Hand and Upper Extremity Care: Specialization-Get the Secret Out!
By: Mojca “MO” Herman, MA, OTR/L, CHT
The epidemiology of upper extremity injuries is not well studied; furthermore it appears the rate of incidence is not predicted to slow down any time soon. A 2012 retrospective national study estimated that 3,468,996 upper extremity trauma cases were treated in the emergency department (Oootes, Lambert, & Ring, 2012). The impact that these injuries place on an individual can be life altering; exacerbated by family and work obligations, insurance benefits, as well as emotional, physical, mental and financial strains.
In light of increasing costs and decreasing reimbursement, it is acutely important that individuals with an upper extremity injury pursue the most appropriate and specialized providers in a timely manner. The first step to specialization involves finding an orthopedic doctor that exclusively treats upper extremity injuries; a hand surgeon. The second step entails locating a hand therapist who specializes in upper extremity rehabilitation; a Certified Hand Therapist (CHT). Hand surgeons reliably refer patients to CHTs and the specialty of hand therapy.
The following case study outlines a simple injury that resulted in an unnecessarily time consuming, frustrating and costly recovery.
A 37-year-old right hand dominant female sustained a left index finger injury on 7/8/14 while on vacation with her family. She is a married mother of 2 children, employed full time as an Administrative Assistant, and is extremely active with various outdoor hobbies.
The mechanism of injury was a sudden stop on a ski boat that caused the patient to slice the web space of her index finger on a hinge. She went to the ER the same day, had x-rays taken that were negative, received 7 stitches, and was instructed to keep her finger dry for 14 days. She was not given a referral for any specialized follow-up; furthermore she was not advised to perform any exercises. She was only advised to return in 2 weeks for stitch removal.
Since her injury occurred while on vacation, she had her stitches removed at home, but did not receive further medical intervention.
One month after the injury, her finger was getting worse; it was stiffening into a bent position resulting in less ability to straighten. Her chronically bent finger was impacting her functional use during daily life. She opted to consult with her general orthopedic doctor, who took further x-rays that were negative, and referred her to general physical therapy.
She attended general physical therapy for approximately one month, and overall did not make any sustainable gains.
She returned to her orthopedic doctor who ordered an MRI, and the results were negative. He referred her for a second opinion.
The second opinion also took x-rays and sent her to therapy but did not give her a direct referral since she lived far away.
Approximately 2 months had passed since her initial date of injury, and her finger was progressively losing extension and function. She referred to it as a “hook finger”. Needless to say she was frustrated.
She decided it was time to take matters in her own hands, and advocate for herself since she felt the medical system was failing her finger. She conducted her own research and located a reputable hand surgeon in her local area.
She consulted with the hand surgeon, her third doctor, approximately 2.5 months after her injury. He reviewed her MRI, diagnosed her with proximal interphanlangeal (PIP) joint flexion contracture, and referred her to hand therapy. He did inform her that with the time delay, she might have to face surgery if the therapy was not successful.
Approximately 3 months after her initial injury, on 10/1/2014, she consulted a Certified Hand Therapist at. She underwent a detailed and comprehensive evaluation that included assessment of her edema, range of motion, strength, pain, sensation, and functional impairment. Her main subjective complaints included pain, lack of motion and dropping items due to motion loss and inability to grip. Her immediate short-term goals were to make a full fist and fully open her finger so that she could resume her hobbies and be more productive at work.
She openly expressed pessimism in any hopes of more recovery given her lengthy and time-consuming visits to endless doctors with no improvements. She was also worried about the costs she was incurring.
Given that she wanted to avoid surgery, she was willing to give therapy one more try since she was now FINALLY consulting with a specialist in upper extremity rehabilitation.
Based on the detailed evaluation, she was given a custom tailored home exercise program for range of motion, edema management and splinting (Wollstein, R., Rodgers, J., Ogden, T., Loeffler, J., & Pearlman, J., 2012).
For edema management, she was educated on: retrograde massage, compression wrap for the finger, and ice.
The importance of general movement and range of motion was also stressed as she was compensating by using the rest of her digits, avoiding the index finger all together. She was initially directed to “buddy tape” to her middle finger to cue her to integrate it back into her daily living until it became more automatic.
Regarding splinting, a finger based serial static custom PIP (DIP was included) extension orthosis was fabricated (Puri, et al., 2013). It was created at the end of the therapy session when she was in as much PIP extension as possible. She was instructed to wear it at night and intermittently during the day (Glasgow, Wilton, & Tooth, 2003). Over the duration of her sessions, it was serially molded in greater PIP extension as the tissue allowed for it.
Had she not been so compliant with her daily home exercise program, a PIP/DIP flexion strap for daytime would have been indicated – to regain terminal flexion; but her self-directed exercises ultimately led to improved end flexion.
Outcomes were measured using objective tools including: grip dynamometer; pinch gauge; manual muscle testing (MMT); ROM with goniometer; Semmes-Weinstein Monofilaments for sensation; measuring tape to track improvement in edema; Visual Analog Scale for pain; Upper Limb Functional Index (ULFI) (Gabel, Michener, Burkett, and Neller, 2006) in addition to the Functional Independence Measure (FIM) to capture global occupational engagement.
Despite her uphill battle, she was motivated and compliant. She met her short-term goals in 3 sessions and was astonished at the rate of recovery in the hands of an expert. Simple phrases she expressed in her short time of specialized care:
“If I had only known you existed, I would have come directly to you.”
“ I would have saved so much time and money.”
“You need to get the word out. I will tell my orthopedist about you.”
“I accomplished more in three sessions than I did in the past 3 months.”
In light of changing healthcare, there is a greater need for educating the community regarding the existence of hand and upper extremity specialization, as well as for advocacy of the specialized care. Thanks to direct access to Internet search engines, websites, and patient reviews, informed research is readily available to the provider and consumer. In order to ensure efficiency, maximize recovery, and reduce costs, individuals with arm injuries need to advocate to be seen promptly by the hand and upper extremity experts. Help us get the secret out.
Information about CHT
What is a Certified Hand Therapist (CHT)?
A Certified Hand Therapist (CHT) is a board certified occupational or physical therapist that has a minimum of five years of clinical experience, a minimum of 4,000 hours in the direct practice of hand therapy, and has successfully passed a comprehensive advanced upper extremity exam. A CHT is the ultimate specialized credential a hand therapist can achieve.
What diagnoses does a hand therapist treat?
Surgical and non surgical conditions can include but are not limited to: finger/thumb sprains/strains, ligament and tendon injuries, dislocations, wrist fractures, carpal tunnel syndrome, trigger fingers/thumb, arthritis, tennis elbow, golfers elbow, repetitive strain injuries, nerve injuries/compressions, DeQuervain’s, thoracic outlet syndrome, frozen shoulder, rotator cuff injuries, general upper extremity fractures, amputations, burns, and tumors/cysts.
Hand therapists are trained in the use of various modalities to help reduce pain and swelling, i.e., ultrasound, heat, ice, paraffin, kinesiotape, iontophoresis, and other modalities that can assist with muscle re-education, i.e. electrical stimulation. Hand therapists are also advanced trained in ergonomic education, work hardening, activity modification as well as energy conservation and joint protection.
Skilled hands-on techniques include: soft tissue manipulation for swelling, scar tissue, and muscle tightness; manual stretching/mobilization of tight joints and muscles, as well as wound/scar management including desensitization and sensory re-education.
Lastly, hand therapists are remarkably proficient in assessing the need for custom splints/orthoses for various purposes. These could range from initial acute protection, to mobilizing stiff joints, as well as providing a safeguard when individuals resume life, work, sports and hobbies. Hand therapists are highly skilled at fabricating, adjusting, modifying and progressing the splints as the healing tissues improve. Customized splinting is a paramount adjunct to the hands-on therapy provided by hand therapists.
How do I find a Certified Hand Therapist in my area?
There are two entities that have searchable databases for locating a certified hand therapist. First, The Hand Therapy Certification Commission (HTCC) represents 6,005 Certified Hand Therapists worldwide. (CHT’s by profession: 85% Occupational Therapists, 14% Physical Therapists, and 1% is represented by both professions.) Second, most CHT’s belong to theAmerican Society of Hand Therapists (ASHT), a professional organization comprising of over 3200 licensed occupational and physical therapists worldwide specializing in the rehabilitation of the upper extremity.
About the Author
Mojca, “MO” Herman, MA, OTR/L, CHT, a former Olympian, has over 20 years of clinical experience and is currently in her 12th year of private practice in Torrance, California at the Advanced Therapy Center, an outpatient hand therapy clinic that specializes in hand and upper extremity care. Mo is involved in various hand therapy-related activities. She serves as a member of the ASHT Board of Directors and is an annual guest lecturer at the USC Graduate Occupational Therapy Program and at the UCLA Hand Surgeon Conference. She has co-authored several chapters on a variety of hand therapy topics for books and journals and has presented various courses at local and national level conferences. She is the recipient of the ASHT 2014 President’s Award in recognition of society contributions.
Gabel, C.P., Michener, L.A., Burkett, B., & Neller, A. (2006). The Upper Limb Functional Index: Development and determination of reliability, validity, and responsiveness. Journal of Hand Therapy, 19(3): 328-349.
Glasgow, C., Wilton, J., & Tooth, L. (2003). Optimal daily total end range for contracture: Resolution in hand splinting. Journal of Hand Therapy, 16(3), 207-218.
Ootes, D., Lambers, K.T., & Ring, D.C. (2012). The epidemiology of upper extremity injuries presenting to the emergency department in the United States. Hand (N Y). 7(1): 18–22.
Puri, V., Khare, N., Venkateshwaran, N., Bharadwaj, S., Choudhary, S., Deshpande, O., & Borkar, R. (2013). Serial splintage: Preoperative treatment of upper limb contracture. Burns, 39(6): 1096-1100.
Wollstein, R., Rodgers, J., Ogden, T., Loeffler, J., & Pearlman, J. (2012). A novel splint for proximal interphalangeal joint contractures: A case report.Archives of Physical Medicine and Rehabilitation, 93(10): 1856-1859.