NATIONALLY SPEAKING
Hand Rehabilitation
H
and therapy has developed
as a specialty of occupational therapy and physical
therapy in response to advances in
surgical techniques that enabled surgeons to perform more complex functional restoration of the upper extremity. Therapists have become
knowledgeable about surgical procedures and designed treatment programs for upper extremity conditions.
The foundation of hand therapy treatment is derived from the traditional
skills and knowledge of both occupational therapy and physical therapy
combined with innovative approaches
to treatment based on clinical experience. Hand therapists are occupational and physical therapists who
have become proficient in the application of these advanced clinical
skills to treat upper extremity dysfunction.
Hand therapists idenitify themselves as physical therapists or occupational therapists specialiZing in
hand rehabilitation because they recognize that their professional education serves as the foundation for their
specialization in hand rehabilitation.
The similarities in education and
practice facilitate communication and
form areas of overlap in clinical practice. The differences in treatment
techniques encourage the sharing of
knowledge, which leads to a greater
number of therapeutic options. The
fundamental similarities and differences between occupational and
physical therapy have proVided a basis
for the successful blending of the two
profeSSions into an advanced specialty. Specialization also led to a revaluation of the traditional roles that
therapists assume and created a need
to define and clarify those roles.
Mary C. Kasch
Role Delineation Study
of Hand Therapy
The American Society of Hand Therapists (ASHT) was incorporated in
1977 to promote continuing education, research, publications, and standards of practice in the rehabilitation
of the upper extremity. As the ASHT
grew, it became apparent that membership in the society was viewed as
an implied form of certification. Some
Mary C. Kasch, OTk, eVE, is Director of
the Hand Rehahilitation Center of Sacramento, a division of Therapy Management, 1020 29th Street, Suite 250,
Sacramento, California 95816. She is
an active founding memher and a
past president of the American Society of Hand Therapists.
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employers reqUired ASHT membership, and some physicians and insurance carriers referred patients only to
ASHT members. The society did not
wish to "certify" therapists in this
manner; therefore, in 1984, it began
to investigate how to establish a formal certification program.
The society contacted the National Commission for Health Certifying Agencies (NCHCA), now known
as the National Organization of Competency Assurance (NOCA), which
establishes standards of quality for
certification programs. The criteria of
the American Medical Association
Committee on Allied Health Education and Accreditation were also reviewed. In accordance with NCHCA
gUidelines, the ASHT performed a
role delineation study to determine
the theory and knowledge as well as
the actiVities, skills, and modalities
that are essential to hand therapy.
Study respondents evaluated the
theory, knowledge, and activities,
skills, and modalities in the four dimensions of frequency, importance,
education, and learning (Chai, Dimick, & Kasch, 1987).
Fundamental theory and knowledge include a comprehensive understanding of (a) upper extremity
anatomy and how it is altered by pathology; (b) muscle, sensory, and vascular physiology; (c) kinesiology and
the biomechanics of the upper extremity; (d) the histology of tissue
healing and the effects of immobilization; (e) the effects of temperature
and electrical currents on tissue; and
(f) surgical procedures of the upper
extremity. The activities, skills, and
modalities arise from the application
of theory and knowledge in clinical
practice.
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Hand Therapy Certification
One purpose of the role delineation
study was to define the content areas
for a certification examination, Certification is the process by which a nongovernmental agency or professional
association grants recognition to a
person who has met certain predetermined qualifications (e,g" successful
completion of an examination), The
benefits of certification for individual
therapists include professional recognition, the attainment of advanced
knowledge, and the achievement of a
personal and professional goal. Certification also helps to ensure the competency of practitioners prOViding services to the public, lends credibility
to the certifying agency, and allows
the agency to set standards for the
profession, The ASHT is developing a
certification program in hand therapy
and has contracted the American College Testing (ACT) Program as the
consultant for both the role delineation study and the certification examination, The first certification examination in hand therapy will be
administered in 1991. Hand therapy
review courses, a study guide, and a
field testing program will be offered
prior to the examination, Complete
information about the certification
program is available from the American Society of Hand Therapists, Hartwell Plaza, 1027 Highway 70 West,
Garner, NC, 27529,
Hand Therapy Practice
The role delineation study revealed
that respondents had practiced for an
average of 11 years and specialized in
hand therapy for an average of 6Y2
years. They were most likely to provide hand therapy services in general
hospitals or in therapist-owned private practices (Chai, Dimick, &
Kasch, 1987),
The majority of hand therapists
are primarily involved in clinical practice, although many also spend time
in teaching, research, and administration, Teaching tends to be informal
rather than formal, occurring in the
clinic, in study groups, or in journal
clubs rather than in the classroom,
Hand therapists frequently act as consultants on both a formal and an informal basis, Clinics may contract an
established hand therapist to consult
on practice or administrative issues,
Consultation frequently takes place
informally, through networks such as
the ASHT or the American Occupational Therapy Association (AOTA),
The case management activities
of hand therapists most often occur in
worker's compensation cases when
the injured worker may require a variety of services and referrals that range
from primary care to vocational rehabilitation, Although rehabilitation
nurses typically serve as case managers in worker's compensation,
some occupational therapists are consultants to insurance carriers and
make recommendations for comprehensive care, The groWing need for
case managers could appropriately be
filled by occupational therapists who
understand the worker's compensation system, Strategic marketing is
recommended to educate insurance
carriers about the training and expertise of occupational therapists,
Experience in Hand Therapy
As in any advanced specialty, entry
level occupational therapists may feel
there are limited opportunities to obtain experience in hand therapy, Occupational therapists who wish to
gain skill in hand therapy can best
learn under the direct supervision
and training of an experienced hand
therapist, because it is difficult to ob·
tain a comprehensive understanding
of hand dysfunction when working independently, Many therapists feel that
a hand therapist should undergo a
training period that consists of at least
1 year of general rehabilitation experience and 2 years of hand therapy experience, During this 2-year training
period, the hand therapist should gain
proficiency through clinical experience, should attend continUing education seminars, and should complete
an independent study program using
hand rehabilitation literature to establish a sound theoretical basis for
treatment.
Some centers offer (a) an optional third affiliation (in addition to
the reqUired affiliations) to new graduates or (b) advanced clinical training
for experienced therapists who are interested in exploring hand rehabilitation as a specialty, Therapists who are
sure they want to pursue this specialty
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may need to be creative to obtain the
experience they need, Some hand
centers will train per diem therapists
who can eventually move to staff positions, Some therapists are now contracting for a 2-year training program
with an incremental salary range; the
therapists' salary level increases as
their skills and knowledge increase:
and they can work more independently, carry a greater patient load,
and thus increase clinic revenue,
There will certainly continue to be a
shortage of experienced hand therapists, which creates an excellent job
outlook for those who are well
qualified.
Contributions of Occupational
Therapists to Hand
Rehabilitation
Occupational therapists have contributed significantly to the research and
literature on hand rehabilitation in
textbooks, journals, monographs, and
Video presentations, Many of the contributors to Rehabilitation of the
Hand (Hunter, Schneider, Mackin, &
Callahan, 1984) are occupational therapists, The Journal ofHand Therapy,
published by Hanley and Belfus,
began quarterly circulation in 1987
with original research and clinical articles, Occupational therapists played
a role in establishing this publication,
The Hand practice information
packet, published and distributed by
AOTA, includes literature citations of
more than 300 occupational therapists; it continues to be one of the Association's most popular packets,
Many leaders in the field of hand
therapy are occupational therapists,
including nine ASHT presidents, In
the role delineation survey, 72% of
the respondents identified themselves
as occupational therapists (Chai, Dimick, & Kasch, 1987), Occupational
therapists have contributed significantly to the growth of hand rehabilitation, and the profession should be
proud of the accomplishments of its
members,
The Future of Hand Therapy
As surgical techniques and technology continue to improve, the need for
specialized hand care will grow, and
therapists will need to further de-
March 1989. Volume 43, Number 3
velop and modify literature-referenced treatment protocols based on
the concepts of wound healing and
tissue maturation. Continuing education, research, and publications will
be critical to the continued development of hand therapy. Reimbursement issues will become increasingly
important as insurance carriers attempt to limit payments for treatment
of non-life-threatening problems. Occupational therapists will be asked to
demonstrate efficient and effective
treatment programs and the appropriate use of resources. Occupational
therapists are uniquely trained to
adapt the environment to a person's
special needs and to facilitate a person's functional restoration; these par-
ticular skills support the societal goal
of making the best possible use of
available resources. Hence occupational therapists are presented with
challenging opportunities. For instance, in California recently, the
rules and regulations governing the
provision of vocational rehabilitation
services under worker's compensation were revised; the first priority is
to return an injured worker to a modified job with his or her previous employer. Job and workplace modifications prOVide an obvious role for
occupational therapists working in
industry, many of whom are hand
therapists.
Hand therapy is only one of a
number of speCialty areas in occupa-
tiona I therapy, but, with a history of
only 11 years of organized activity, it
is one of the most dynamic and rapidly developing specialties. The remarkable growth of hand therapy
challenges all occupational practitioners to be active in their profession. Although individual attainment
of goals is a personal measure of success, each of us contributes to the
whole when we share the same vision.
References
Chai, S. H, Dimick, M. P., & Kasch,
M C. (1987). A role delineation study of
hand therapy. journal ofHand Therapy, 1,
7-17.
Hunter,]. M., Schneider, L. H,
Mackin, E.]., & Callahan, A. D. (1984). Rehabilitation of the hand. St. Louis: C. v.
Mosby.
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