Abstract
BACKGROUND:
Certified Hand Therapy is a subset of occupational/physical therapy that is relatively unknown to the common individual. Certified Hand Therapists (CHTs) help those with upper extremity injuries, whether it be those with workplace injuries, those who suffered a traumatic injury or those recovering from major surgery to reach the point where they are able to be independent and back to doing daily life activities.
OBJECTIVE:
This study aimed to discern the roles that Certified Hand Therapists have in rehabilitating individuals with upper extremity injuries, to assess their participation in work-related injury prevention, to examine with whom CHTs interact during the rehabilitation process, and to gain insight into how the relationships between CHTs and occupational safety professionals can be improved.
METHODS:
Structured interviews were conducted with eight occupational therapists who are Certified Hand Therapists or are in the process of being certified. Interviews were recorded, transcribed and analyzed to determine themes relative to the study objectives.
RESULTS:
Content analyses determined trends in job roles, interactions with occupational safety professionals, the importance of patient education in prevention and rehabilitation and barriers to effective treatment of work-related injuries.
CONCLUSION:
CHTs shared similar thoughts regarding their profession. CHTs revealed common themes in the eight interviews conducted. Specifically, many CHTs believe education is a vital part of the profession in terms of improving the profession and in the rehabilitation process. In addition, patient compliance and the current workers’ compensation system were seen as challenges when rehabilitating patients.
Keywords
Introduction
Background
In 2019, within the United States, there were 2,814,000 recorded cases of nonfatal injuries and illnesses that occurred within private industry [1]. These cases resulted in 888,200 days of work lost among the injured, ultimately inhibiting maximum productivity in these industries. Of the recordable cases, 295,180 involved sprains, strains, and tear injuries and 136,190 cases stemmed from injuries to the back. 244,000 cases were the result of accidental slips, trips and falls [1].
Many times, the injuries that afflict an individual in their respective industry occur in their upper extremities. In 2014, upper extremity injuries accounted for 346,170 cases of people who sustained injuries within their workplace, and the incidence rate for this number was 32 cases per 10,000 full-time workers. In addition, upper extremity injuries ultimately accounted for the highest percentage of injuries seen among full-time workers [2]. Of the 346,170 cases, approximately 40% were related to hand injuries, accounting for 137,440 cases. These upper extremity injuries included sprains, strains, tears and fractures, along with symptoms like soreness and pain in the upper extremities [2]. Other traumatic injuries, such as amputations accounted for 4,900 cases; chronic injuries, such as carpal tunnel syndrome accounted for 7,970 cases respectively [2].
The subspecialty of Certified Hand Therapy is a relatively new field, established in 1991 [3]. It was created to acknowledge occupational and physical therapists who had significant knowledge in rehabilitation of the upper extremities, including shoulders, elbows, wrists, and hands [3]. Becoming a Certified Hand Therapist (CHT) encompasses a great deal of work and practical experience. A CHT is an occupational or physical therapist who has a minimum of three years of clinical experience, including 4,000 hours of clinical practice in hand therapy [3]. To become a CHT, clinicians must also successfully pass a comprehensive exam of advanced clinical skills and theory associated with upper quarter rehabilitation [3]. The role therapists, including CHTs play in the treatment and prevention of upper extremity injuries is significant [4, 5], but has sometimes gone unnoticed and is underappreciated. There may be some explanation for this –there are only 6,228 CHTs worldwide and the research pertinent to this profession is still limited [3].
Although limited, the body of literature involving hand therapy is growing and supports the need for specialization and additional research related to the field. Keller and colleagues [6] identified that therapists spend most of their direct patient care time (54%) performing therapeutic interventions focused on the hand region (36%). In a separate study with CHTs, Dale and colleagues [7] identified that CHTs spend a significant amount of their time on adaptation, education and strategy, when handling a patient’s hand injury, including those injured at work, because of the cost containment environment that exists. New and emerging roles related to treating workers and preventing worker injuries have progressed as well. Research has begun to explore services the CHT could offer to industrial workplaces [8], including ergonomics education [9].
Although the studies mentioned above provide information on the profession, more information needs to be known, particularly since work-related hand and upper extremity injuries occur frequently, resulting in worker disability and organizational productivity loss. CHTs may be able to contribute significantly to improving worker health, safety and wellbeing, particularly if they are able to collaborate with occupational safety and health professionals. Collaboration between occupational safety and health professionals and CHTs could potentially reduce the number of work-related injuries seen annually and effective communication between the professions could result in more effective return to work strategies. Giving a voice to CHTs as to how their profession could be improved to better serve patients and prevent upper extremity injuries is warranted.
Purpose
The purpose of our study was to identify the role of CHTs in the rehabilitation and prevention of work-related injuries, to identify challenges to effective treatment and the prevention of work-related hand injuries, and to identify facilitators that would help facilitate more efficacious treatment of work-related hand injuries.
Methods
Participants
Eight hand therapists participated in the interview process. These participants included 7 females and 1 male. Seven of these therapists were CHTs and one was working toward certification. Participants were recruited from an organization that provides therapy and rehabilitation services, including hand therapy. Participants reside and work in the continental United States, with most participants located in the midwestern and northeastern United States.
Participation in the interviews was voluntary. Prospective participants were contacted via email to arrange an interview. The email followed a specified script that included an attached, written consent document. For those interviewed, the interviewer followed a script, in which the interviewer referenced the consent document and obtained verbal consent from all participants before the start of the interviews. Prior to the initiation of the present study, Institutional Review Board approval for the study was obtained through Indiana University –Bloomington.
Data collection and analysis
Structured interviews were scheduled and completed with a sample of hand therapists in March and April of 2021. Each interview was conducted by means of a telephone call. A script was used to ensure that each participant understood the purposes of the interview and the same questions were presented to each participant. During each interview, the interviewer asked eight specific questions to each participant (see Fig. 1). After the question was asked, the interviewer did not intervene unless the participant asked for clarification or to repeat the question. The participants provided their full response without interruption. Additional probing questions were not asked, given the focus of the study was on the specific questions created by the research team. The interviewer did not go on to the next question until the participant fully answered the question, stopped talking or confirmed they were finished with their response. The interviews were recorded using a digital recorder. The digital recording was then transcribed verbatim by a member of the research team (initialed AB) so that transcripts could be analyzed. A quality check was completed by the other member of the research team (initialed TS) to ensure the transcription text accurately represented the responses of each participant.
Research interview questions.
Each transcript was separately analyzed by the two members of the research team. Both researchers read through the transcripts and identified what they felt were the main themes within the response to each question for each participant. The themes were then compared across the eight participants. The prominent and consistent themes across all participants were recorded. The main themes that emerged for each research member were then compared. Inter-rater reliability was high based on the context and quantity of identified themes.
Results
As noted above, the qualitative research study had four objectives in mind.
Researchers wanted to identify the role of CHTs in the rehabilitation process of work-related hand injuries and identify the role of CHTs in the prevention of work-related hand injuries. Further, researchers wanted to identify barriers or challenges to effective treatment and the prevention of work-related hand injuries and to identify facilitators that would help facilitate more efficacious treatment of work-related hand injuries.
Inter-rater reliability between the research members was high based on the context and quantity of identified themes. The two researchers independently identified themes for most questions at a rate of 100%. Where there was discrepancy, it was with how one researcher interpreted a word differently. For instance, one researcher included the theme “discussion with patient” separately from education, while the other researcher categorized that point as education.
The research team was able to identify trends in CHTs’ responses regarding their role in the rehabilitation and treatment of work-related hand injuries. One researcher (AB) noted that six CHTs focus their efforts on both return to work and return to functional use. One researcher (TS) noted that seven CHTs focus their efforts on both return to work and return to functional use. The difference is likely attributed to AB separately indicating that one CHT commented her focus is on returning the worker back to full duty. TS rated this under the return to work and return to functional use theme. Both noted that one CHT indicated her focus was on the treatment of traumatic hand injuries but did not mention a focus on return to work or return to functional use.
Regarding injury prevention, nearly all CHTs commented that they have little to no interaction with employers and are not generally involved in prevention efforts at employer facilities. Most prevention efforts are focused on preventing recurrence and not on exacerbating current problems as they are mostly working with patients that are rehabilitating. Regarding prevention, both researchers determined that the main focus of prevention is through educating clients or patients. AB noted that six CHTs commented that their prevention work is completed through education and one through discussions with patients. TS noted seven CHTs commented that their focus on prevention is through education, which included the one CHT that mentioned discussion. TS believed this was meant as a form of education. Both AB and TS noted one CHT indicated the focus of the CHT is not on prevention.
As previously mentioned, nearly all CHTs commented that they have little to no interaction with employers. Six CHTs commented that they never interact with employers, particularly occupational safety and health professionals at their patient’s places of employment. One CHT commented that they have very little or limited interaction and estimated that this happens in 10% of their cases. Seven of the CHTs commented that their interaction related to work-related injuries is with nurse case managers. One CHT commented “I have never interacted with a workplace safety professional. Nurse case managers, yes, all the time.” One CHT indicated that they sometimes have contact with an employer representative, but not a safety and health professional. Of potential concern is that there is generally a lack of interaction and no direct communication between the CHT and the employer as they rely on the nurse case manager, who is not necessarily working for the employer, but the insurance carrier, to communicate the treatment plan and provide status updates. One CHT stated “Case managers are pretty much keeping them apprised as to where the patient is at the time and what the restrictions might be.”
The research team was interested in identifying barriers to effective treatment and the prevention of work-related hand injuries. Three CHTs reported their biggest barrier or challenge was with patient compliance. Additionally, three CHTs commented that the overall workers’ compensation system was problematic and was a barrier to effective treatment and rehabilitation. Particularly, CHTs felt barriers related to workers’ compensation existed because employees had to return to work to perform duties outside of restrictions, because of poor relationships between patients and their employers, and because there were problems obtaining approval for continued services. A lack of communication was noted by one CHT and another CHT commented that the barrier was related to “people” in general. It was not fully evident what the therapist meant by this statement.
One concern among the researchers was how quickly injured workers were being treated or how quickly the CHT was involved in rehabilitation services. Nearly all CHTs commented that the initiation of their services varies based on whether they are involved in non-surgical or surgical cases. Generally, it appears that rehabilitation services are initiated within days after surgery. Non-surgical cases vary, but it was evident most CHTs believed services were initiated approximately two weeks after problem onset. Although most indicated involvement started within a few weeks and within days of surgery, a therapist did note that sometimes it has been longer. This therapist indicated “I’ve seen people and it’s been 2 weeks. Sometimes it’s been 12 weeks. It’s all over the place.” This phenomenon likely needs to be more thoroughly examined with quantitative data from medical records. This seems to be an issue worth more exploration. One therapist noted “This is complicated. It depends on what’s going on.”
Lastly, the research members were interested whether facilitators existed that would help facilitate more efficacious treatment and/or rehabilitation of work-related hand injuries. Three CHTs indicated additional education in the context of workplace injury prevention and interaction with occupational safety and health professionals would be beneficial. One CHT felt a mentoring program would be beneficial to bolster knowledge, skills, and abilities in this area. Additionally, increased knowledge of work operations and job descriptions would be beneficial. One CHT commented that involving CHTs in implementing workplace solutions, particularly those related to the prevention of upper extremity musculoskeletal disorders, would be beneficial as they would be able to offer their expertise to prevent problems.
Discussion
General discussion and implications
Researchers learned a significant amount about the CHT profession as a result of conducting the interviews and completing the present study. Researchers were able to garner information on CHT rehabilitation and prevention techniques to delineate whom CHTs communicate with during the rehabilitation process, identify CHTs’ perceptions of the biggest hindrances that impact the efficacy of their job, identify the time span between injury and rehabilitation initiation, and pinpoint improvements for the profession and the CHTs themselves.
When looking at the results, there are several things that are noticeable. As previously mentioned, it is evident that education has a big impact for both rehabilitation and the prevention of upper extremity injuries. With the analyses we conducted, we were able to discern the roles that a CHT plays in treating and preventing upper extremity injuries. The most prevalent answer that was presented regarding a CHTs role in treatment and rehabilitation was case management, developing treatment plans and programs for patients, treatment, and strengthening. The main foci were on return to work and return to functional use. The most prevalent answer that was presented regarding preventing future upper extremity injuries was providing education to the patient with the injury.
Research findings highlighted factors necessary for effective rehabilitation services. Seven CHTs described their focus in rehabilitation centers around education with one CHT saying, “So, education is very important –so when you’re seeing them for their therapy, you want to simultaneously talk to them about the kind of work they do.” The response by this CHT was similar to other participants, who cited education as being the most important proponent for rehabilitation. CHTs’ educational efforts with patients, including ergonomics, are an important aspect in preventing hand injuries, specifically carpal tunnel syndrome and other strain/sprain injuries [4, 11].
Education is important when combining occupational therapy and ergonomics education. Ergonomics is the application of scientific principles and methods focused on fitting workplace conditions and job demands to the capabilities of the working population [11]. Much of this focus is on preventing musculoskeletal disorders [12, 13]. A core aspect of ergonomic programs is training and education [12, 13]. Historically, ergonomics and occupational therapy share similar backgrounds and characteristics [10]. Therapists, including CHTs, are well positioned to support ergonomic programs due to their background in human physiology, task analysis, knowledge of disease processes, experience with work modification, and their ability to identify and implement effective workplace accommodations [10, 14]. As such, ergonomic programs, in combination with hand therapy programs, should prioritize education, with emphasis on recognizing work-related risk factors for the “upper quarter” and identifying signs and symptoms of “upper quarter” disorders.
Our research findings do have some implications for occupational safety and health management, that would benefit patients. Our findings suggest that collaboration between CHTs and occupational safety and health professionals is relatively non-existent. Of the eight CHTs interviewed, only one indicated that they communicated with safety professionals during the rehabilitation process. The one participant who indicated some interaction, gave a rather ambiguous answer, indicating that they sometimes correspond with safety managers, but that it was dependent upon the industry. It appeared that this communication was somewhat irregular.
Interaction with occupational safety and health professionals would be especially beneficial for the employer and the patient, as therapists, including CHTs, are able to assist with identifying and implementing effective workplace accommodations [14]. Additionally, regular correspondence and communication between CHTs and occupational safety and health professionals would benefit the patient, as collaboration would help prevent injuries and would ensure workers are returned to work in a more efficient manner. With increased collaboration, there is increased patient compliance and more effective return to work [15, 16].
A comment by one CHT illustrated how a lack of communication can negatively influence effective return to work strategies. She indicated “there might be a little disagreement between what I think might help and what workers’ comp and the employer thinks should be going on as well.” Having more open and direct communication, where the CHT communicates with the employer, particularly occupational safety and health professionals, would foster increased understanding and more positive patient outcomes.
Limitations and future research
Future research is recommended. Additional research with more CHTs is warranted as having a small sample was a limitation in this research study. Having only eight CHTs may limit the responses and themes obtained. Additionally, given the format of the study and interview process, some participant responses may be influenced by social desirability. In addition to the qualitative study completed, a more robust mixed-methods approach may be warranted to garner more details through quantitative research methods, such as collecting survey data.
To further explore this phenomenon, research obtaining the perspectives of patients, nurse case managers, and employers is recommended. Research needs to examine the perspectives of all those involved, who have interactions with CHTs regarding treatment and rehabilitation services for work-related upper limb injuries and/or disorders. This research would provide additional insights that may improve how patients receive treatment, are rehabilitated, and are returned to work.
Conclusions
The results of this study contribute to the literature on the role of hand therapy and perceptions from its practitioners. CHTs significantly contribute to the overall health and wellbeing of patients and particularly can foster the return to work of injured workers. This is important as upper extremity injuries, including hand injuries, are problematic among workers, accounting for a majority of workers’ compensation injuries.
Through the eight interviews conducted, the primary findings revealed that patient education was an important aspect when it came to helping rehabilitate a patient with an upper extremity injury. Education was also a part of what a CHT might do to help prevent an injury from occurring. It was determined that most CHTs do not correspond with occupational safety and health professionals, nor the employer. These are important findings because it displays an area where improvements could be made to provide more clarity between all individuals involved in the rehabilitation process. Contact with occupational safety and health professionals could also help in preventing future worker injuries [10, 18].
This research has implications for the field of hand therapy. The research provides additional insights into this therapy, how CHTs go about conducting their work, barriers to effective patient care and how interactions might be improved, particularly with employers to bolster patient outcomes. With this knowledge, future research could take place to corroborate the researchers’ findings and to provide guidance on developing necessary interventions that could help enhance productivity, provide for better all-around work conditions, and bolster patient outcomes.
Footnotes
Acknowledgments
The authors would like to acknowledge MaryLynn Jacobs, MBA, MS OTR/L, CHT, Senior Director, Hand Therapy Services, ATI Physical Therapy and Ginger Dayton, CSP, Corporate Safety Director, ATI Physical Therapy and Worksite Solutions for their guidance and support to initiate and complete this research project.
Conflict of interest
The authors declare no conflict of interest.