hayley m. shelton department of occupational therapy

OCCUPATIONAL THERAPY’S ROLE IN HAND THERAPY

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Occupational Therapy’s Role in Hand Therapy: Approaches and Perspectives

Hayley M. Shelton

Department of Occupational Therapy, Indiana University


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Acknowledgements

The completion of this doctoral capstone experience would not have been possible without the

tireless support and assistance of many individuals. I would like to express my sincere thanks to

the following individuals:

Sally Roscetti and Valerie Goodwin, my capstone mentors, for being willing to take on a

fourteen-week capstone student. Their knowledge base and expertise constantly challenged

me and increased by understanding of hand therapy diagnoses and treatment protocols. Thank

you for taking on the role of mentor and helping me to become a better clinician.

Dr. Albright, my faculty adviser through the capstone experience, for helping shape my thinking

surrounding this project. Thank you for always being available for meetings and discussions to

narrow down my experience, goals and objectives. Without your guidance, this project would

have not come to fruition.

Community Physical Therapy and Rehabilitation – Hillsdale Office, for being willing to accept a

student, in the midst of COVID-19, and allow me to gain additional insight into upper extremity

rehabilitation through shadowing multiple therapists.

Lastly, to my family, fiancé, and fellow classmates, this would not have been possible without

the constant love and support from all of you. Your constant encouragement has been such a

blessing through this whole process – thank you.


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Table of Contents

Abstract ................................................................................................................................. 4

Introduction .......................................................................................................................... 5

Needs Assessment ................................................................................................................. 6

Literature Review and Gap Analysis Statement ........................................................................ 8

Model for Capstone Completion .......................................................................................... 11

Capstone Project Plan and Process ....................................................................................... 12

Plan .......................................................................................................................................... 12 Goals ........................................................................................................................................ 12 Program evaluation ................................................................................................................. 13

Capstone Project Implementation ........................................................................................ 13

Table 1 ...................................................................................................................................... 15

Capstone Project Evaluation ................................................................................................ 15

Provocative Testing .................................................................................................................. 16 Occupation Based Interventions .............................................................................................. 16

Capstone Discussion and Impact .......................................................................................... 17

Conclusion .......................................................................................................................... 17

References .......................................................................................................................... 19

Appendices .......................................................................................................................... 21


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Abstract Hand therapy is a practice area within occupational therapy. Occupational therapists have a

unique skillset in which they are able to treat patients with upper extremity musculoskeletal

injuries while realizing that each patient is an occupational being. The purpose of this capstone

was to identify reasons occupational therapy practitioners lacked occupation-based

interventions in treatment sessions, search the literature to find the best way to implement

occupation-based interventions, and for the capstone student to utilize the findings from the

research to provide the best possible patient care. Research suggests a combination of the

biomechanical frame of reference and occupation focused frame of reference is the best

approach to patient care in hand therapy. However, having the skillset to do that comes after

months of experience. This capstone student identified the ways having a capstone in hand

therapy in addition to a level II fieldwork in hand therapy advanced their skillset past that of an

entry level practitioner. The capstone student implemented occupation-based interventions

into treatment sessions and utilized advanced skills, such as provocative testing, to advance

their skills beyond a level II fieldwork student. The student then created a table outlining the

differences between a fieldwork student and a capstone student for future students and

practitioners to use as a reference.

Keywords: hand therapy, occupational therapy, occupation-based, capstone student,

advanced clinical skill


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Occupational Therapy’s Role in Hand Therapy

Introduction

A qualified hand therapist is able to assess and treat individuals who have conditions

affecting the hand or upper extremity. Hand therapists work in close contact with physicians

and the patient to reach each patient’s desired outcome. According to the American Society of

Hand Therapists (2020), hand therapists can be either occupational or physical therapists who

have passed a certification exam and achieved at least 4,000 hours of hand therapy practice. Of

hand therapists, approximately 80% are occupational therapists (Hand Therapy Certification

Commission, n.d.). Occupational therapists are uniquely trained to focus on people as

occupational beings, however, hand therapy challenges that notion, as it has historically utilized

a biomechanical frame of reference. Literature has long suggested that occupation-based

treatments in hand therapy are the gold standard, however, implementing them in today’s

health care field is challenging.

Over the past decade occupational therapy has been going through a paradigmatic shift

towards viewing a person as a combination of their participation in daily activities and

occupations, instead of viewing them as their level of impairment or disability (Robinson,

Brown, & Obrien, 2016, p.293). At Community Physical Therapy and Rehab, the capstone

student will be challenged to gain advanced clinical skills while still remaining occupation

focused in intervention approaches. Robinson, Brown, and O’Brien (2016, p. 293) stated,

“…therapists must avoid neglecting the unique occupational needs of each individual by fixating

on specific anatomical structures and failing to acknowledge clients as occupational beings.”

The purpose of this Doctoral Capstone Experience (DCE) is to further develop clinical skills as an


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occupational therapist focusing in hand therapy, and doing so while remaining occupation

focused.

Needs Assessment

The lack of occupation-based interventions in hand therapy has been well studied. What

has not been as well studied is how to shift the focus in hand therapy clinics to more on

occupation rather than function. That is one of the two problems the capstone student will be

addressing in their doctoral capstone. As a student entering into a hand clinic, knowledge

gained from the literature and didactic course work will be used to ensure implementation of

occupation-based approaches to the caseload at Community Physical Therapy and Rehab. The

capstone student will tailor interventions to be more holistic and patient focused, by focusing

on the patient and their specific occupational needs.

Interview and Results Interpretation

Community Physical Therapy and Rehab is an outpatient orthopedic clinic that focuses

on musculoskeletal disorders of the body. This clinic is affiliated with the Community Health

Hospitals. At this location there are a vast number of physical therapists (PT’s) and physical

therapy assistants (PTA’s), and there are three occupational therapists (OT’s) who specialize in

upper extremity rehabilitation. The capstone site mentor is a certified hand therapist. The other

OT’s on site are actively working toward attaining their certification in hand therapy.

The plan for the need’s assessment interview was to compile questions that will assist in

better understanding conditions seen at the clinic, demographics of patients seen at the clinic,

and what daily clinic flow looks like. At the capstone site, the main focus will be to gain

advanced clinical skills in hand therapy that would not be able to be achieved by simply


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completing Level II Fieldworks. Determining how to differentiate the capstone and fieldwork

was a major discussion between the capstone student and the capstone mentor. Based on the

common conditions identified by the capstone site mentor, the student was able to get a better

idea of injuries, conditions, or diagnoses in which advanced clinical skills can be gained it.

Listed below are questions asked during the needs assessment interview:

• Can you give me a brief description of what a typical day looks like for you?

• What are the common diagnoses seen at this particular clinic?

• Where do most of your referrals come from? Which doctors/types of doctors refer to

you the most?

• Are you aware of the demographics of a majority of your patients?

• Are there any other stakeholders or people I may be working closely with that you feel I

should be in contact with?

• Have you or this clinic had a previous DEC student? And if so, what have they done?

These questions provided the student with insight into how this clinic serves its patients and

what exactly that looks like on a daily basis. More information was gained on common

conditions seen at this clinic and what further literature review is needed to provide

occupation-based interventions for similar patients. These questions directly relate to

occupational therapy and the services occupational therapists provide. While hand therapy

typically utilizes a biomechanical framework, we also have the unique lens of looking at

occupational engagement and performance.


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Best Practices According to the literature, the best practice for occupational therapists in the hand

therapy setting is to implement occupation-based interventions alongside exercise

prescriptions and physical agent modalities (Robinson et al., 2016, p. 293).

According to Robinson et al:

Findings indicated that the use of occupation simulation for individuals with

acute or chronic hand injuries resulted in statistically significant higher levels of

improvement in patient-rated outcome measures as well as pinch, grip and

range of motion compared to those who underwent traditional exercise-based

treatment. (p.295)

There appears to be an issue with knowledge translation from what research is indicating and

current practice.

Problem Statement

Based on the results of the needs assessment, two problems arose that the student will

be addressing. The two problems are intricately connected to one another. The first is how

does the student gain advanced clinical skills in hand therapy while still remaining occupation

and evidence-based, even if the clinic does not support that way of practice? The second is how

can the student accurately measure the advanced clinical skills gained that set them apart from

a Level II Fieldwork Student?


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Literature Review and Gap Analysis Statement

Occupation and Hand Therapy

According to Robinson et al. (2016), “Hand therapy differs from other occupational

therapy specializations because it merges occupational therapy and physiotherapy practice

approaches to treatment” (p. 293). Amiani (2004) suggested the merging of occupation-based

hand therapy and sound biomechanical principals as a way of balancing the treatment

approaches with the importance of occupation as a therapeutic mechanism. Many occupational

therapists who practice in hand therapy settings have affirmed not only the value of

occupation-based treatments, but also wanting to incorporate them into their practice

(Colaianni et al., 2015). However, there are many reported barriers to implementing

occupation-based interventions into hand therapy. According to Colaianni and Provident (2010,

p. 130), “Reported barriers to occupation-based interventions include logistic issues,

reimbursement issues, the limitations imposed by the client’s medical conditions or the

treatment protocol, and creditability of occupation-based interventions.”

Jack and Estes (2010) directly address the difficulties clinicians cited with applying occupation-

based interventions into practice:

This investment of time and self appears incongruent with today’s health care system, in

which productivity is paramount and treatment time is curtailed, yet accountability to

both patient and payer sources is essential. In this era of managed care, hand therapy is

increasingly perceived as a practice area in which mechanical skill must often

overshadow client-centered approaches to meet health insurer demands. (p. 82)


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The problem hand therapy clinicians are left to figure out is how to balance what they know is

best practice, with the constraints of today’s health care system.

According to the literature, the best practice for occupational therapists in the hand

therapy setting is to implement occupation-based interventions alongside exercise

prescriptions and physical agent modalities (Robinson et al., 2016, p. 293).

According to Robinson et al:

Findings indicated that the use of occupation simulation for individuals with

acute or chronic hand injuries resulted in statistically significant higher levels of

improvement in patient-rated outcome measures as well as pinch, grip and

range of motion compared to those who underwent traditional exercise-based

treatment. (p.295)

In a study conducted by Grice (2015), the primary reason listed by clinicians for not

utilizing occupation-based assessments and treatments was simply a time limitation. However,

in that same study, 79% of participating clinicians believed utilizing occupation-based

assessments and treatments were important for the hand therapy population. Daud et al.

(2016) conducted a randomized controlled trail in which therapeutic exercise alone versus

therapeutic exercise and occupation-based interventions were utilized. In analyzing the

Disabilities of the Arm, Shoulder, and Hand (DASH) scores for patients, Daud et al. fund that

there was a statistically significant difference between scores. Patients who received

therapeutic exercise and occupation-based interventions had more improvements on the DASH

compared to those who only received therapeutic exercise. The literature is clear on what


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works best in hand therapy, yet there is still a disconnect from what is evidence-based and

what is currently happening in practice.

Determining the Gap

For this capstone experience, the presented cap is within the students’ own knowledge.

The student will be completing this experience at Community Physical Therapy and Rehab to

gain advanced clinical skills in hand therapy. This student has already completed a Level I

Fieldwork in an outpatient hand therapy clinic, a twelve-week Level II fieldwork in outpatient

hand therapy clinic that focused mainly on a biomechanical frame of reference, gained over 200

shadowing hours in an additional orthopedic hand clinic, and spent a summer as a tech at a

hand therapy clinic. Despite these opportunities, the student’s knowledge is still equivalent to a

Level II fieldwork student. Even with this past experience, there is still a gap within the

student’s own knowledge in hand therapy. The goal of this this capstone experience is to

narrow the gap in knowledge during the fourteen weeks spent at the DCE site.

Model for Capstone Completion

In order to provide a theoretical basis for this capstone project and guide clinical

reasoning of this process, the Person-Environment-Occupation-Performance (PEOP) Model with

be utilized. According to Strong et al. (1999), the PEOP model allows for practitioners to

systematically approach the analysis of occupational performance issues while considering the

complexities of human functioning and experience. This model will allow the student to frame

thinking in a way that allows for occupational performance and participation to be blended

with sound physiologic therapeutic processes. People are more than their physical disabilities


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or conditions. People perform occupations and interact with their environment. Thus, it is

important to take all parts of a person into consideration when providing therapeutic services.

For this capstone, being able to balance meaningful occupations with orthopedic recovery

principles is the gold standard. By using this model, the student will have a consistent

theoretical base to guide thinking and implementation of the capstone project.

Capstone Project and Plan Process

Plan

After conducting an in-depth needs assessment, literature review, and taking time to

determine the gap, the plan for the capstone experience was identified. The student will be

completing hands on clinical care four days a week, focusing on occupation-based care, and

take the additional day to work on synthesizing learning and knowledge in a way to show

advanced skills in hand therapy compared to a level II fieldwork student.

Goals

Prior to the beginning of the doctoral capstone experience, several goals and objectives

were identified to guide the process along. These goals were created in collaboration with the

site mentors and my faculty advisor. The goals and objectives are found below:

Project Goal 1: Gain advanced clinical skills in occupation focused hand therapy, beyond that of

a Level II Fieldwork student, by participating and leading treatment and intervention sessions

for patients with upper extremity injuries.

Objective 1: Maintain a case load of patients within 14 weeks, that will give me an

additional 14 weeks of advanced clinical practice beyond that of a Level II Fieldwork

Student.


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Objective 2: Research various rehabilitation protocols for common upper extremity

diagnoses and the outcomes associated with the different protocols.

Objective 3: Draw conclusions and synthesize knowledge gained over the previous two

hand therapy fieldwork experiences.

Project Goal 2: Gain advanced knowledge and skills in provocative testing and objective

measures for common upper extremity conditions

Objective 1: Research various provocative tests for common upper extremity diagnoses.

Objective 2: Research the specificity and sensitivity of previously identified provocative

tests.

Objective 3: Complete provocative test on patients or other clinicians to reinforce skills

learned and to gain feedback on technique and accuracy of the tests.

Project Goal 3: By the end of the 14-week capstone experience, be able to show the way the

gap in my knowledge has closed compared to the beginning of the capstone experience.

Objective 1: Provide a handout of various provocative tests learned and completed for

the upper extremity.

Objective 2: Be able to verbalize the differences between a fieldwork student and a

doctoral capstone student gaining advanced clinical skill in hand therapy.

Evaluation

In order to determine the success of the capstone experience, the student will complete

a verbal report discussing the differences found between a capstone student and a fieldwork

student in the hand therapy setting. This verbal report will include the differences the student

has been made aware of. It will also show how clinical skills have been advanced beyond that of


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a fieldwork student. Additionally, it will highlight how the student utilized an occupation-based

lens within a biomechanical model. The verbal report will assist the clinicians in understanding

the difference between the two experiences and be something they can use moving forward

with other students. A presentation will also be created outlining major provocative tests for

the upper extremity. This presentation will show which ones were mastered during the 14-

week capstone experience, compared to the 12-week fieldwork experience. This presentation

can be found in Appendix A.

Capstone Project Implementation

Over the first four weeks, the student began implementing more occupation-based

interventions within the hand therapy setting, as well as utilizing provocative testing to

accurately and efficiently identify probable causes of musculoskeletal pain. At week 7 the

student was carrying up to 75% of the full caseload consistently. During those weeks, the

student focused on occupation-based means of providing upper extremity rehabilitation.

Interventions were tailored to focus on meaningful occupations. For example, one patient

sustained a distal radius fracture that required an open reduction internal fixation. In the initial

visits, care was taken to protect the healing fracture, manage edema, and work on finger range

of motion and gentle wrist motion. As the patient progressed and we were able to begin more

aggressive motion and strength training, the student utilized occupation-based approaches to

rehabilitation. This patient was an avid musician and was worried about her strength of holding

and plucking the strings of her guitar. The student utilized putty with beads for work on string

plucking. The student also focused on marble raking to facilitate greater tendon gliding to the

distal interphalangeal joint, which is very important for a guitarist to have.


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Over the final seven weeks of the capstone the student was managing a full case load of

patients and completing all evaluations, progress reports, and discharge summaries. Every

evaluation the student was required to use provocative testing to better understand and

identify sources of pain and probable diagnoses of patients. The skills utilized were beyond

those required for a level II fieldwork student and considered advanced practice for a student.

During the off-site days the student compiled a list of provocative tests for the upper

extremity and identified their various sensitivities and specificities. The student then took care

to utilize those tests when appropriate on patients.

During the fourteenth and final week of the capstone experience, the student was able

to verbalize the differences between a level II fieldwork student and a capstone student who is

gaining advanced clinical skill in hand therapy. The results and synthesis of the differences can

be found in Table 1. These foundational differences helped to better differentiate the two

experiences and can be used furthermore for clinicians and students as a means to understand

the distinct value of both fieldwork and capstone.

Table 1

Comparing and Contrasting Level II FW Student and Doctoral Capstone Student in Hand Therapy

Level II Fieldwork Student Capstone Project Evaluation

• 12 weeks long • General entry level skills • Works up to full caseload by end of 12-

week experience • General understanding of commonly

seen conditions and injuries • Close supervision from educator • Able to fabricate basic orthoses • Introduced to dynamic orthoses

• 14 weeks long • Advanced clinical skills • Able to reach full caseload within 7 weeks • Advanced understanding of conditions

and injuries and typical progression • More autonomy from educator • Able to fabricate more complex orthoses • Able to fabricate variety of dynamic

orthoses


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Capstone Project Evaluation

A level II fieldwork student should, by the end of the experience, be considered an entry

level practitioner. Over the course of the 12-week experience, the student should reach full

case load by the last week. A doctoral capstone student already has experience and is able to

jump into a full caseload once learning the specifics of the certain clinic. The capstone student

is also already familiar with general diagnoses and begins to gain a greater understanding of

typical disease progression or injury healing and is better able to understand when things are

not progressing as they should. That is a valuable asset that is usually gained after one has

begun their first job. A capstone student is also able to look beyond a purely biomechanical

frame of reference and begin to utilize occupation-based interventions, which literature has

suggested is best care for patients. Having a capstone in advanced clinical skill allowed the

student to gain those foundational skills before gaining employment which is very beneficial

and marketable when looking for jobs.

Provocative Testing

A capstone student, by the end of their rotation, will have 26 weeks of experience in

whatever clinical setting they are choosing to gain advanced clinical skill in. That equates to

approximately half a year dedicated to focusing on, learning, and refining specialized skills to

better prepare them for their future in occupational therapy. As part of gaining advanced

clinical skills in hand therapy, the capstone student was able to learn and implement various

provocative tests for the upper extremity. Provocative tests are utilized as a means to detect

whether certain conditions are present in a patient. While these tests are not always sensitive


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and specific in nature, they allow clinicians to better understand what may be causing pain for

the patient. These tests are helpful when practitioners receive a general referral.

In some hand therapy clinics, referrals are generalized to “hand pain” or “elbow pain”. It

is up to the therapist to identify probable causes of the pain. Therefore, provocative tests are

an essential skill for practitioners to have. The capstone student had minimal knowledge in

provocative testing prior to the capstone. As a fieldwork student, more time was spent on basic

skills and less time was devoted to advanced learning.

Occupation Based Interventions

Literature suggests that occupation-based interventions in combination with

biomechanical exercises produces the best therapeutic results for patients (Robinson et al.,

2016, p. 293). The capstone student had 12 weeks of experience treating hand and upper

extremity injury patients. During that time, the student mastered biomechanical exercises.

Therefore, when on capstone, they were able to implement more occupation-based

interventions and had the ability to think critically how to combine the two frames of thinking

in order to provide the best care for patients. This was affirmed by the capstone site mentor

who stated in the final evaluation that the student showed competence in critical thinking and

ability to combine occupation specific tasks with biomechanical processes to create effective

patient centered treatment sessions.

Capstone Discussion, Impact, and Sustainability Plan

Since the capstone student’s project was more tailored as an experience to gain

advanced clinical skills in hand therapy, the impact and sustainability plan was more focused on

the student retaining knowledge rather than the community site being left with a project to


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sustain. The capstone student’s knowledge base grew exponentially during the fourteen-week

experience. They gained confidence in treating patients, providing interventions, and

understanding more complex diagnoses and injuries. The sustainability plan for the student is

to use the knowledge gained to retain a job in hand therapy and keep expanding their

knowledge base. After three years the student plans to sit for the certified hand therapist (CHT)

exam to show how the knowledge they gained enabled them to attain advanced credentials in

hand and upper extremity rehabilitation.

The capstone student left the site with a knowledge base about the differences between

a fieldwork student and a capstone student. Clinicians are still learning the differences between

the two experiences and how the focus of the experiences differs. The student is also leaving

the clinic with an outline of provocative tests along with their specificity and sensitivity of each

test. That presentation can be referenced indefinitely.

Conclusion

Hand therapy is a small sector of occupational therapy. Historically it has been criticized

for its lack of focus on occupation, however, hand therapy has been shifting its focus to a

combination between biomechanical and occupational frames of reference. When the

capstone experience was added to the occupational therapy school plan of study, it allowed for

the opportunity for students to gain advanced clinical skill in an area if interest. This additional

fourteen-week experience provided this capstone student with the opportunity to advance

their skill set and apply more occupation-based interventions, as well as gain higher knowledge

levels about hand therapy conditions and diagnoses. The identified gap in the students’

knowledge was narrowed and the understanding of how a capstone student differs from a


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fieldwork student was also identified. More research and understanding is still needed to

address the differences between the two students in other areas of practice, however this

project can be used as a foundation for others to frame their thinking.


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References

Amini, D. (2004). Renaissance occupational therapy and occupation-based hand therapy. OT

Practice, 9, 11-15.

Bhavnani, G. (2000). Toward occupation-based practice in hand rehabilitation. Physical

Disabilities, 23(4), 1-2.

Colaianni, D., & Provident, I. (2010). The benefits of and challenges to the use of occupation in

hand therapy. Occupational Therapy in Health Care, 24(2), 130-146.

Colaianni, D. J., Provident, I., DiBartola, L. M., & Wheeler, S. (2015). A phenomenology of

occupation-based hand therapy. Australian Occupational Therapy Journal, 62(3), 177-

186.

Daud, A. Z. C., Yau, M. K., Barnett, F., Judd, J., Jones, R. E., & Nawawi, R. F. M. (2016).

Integration of occupation-based intervention in hand injury rehabilitation: a randomized

controlled trial. Journal of hand therapy, 29(1), 30-40.

Grice, K. O. (2015). The use of occupation-based assessments and intervention in the hand

therapy setting–A survey. Journal of Hand Therapy, 28(3), 300-306.

Hand Therapy Certification Commission. (n.d.). Who is a certified hand therapist? Retrieved

from https://www.htcc.org/consumer-information/ th6e-cht-credential/who-is-a-cht

Jack, J., & Estes, R. I. (2010). Documenting progress: Hand therapy treatment shift from

biomechanical to occupational adaptation. American Journal of Occupational

Therapy, 64(1), 82-87.

Robinson, L. S., Brown, T., & Obrien, L. (2016). Embracing an occupational perspective:

Occupation-based interventions in hand therapy practice. Australian Occupational


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Therapy Journal, 63(4), 293–296. doi: 10.1111/1440-1630.12268

Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the

Person-Environment-Occupation Model: A practical Tool. Canadian Journal of

Occupational Therapy, 66(3), 122–133. https://doi.org/10.1177/000841749906600304

Why See a Hand Therapist. (2017, June 27). Retrieved June 11, 2020, from

https://www.asht.org/patients/why-see-hand-therapist


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Appendix A

Provocative Testing Presentation


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hayley m. shelton department of occupational therapy

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