me during treatment?” and “what do you hope to achieve?”. I often get the following answer: “I want you to make my hand better”, or “I want you to take away the pain”, but most of all “I want it to be as before”. They sometimes expect me to solve their problem. When I tell them, their hand is not a car, and that I’m not a mechanic, they can’t leave it with me to solve the problem, they seem surprised. I explain a hand is more like a plant, a living creature that happens to belong to them and it is their responsibility to take care of it and try to heal themselves. It’s my responsibility to educate them about their condition, what exercises or activities they can do, how to take care of their hand and support and coach them to take back control. The result will be best if they join me in my efforts and take their own responsibility for the rehabilitation.
Therefore, it is with great interest that I read the dissertation of Brocha Stern titled: ”SelfManagement in Adults after Distal Radius Fracture: a mixed methods exploration.” Reading this dissertation, I got more and more confirmed in my belief, that self-management and client activation to take responsibility for their own healing process is indeed the key to successfully treating both hand and neuropathic pain patients.
With this article I would like to give you a short overview of Stern’s dissertation and the key elements that helped me understand the importance of self-management. Although the dissertation is about self-management after Distal Radius Fractures (DRF), I strongly believe the findings can be applied to any other disease or trauma to the hand or other body parts and definitely for neuropathic pain patients. Stern is an Occupational therapist and the holistic view she used in her research is very interesting.
In her dissertation Stern states, Karl et al (2015) found that DRF are the most common upper extremity fractures of the human body for people over 50 years of age and second in the age of 35-49 years (Stern, 2020). Understanding all aspects of recovering from DRF helps to optimize health care outcomes and minimize health care costs. Most studies so far, concentrate on the biomedical models and pathophysiology in predicting the outcomes. Health after DRF was historically assessed using radiographies, range of motion, and strength measures (Stern 2020). Only more recently there is more interest in Patient-Reported Outcome Measures (PROMs). Stern therefore, chose to concentrate on the role of the individuals’ cognitions and behaviours in managing the sequelae of the injury in her study. In literature Stern finds evidence that suggests the focus on behaviour after DRF should not be delimited to adherence to medical recommendations, such as exercise prescription. Instead, considerations of behaviour should be expanded to how individuals manage symptoms and engage in functional activities at home (Stern, 2020).
With an exploratory mixed methods study she tried to describe and understand selfmanagement in adults after DRF. For this study Stern developed a framework to enable a systematic and holistic investigation of recovery after DRF and understand the role of risk and protective factors in self-management in adults after DRF.
The framework helped to structure the gathered information in Self-management process (knowledge and beliefs, behaviours, social facilitation), Perceived Health (physical, mental, social) and Risk and protective factors (personal, injury, environmental). In the study, Stern positioned perceived health as the outcome of self-management because of her recognition of the client-centered experience of recovery.
She gathered information from 31 patients, aged between 45 and 74, with an unilateral DRF within 2-4 weeks after discontinuation of full-time wrist immobilization. The qualitative information was gathered by using a semi-structured interview guide. The quantitative measures were different Patient Reported Outcome Measures, including the Patient Rated Wrist Evaluation (PRWE).
Most interesting outcomes of Qualitative measurement Stern found, involved the selfmanagement process. Both health care providers and laypersons contributed to the behaviours and cognitions by providing information, practical assistance, and emotional support. It was noted that limited or ambiguous information constrained the self-management process and contributed to uncertainty. A paternalistic health care model restricts the client’s activation and responsibility. Both must be avoided by health care professionals.
The Self-Management Process is described as Transitioning from Hurting to Healing with three underlying themes: 1). “learning because of my injury”, 2). “working and hoping toward healing”, and 3). “getting back to my normal self.” (Stern, 2020)
As a DRF is, like all injuries or diseases, never a planned event, most people have limited knowledge of consequences for daily life activities or medical management. This may cause uncertainty about the recovery and what movements and activities can be done safely. Stern found learning was experienced as an empowering component of the self-management process to facilitate healing (Stern, 2020). Learning can be seeking and receiving information about the symptoms and helps to decrease fears and increase the sense of control. Learning is also the experience of living through the injury and finding your own strategy to cope with all the challenges encountered. This involves an active engagement in the recovery process, “working”, which can only be done by the patient himself, supported by health care providers and their environment. “Getting back to my normal self” is an important goal most patients have and seems to be an important indicator of healing. Normal can be either the pre injury status or normal according to social or cultural norms. Temporarily having an extremity that does not look, feel, or act like your normal extremity, can give feelings of disconnection. The patient might feel less responsible for this extremity. The reconnection needs to take place before the patient can feel healed. The disruption of the normal body can also lead to disruption of the normal identity, when work, sports or social activities are disrupted as well.
As outcomes from the quantitative measures Stern found a moderate to strong correlation between self-efficacy for managing symptoms, emotions and daily activities and pain interference and perceived physical health. As self-efficacy to manage symptoms increased, pain and wrist-specific dysfunction, depression and anxiety decreased and participants reported better perceived health.
At last Stern compared qualitative and quantitative descriptions of self-management for participants with low and high Self-Efficacy (SE) for managing injury. She divided the participants in two groups, one half showing low SE and the other half showing high SE. Overall, the Low-SE subgroup reported poorer perceived physical, mental, and social health than the High-SE subgroup as per qualitative and quantitative data (Stern, 2020). The High-SE subgroup described greater reliance on themselves for medical, emotional and role management. They were less uncertain and more confident in their ability to move and use their hand than the low SE subgroup. They also showed more self-directed behaviours to manage the sequelae of injury.
Stern’s conclusions
In 2006 Bunketorp et al found that supervised therapy increased self-efficacy and decreased fear of movement more than independent exercise in clients with a non-chronic musculoskeletal condition (Stern, 2020). Together with her findings Stern proposes that self-management should be explicitly considered to optimize recovery after DRF and similar injuries (Stern, 2020). There is a large role for health care professionals to stimulate self-management in their patients by providing information about the injury, their expected recovery and how to move safely and use the extremity. A disruption of one’s physical capacity to function in their normal roles, leads to disruption of the occupational identity and participation. Occupation based interventions may facilitate self-efficacy, reconnecting to one’s body, taking back one’s identity and lead to less chronicity and lower the health care costs.
My opinion
Especially the part about “getting back to my normal self” is a very interesting part for neuropathic pain care. Patients with neuropathic pain very often have the sensation of being disconnected from their painful body part, sometimes for many years. When after the diagnostic testing the pain can be explained, the patient gets hope. Giving the tools (exercises) to treat the problem themselves, gives them back their self-efficacy. And when the pain reduces, they get back to their normal self and life.
REFERENCE
• Karl, J.W, Olson P.R. & Rosenwasser, M.P. (2015). The Epidemiology of Upper Extremity Fractures in the United States, 2009. J Orthop Trauma, 29(8), e242-e244.
• Stern, B. Z. (2020). Self-Management in Adults after Distal Radius Fracture: A mixed methods exploration (Doctoral dissertation, New York University) (pp. 1-297). Ann Arbor, MI: ProQuest.
