HAND THERAPY

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LITERATURE REVIEW

HAND THERAPY AND EXTENDED SCOPE PRACTICE

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Introduction

This literature review focuses on the roles of hand therapy notably the linkage between
clinical and surgical practice for hand-related disorders. The literature review will engage the
current literature on the professional development of hand therapist and how it has changed over
the last 15 years. The selection of literature is evenly distributed for the time-based analysis. The
review will look into extended scope practice, barriers, and future application of hand therapy in
both physical and occupational therapy.
Key words
Hand therapy, Extended-Scope Practice (ESP), occupational therapy, physical therapy,
physiotherapy, Hand therapy roles, Continuing Professional Development (CPD)
Key word search for each section are explained in each section.

Hand therapy roles

The search keywords/phrase combination for this section was Hand therapy roles,
functions. The inclusion criteria included only peer reviewed journal articles. The articles were
chosen randomly with specific bias on relevance and British literature.
In the current dispensation, hand therapists perform more tasks than their counterparts did
a decade ago. According to Valdes, Naughton and Burke (2015), do general practice
consultancy, conduct diagnostics, refer patient for investigative tests, and person tests. Further,
hand therapists perform therapeutic functions that extend from clinical roles, they engage with
other specialists notably doctors to relieve them some routine duties, including and not limited to

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splinting, removal of surgical stiches and other aids, and scar management. These roles are
common among hand therapists working under surgical practitioners. Some of these functions
start before the surgical practice. Hand therapists perform physical exercises to patients in
rehabilitation. According to Toemen and Midgely (2008), hand therapists conduct tests notably
electrotherapy, conduction and ensuring organization of home-based care, self-care and assisted
care in hospital and outpatient environment.
Health professions tend to converge and the boundaries in practice are changing rapidly.
In the context of interlink ages of health practitioners, a hand therapist presides over orthopaedic,
and rheumatic of the hand (Daker-White, Carr, Harvey, Woolhead, Bannister, Nelson, 1999).
Further, hand therapists work with neuromuscular specialists in complications affecting nerves.
Daker-white and colleagues examined orthopaedic therapists and their roles in hospitals and
practice. They found out that orthopaedic therapists reduced direct hospital costs while also
reducing the burden on doctors and surgeons (1999 p.648). In the research, though orthopaedic
physiotherapists are specialists, the role of extended scope including other specialised training in
other fields. The research had a short follow-up despite being the only known controlled trial and
perhaps with a longer follow-up, they would have reported with more authority on key research
agendas. The authors concluded that trained physiotherapists are adequately capable of
conducting triage referrals (p.649). The use of therapists works to plug the hole where surgical
options may not work to rectify disorders. Lastly, the authors point at the lack of blinding in the
samples as a strength in ensuring practical application.
Health promotion is dependent on health service delivery. Timely health service delivery
does not only save time but also saves resources. Regarding time, Ellis and Kersten (2002) argue
that the purpose of extended scope practice which gives rise to the specialist group of therapists

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notably occupational therapists is a realignment of the healthcare system with an aim of saving
time lost by patients. Hand and occupational therapists work in pre and post environments
mostly in screening, surgical, and other clinical settings to conduct pre-examination or follow-up
on already existing case management. In such environments, occupational therapists work to
enhance the quality and speed of care to allow the patient to return to normal productive
functionality (p.119). In pre-examination stage, the authors observed that the hand and
occupational therapists provided timely recommendations regarding cases. The advice enhanced
the quality of intervention. In new clinics, therapists do initial contact with follow-up cases or
joint and nerves patients, conduct initial diagnosis and case review of hand and other injuries
(p.120-1). The authors used a qualitative research design, themes are well developed and no
notable research drawback emerged.
After surgical procedures, patients require assistive devices like continuous passive
motion (CPM). Hand devices like CPM are aimed at enhancing nerve, rheumatic or tendon
motion. Schwartz and Chafez (2008) studied the use of CPM in hand rehabilitation noting that
such use of devices may not have significant effects. Hand therapists however use such devices
in encouraging patients to exercise without putting pressure of individual musculoskeletal or
surgical conditions of the therapy. The authors conducted a retrospective research design, which
is prone to confounders and bias. The use of the research relies on the overarching agreement
with other researches on issues of importance to the study including the active benefits of
therapeutic rehabilitation. The research did not control for accuracy in measurement both
preoperatively and post operatively which provides another doubt for reliability. The research
however points to the important role that occupational therapists do before and after surgery and
possible popular use of locomotion devices in aiding rehabilitation and faster recovery of the

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patient. The research points to the underlying role of ensuring that patients return to normal
functional capacity within the optimally possible time (pp.261-2).
Occupational therapy borrows from other practice. In most cases, hand therapy works as
a cross-sectional practice. As Shin (2010) noted, the use of reflexology, acupuncture and other
traditional remedial medical practices is popular in occupational therapy culture and so in hand
therapy. Shin observed the use of such a traditional remedy the Koryo Hand Therapy. Using a
two-group experimental design to test quantitatively hypotheses, she found the use of Koryo
Hand Therapy beneficial to menopausal women (p.141). Although this research is not related to
occupational hand therapy, the relevance of the tackled topic shows the diversity and purpose of
hand therapy as a health profession. Notable in this research is the conclusion that Koryo hand
therapy can correct determinants of nervous imbalance relevant to rheumatic therapists. Such use
signifies the growing scope of handling rheumatic conditions like arthritis as a way of enhancing
dexterity among patients.
In accidents and emergency departments can cause strains in delivery of care. Peck and
Turner (2013) engaged in the development of therapy-led clinics and the functional capacities
under which they operate. Hand trauma injuries are common in daily activities and so are the
cases in hospitals. To remove pressure on hospital settings, creation of hand trauma clinics in
Britain as a system aid to extended scope practice is evident. In their evaluation of the
involvement of hand-trauma therapists and subsequent enhancement of their skill-set to support a
multidimensional notably musculoskeletal, orthopaedic and rheumatic disorders, enhances the
capacity, range of practice and support to other professions (p.91). Further, the authors
confirmed the value of occupational therapists in their ability to use their professional
development and experience to reduce cases referred for surgical procedures and their ability to

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handle the cases within their capacity using their gained skill-set. The research design is not
stated and the methods unclear, but the conceptual analysis and grounds of conclusion are
evident.
Education/continuing professional development of hand therapists
The search terms for this section were Education continuing professional development hand
therapists. The inclusion criteria was relevance and peer reviewed journal articles. 10 articles
were initially picked and only those that reflect significant issues worth addressing in the review
were picked.
At the beginning of the millennium, therapists had a high turnover (Collins, Jones,
McDonnell, 2000). The blame was placed on the lack of motivation in training, development and
functionality of the healthcare system. Healthcare system focused on profiteering moves making
it hard for occupational therapists whose work is labour and personnel intensive yet lacking in
financial incentive. The development of new professions such as hand therapy provided new
enthusiasm for prospective therapists and motivation for existing therapists (p.3). Using selfadministered questionnaires and a combination of mixed methods in analysis, the authors found
out that such new role within the healthcare system provided hope for those contemplating career
changes (p.3). Most of the concerns cited by therapists was that their efforts were poorly
motivated and rewarded. As a common understanding, the authors point tout the demanding
nature of therapy-based patient care requiring technical, innovative and extended scope of
approach. The advised the need to enhance professional development beyond the normal
extended scope practitioner-led training and development (p.11).

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Hand therapists training include capacity to perform four key functions in healthcare. The
therapist must be capable of using basic and fundamental science-based knowledge. The
therapist must be proficient in evaluation of upper extremities. Ability to form independent but
informed prognosis is imperative. In addition, the person must have capacity to organize
professional practice (Dimick, Caro, Kasch, Muenzen, Fullenwider, Taylor, ... & Walsh, 2009).
Because of this enormous range of expended proficiency, certification of hand therapists and
professional development has gradually changed and grown over time. Inclusion of a wide range
of proficiency aimed at making the therapist aware of the conditions necessary for consideration
before engaging the patient ensures that the level of innovativeness required is immense. Further,
in this paper, the authors noted the bulging professional diversity as a key ingredient to the
training programs and academic requirements of certification to work as a hand therapist.
Although most physiotherapists and occupational therapists are nurses, further requirements to
enhance proficiency in the upper extremity functions only serves to enlarge the professional
scope of the therapist (p. 372). This review focuses on the experiential position of existing
professional and certified practising hand therapists.
One of the professional development expected of a therapist is capacity to administer a
health facility. In such a move, the administration of a clinic by a hand therapist can enhance
capacity to create fully developed departments and care centres where referral to a hand therapist
is possible (Warwick & Belward, 2004). Alternatively, organization of such departments prove
efficient in handling and sorting out hand disorders. The author proved that having a consultant
wing and a hand therapy wing could enhance the suitability of cases handled by each (p.26). for
example, patients requiring both nerve conduction studies and electrophysiology diagnostic tests
from the general practitioner and therapist, respectively, can take advantage of having a one way

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care delivery. The patient will not have any more referral when such order of events is followed.
Unlike in other cases where any hand-related complication is referred to the therapists to conduct
tests. Such a case leads to more than one referral to ascertain the clients condition. The capacity
to align therapeutic care with consultant care in a general and specialised care is dependent on
the capacity and efficacy of the two departments (p.26).
While evaluating the need and the technical application of continued professional
development among and between increasing areas of physical and occupational therapy, French
and Dowds (2008) acknowledge the challenges envisaged by most professionals. While there is a
need to ensure that the professional capacity improves with increased research, inventions and
technological advances, there are barriers to extensive and practice-led professional growth.
Apart from professional growth, the value and application of research, reflective practice and
updated technical capacity to improve patient care is expected (p.193-5). The future lies in
overcoming the challenges of cost of development and sustainability of extensive specialization.
The authors of the research used literature review to examine what the other researchers
concluded. There is no particular concern preventing the use and adoption of this review work.
The authors conclude that development of specialist positions notably in the consultant level of
therapy, extended scope practitioner like hand therapists, and others find documenting
professional growth a challenge (p.195). The need to enhance a nomenclature to understand the
acquisition of specialist soft skills is recommended as a way of enhancing understanding of
individual professional position.
Though professional development is highly encouraged, core experience skills (soft
skills) that prove successful in therapy practice. In their research, Chipchase, Johnston and Long
(2012) advised on the growing overemphasis on professional notably academic development

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without focusing on its veracity. In their evaluation, every effort in healthcare system must be
evaluated on how it improves the quality of care and overall impact on the patient. They
evaluated the course content of most of the professional development courses noting the
continued emphasis on administrative, enterprise and commercial purposes. For example,
professional seek the reasons to refer to their consultant capacity mostly through professional
certification, but with little regard of ensuring consultant capacity in practice. Such issues
emerge as educational institutions venture with the popular consumerism to keep up with
competition (p.90). The review does not show how the review was conducted. The use and
acceptance of the source for this review rests on the fact that the paper is peer reviewed and it
allows one to develop the growing discontent on the quality of professional curriculum. The
authors conclude that there is a major disconnect between what is offered and what is required to
improve patient health outcomes. They however place responsibility on the practitioner to know
what their status is and how to align it towards enhancing patient outcomes (p.91).
A major component of professional development is adoption and alignment of research
findings in ones field in professional practice. In their research, Groth and Farrar-Edwards
(2013) envisaged a strong proportion of hand therapists who did not keep abreast with current
research on their field let alone try to use it in professional practice. It is hard for patient
outcomes to improve when research and development are not priorities. In this research, using a
randomized mail survey, the researchers proved that the use of research in practice is appalling
with the highest group having 45% adoption rates. They also observed the influence of age at the
expense of experience and demographic indicators as major differences between and among
group members (p.245). Though the research has its limitations based on the sampling and
possible bias, the population under scrutiny can adequately inform future areas of research

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notably different demographical characteristics. The four groups of certified hand therapists
evaluated notably analytics, pragmatic, sceptic and traditional groups exhibited poor adoption of
research findings with most remaining static to the status quo. Understanding the reasons for this
can help so that focus on improving research adoption can be realized.
How hand therapy has changed over the past 15 years
The search phrase was hand therapy changes over time History of hand therapy The
inclusion criteria was relevance and peer reviewed journal articles. Ten articles were initially
picked and only those that reflect significant issues worth addressing in the review were picked.
To understand these changes, the literature search focused on an inclusive criteria, research ideas
and review of the outcomes. Sources were picked selectively within the 15-year period, two in
every 2-3 years. The Elsevier ScienceDirect database was used to provide a bias of UK
journals.
Hand therapy is an extended scope practice that branched from physical and occupational
therapy. The hand therapists therefore generally have general practitioner knowledge like
occupational therapy and specialist skills in dealing with hand disorders. According to Amadio
(2001), the branch was informed by increased need for specialist skills in the field of physical
and occupational therapy. The argument is that, due to the growing medical cases in terms of
physical and occupational requirements of each case, the need to have specialist skills became
inevitable. During this time, general practice therapy was common with attention to occupational
therapy going to plug the need for therapists in biomechanical fields. According to Sullivan
(2001), the emergence of other neuromuscular, rheumatic and demands of the health system
ensured that such professional skills gained acceptance and development. Wide range of hand

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disorders emerged and the focus veered off the requirements and attentions of either physical or
occupational therapists. The development of a field that focused on Disabilities of the Shoulder,
Arm Hand (DASH) was gaining prominence then with attention on the disorders likely to lead
problems in the mentioned areas. The prominence of the hand in the field is obvious as it bridges
physical and occupational needs of a person. As evident in Sullivan research, the lack of a
universal modality in the practice signified a field in its development with greater promise and
emphasis on diversity of purpose (pp.66-7).
To plug growing need for efficiency in the health system especially in developed
countries of Europe and North America, Practitioner-led clinics become emerged (MacDermid &
Stratford, 2004) as various specialist practice-based fields gained acceptance (Peck, Kennedy,
Watson, & Lees, 2004). A major reason for the development of such practitioner-led clinics was
increase in hand trauma cases. As McDermid and Stratford observed the use of evidence and
research outcome in informing policy and system reviews can be assumed to play a part in such
development. However, they observed several challenges in research application including how
such clinics operated. Being a new idea, the need for extensive application of system, practice
and outcome evidence ought to be thoroughly synthesised. Since this research focused on
evidenced-based practice, it efficacy can be evaluated on the demands of pragmatism. It is
structural and thematically organized to warrant consideration and use in this review. Evaluation
by Peck et al. (2004) showed how responsive and effective such clinics were in improving
patient outcomes. The research showed a positive impact of practitioner-led clinics in both the
patient outcomes and in the efficiency of the whole system. The development and usage of
practitioner-led clinics further show resilience in moderating continuous care, which reduces
healthcare system pressure on demand for personnel involvement.

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According to Stanton (2008) in her review of Barr (2007) lecture, the development of
therapy as a holistic field, one that encompasses the mind, body and science, is inevitable. This
theoretical disposition of hand therapy emerged from the increased attempts and success in
incorporating historical therapies, notably eastern therapies like acupuncture, reflexology and
others. As evident in Kaiser, Bodell and Berger (2008) research, surgical methods may not
function fully without further assistance from therapy. Though science recommends the body,
that is the musculoskeletal, neuromuscular and other physical sides of hand disorders, a blend of
a holistic approach, one that seeks to innovate for case-by-case, remains paramount. Stanton
(2008) shows growing confidence in the acceptance of therapy-led approach as a way of
enhancing restorative capacity to function in an occupational setting. Kaiser et al. (2008) on the
other hand gives a similar response with emphasis on a stronger integration of the services for
patients. The aim is to improve patient outcomes. As expected, patients seek medical attention so
that they can lead a normal, fruitful and comfortable life. Without articulate attention to that
important goal, the efforts of individualized response may adversely undermine provision of
care. The two papers are peer reviewed and systematically organized to warrant acceptance for
this review.
Hand therapy tends towards rehabilitative functions of therapy. Current methods of
rehabilitation have improved to the extent of the use of hybrid methods. According to Liu,
Fujiwara, Shindo, Kasashima, Otaka, Tsuji and Ushiba (2012), such use hybrid methods of
rehabilitation are in use. While evaluating their efficacy, the authors observed the overwhelming
extended scope requirements for functional approaches towards care. The argument is that
rehabilitation of upper extremities have historically proved difficult and all efforts to change the
situation focus on the hybrid requirements of enhancement of the physical characteristics of most

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disorders. In the research, the use of newer rehabilitation approaches is emphasize. Further
research on the changes in the hand therapy includes the development of various approaches and
protocol. Despite dynamism and liberal protocols making sense to most, the referral and
continued resilience in the use of conservative protocols to respond to practice challenges cannot
be overstated. According to Wollstein, Wollstein, Rodgers and Ogden (2013) recommendation
and acceptance of a dynamic approach to care becomes evident. While evaluating the use of
hand therapy protocol among patients with lunate overloads, thy observed the possible need to
other protocols. This is a significant part of development of hand therapy as a collaborative field,
which seeks to enhance success in patient outcomes. Liu et al. (2012) shows how the use of
hybrid methods notably, HANDS and robots, and integration with other methods can enhance
occupational rehabilitation.
As more emphasis in medical care focuses on areas where profit can be achieved, a
growing risk area is that where specialized treatment is required without the incentive of bring
full recovery but improvement of quality of life. Children disorders, for example amyoplasia and
elderly citizens with chronic musculoskeletal and neuromuscular disorders can be time and
resource consuming. The expected outcome for the care may not bring the same level of
enthusiasm among caregivers. As Lake and Oishi (2015), observed, this cases represent a
neglected area but rowing in the community. The development of an extensive lifetime care
protocol involving a holistic and personnel dependant practice is required. Modern ideas about
the changing role of hand therapy to represent a strategic review of existing healthcare needs to
include neglected cases and to increase capacity and ability to function can help facilitate
improved outcomes for such patients. In the review of case study based on outcomes, the authors
show the need to improve elbow flexion among children with amyoplasia. Further, in the same

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theme of changing roles of hand therapists, innovativeness in improving quality of care is

emphasized by Peck-Murray (2015). The use of everyday items or he use of a home setting to
enhance quality of care as a way of removing the burden bestowed upon the extended scope
practitioners.
In this review of the last 15 years, three phases emerge, the phase where the role of hand
therapy is entrenched in other fields (Dependent), when it is independent, and when it seeks to
share some of its practice-based responsibilities.
Introduction of extended-scope-practitioner hand therapists
The original search included extended-scope-practitioner hand therapists The inclusion
criteria was relevance and peer reviewed journal articles. Ten articles were initially picked and
only those that reflect significant issues worth addressing in the review were picked.
Orthopaedics, rheumatologists, surgeons, general practitioners and other established
professional teams work hand in hand to develop a care protocol relevant for each case.
Therapeutic specialists also form part of this specialist group. Due to complications and desire to
align delivery of care, emergence of roles outside the traditional scope call for extended scope of
practitioners (Ellis & Kersten, 2001). The presence of these professional roles give rise to the
growth of the same professional requirements. The need is informed by the need to have relevant
knowledge and skill in such extension of service. As a requirement by most relevant bodies,
notably the British association of therapists, search extensive application comes with expected
training and professional growth. Normally certification is expected and recommended. The
reference term given to this professional is Extended Scope Practitioner ESP. Ellis and Kersten
(2001) further envisage the scope of practice and the field as one that is going beyond

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opportunistic roles, but also one that depends on the training needs of such practice. In their
research, they envisaged networking and professional orientation of the relevant fields to
enhance their service delivery. They arrived at this conclusion following a mixed method survey
using descriptive statistics to inform generalization. The research showed the extent of ESP
participation notably in non-medical or surgical clinic, rheumatology clinics, preoperative and
post-operative environments (pp.127-8).
Because of increased recognition of professional requirements and role-play among
physical and occupational therapists, and the confidence bestowed to them to manage various
disorders, ESP became possible. According to Gardiner and Turner (2002) who evaluated the
clinical diagnosis between ESPs and doctors, the role of ESPs is extensive depending on the
professional requirements of the scope of practice. Using a retrospective audit, they observed
that ESPs (physiotherapists) working in arthroscopy were more accurate that orthopaedic
doctors. The research was not independently audited which leaves room for possible bias. The
authors concluded that further acknowledgement of areas where ESs can assist should be sought
and even development of independent triage clinics facilitated by such ESP work (p. 156). The
challenge lies in enhancement of system level analysis to determine where ESPs can safely be
deployed.
Physiotherapists and occupational therapists forms the bulk of ESPs in UK. Their role
spans in various other medical, surgical and non-medical fields, which prompts evaluation of the
needs and requirements for one to function as an ESP. using a Delphi study, Ellis, Kersten and
Sibley (2005) looked at the roles and requirements of practice among ESPs. Workforce
shortages ranks high in current healthcare system requirements among the things that require
permanent solutions. One way of trying to bridge this disparity of need and availability of

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practitioners is partly filled by the ESPs. In the research, the authors found out the need to have
proper guidelines regarding deployment and roles expected is missing. The problem of
overreaching expectations among ESPs is real and a significant barrier in their development
commonplace. The authors used three questions to come out with the following outcomes. There
was a consensus that an ESP must have 3years of practice, know the scope of their abilities and
have specialist skills in the area of clinical ESP. Secondly, there was significant focus on the
professional capacity to administer and interpret investigative tests as a requirement to function
as an ESP. Regarding role parameters, the authors found emphasis on ability to run outpatient
clinics as the most significant requirement (p.84). ESPs receive support from other healthcare
stakeholders with the majority of the drivers towards ESP-led roles coming from existing
demands in the healthcare (Kersten, McPherson, Lattimer, George, Breton & Ellis, 2007). In the
same research, Kersten et al. (2007) view the ESP debate as a paradigm in the scope of practice.
The driver of the paradigm however does not reflect the holistic healthcare promotion approach.
They further identify patient outcomes, cost benefits, and informed research as the best drivers
for such a paradigm. The research uses a systematic review in an expanded Cochrane approach
to study the drivers growth of ESPs. In evaluating how ESPs work, Rose and Probert (2009)
enthused that ESPs work by altering patient pathways to care (p.96). By doing so, they require
experience, observation and training on specialist needs. The research looked at these issues in
depth. They stressed the need to develop specialist investigative skills of testing, creation of
mock pathways, training and assessment as stages of creation of an ESP clinic. The capacity to
function as assistive experts and independently to exercise leant clinical expertise is an important
stage of development for all ESPs.
Roles and barriers to practice currently and in the future

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The original search included Roles and barriers to practice currently and in the future for
hand therapists and Extended scope practitioners The inclusion criteria was relevance and peer
reviewed journal articles. Ten articles were initially picked and only those that reflect significant
issues worth addressing in the review were picked.
Development and encouragement of ESP roles faces significant barriers. According to
Huisstede, Fridn, Coert, Hoogvliet and European Handguide Group (2014), role definition can
impact negatively on the role an ESP plays in a clinical setting. Further, they noticed the growing
problem with definition of roles in a hierarchy. Even in clinical settings where clinical-led or
practitioner-led clinics, the concern about hierarchy of both protocol and practice is not always
developed well making the role uncertain. The research being a Delphi study shows the possible
issues likely to affect normal functionality in practice. The study is limited to the composition of
the group of participants of the research. However, if this was taken to mean that the group
reflects a multidimensional professional group expected to develop practice. Without a strongly
developed protocol, confusion and time wastage is inevitable. Hansen & Tromborg (2013) agree
with this concern about patient pathways. In their conclusion, they argued that evaluation of
measured functional outcomes relevant to the patient should be the guiding principle (p.2010).
They argue that the existing patient pathways guiding most ESP use tend to focus on the success
factors of practice. ESP being a relatively new protocol especially outside therapy-led practice.
In developing a patient pathway in hand therapy and occupational therapy, emerging
requirements include evidence-based and cost effective methods. Li, Westby, Sutton, Thompson,
Sayre and Casimiro (2009) identified significant concerns about the training requirements and
coordination of resources as considerable barriers to ESP practice. In the research, pursuing of
specialization and certification among and clinical experts seeking to venture in ESP does not

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support the fear of change and acceptance of extended role. Time management, training
requirements, coordination of resources and staff, fear of change and fear of taking more roles
and responsibilities, loss of job diversity and lack of mentors ought to be overcome to enhance
future development of ESP and related clinical practice roles.
The development of specific guidelines notably on matters beyond certification and
mostly on practice remains untrusted by existing functional bodies. A model of certification and
guidelines can work to alleviate deviation from acceptable levels of practice. Further, guidelinesetting efforts do not always collaborate with those of expected implementation always breeding
avenues of further concerns. However, with the implementation of nationwide and preferably
universal protocols, it can enhance the level of job satisfaction and self-efficacy among
upcoming professionals (Huisstede et al. 2014: Chipchase, Johnston & Long, 2012). Further
development of successful ESP role models can play a part in encouraging the grown of the
practice. Practical guidelines can set the tone for other professional seeking to venture into
creative fields, notably in ESP and hand therapy.

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