Julie Penfold looks at the opportunities in this fascinating and complex field of practice.
A niche specialism, hand therapy is the management and rehabilitation of injuries and conditions affecting the hands, wrists and upper limb. This includes the forearm, elbow and upper arm. Both physiotherapists and occupational therapists can become hand therapists, using techniques such as splinting and joint mobilisation to promote rehabilitation. They work in a range of healthcare settings, including NHS trusts and private hospitals, as part of multidisciplinary teams.
The NHS hand therapist
Gary Rigby is a physiotherapist in the hand therapy team at James Cook University Hospital in Middlesbrough, part of South Tees NHS Trust. The team deals with a range of injuries including fractures, tendon and soft tissue injuries, nerve injuries, ligament problems and sprains. They also work closely with the surgery team in providing rehabilitation support to patients after elective surgery, including trapeziectomy, joint replacement and Dupuytren’s fasciectomy. The hand therapy team is made up of two physiotherapists, two occupational therapists and a rotational physiotherapist.
As a band 6 musculoskeletal (MSK) physiotherapist, Mr Rigby moved into hand therapy as part of band 6 rotations. Then his interest in this specialism grew.
‘I was six months into my rotation when a permanent physiotherapist post became available in the hand therapy team,’ says Mr Rigby. ‘I was really enjoying it and decided to specialise. It was luck, being in the job at the right time.
‘You have to think outside the box at times because hands are very complex – every hand is different. And there’s almost an element of engineering with splint-making. That takes practice but you learn on the job.’
Time constraints are a key challenge for the team, says Mr Rigby. ‘We don’t hold a waiting list for hands as patients need to be seen there and then. If we make a patient wait two weeks, the injury will stiffen and seize up, leading to further problems.’ Fitting everyone in means that team members sometimes work into their lunch breaks to ensure patients are seen quickly.
‘Having a hand injury can really affect people’s lives, especially when it’s the dominant hand,’ says Mr Rigby. ‘It can be quite traumatic for patients to function without the use of a hand. If a patient has quite a significant injury, it can be a long rehabilitation process. Seeing patients progress from having no function to ultimately getting their life back is very rewarding.’
Rotations are important if you are thinking about a career in hand therapy, says Mr Rigby.
‘Getting your generalist background in the musculoskeletal field and then working your way around the body, and getting to know the anatomy, will be helpful. As a hand therapist, you’re always learning and developing.
The private practitioner
Physiotherapist Minal Desai specialises in hand therapy at a private hospital in Reading, Berkshire. She is also a member of the British Association of Hand Therapists’ executive committee and its director of bursaries. Ms Desai treats a variety of injuries and conditions, ranging from elective surgery patients who need rehabilitation after dislocation or wrist fracture to more complicated cases in which patients have been told that nothing more can be done on the NHS.
‘There are some chronic, complex cases where patients have been passed from pillar to post and don’t know where to go next,’ says Ms Desai. ‘My strangest case was a patient with a gunshot wound to the hand. The bullet had gone through the bone and one of the metacarpal joints. That developed into a serious case of complex regional pain syndrome and I saw him for a good number of months. I have also seen patients with complications following botched surgeries to the tendon joints and other cases that could have been dealt with better.’
Ms Desai’s interest in hand therapy evolved in the course of her job. ‘I had shadowed the main principal hand therapist on a few occasions when she was making splints. I’ve always had something of a bias towards the upper quadrant and enjoyed treating the shoulder and elbow areas. Hands was the next natural area to progress to and I began to specialise when a role became available through retirement.’
The creative aspects of the work appeal to Ms Desai, who enjoys painting and pottery in her spare time. ‘I find making splints very enjoyable,’ she says.
Seeing the difference that rehabilitation makes to patients with limited function is hugely satisfying, says Ms Desai. ‘It’s particularly rewarding when you see a change in a person – even a minor loss of function can cause a lot of problems. I still see shoulder and neck patients from time to time but I find the rapport I have with hand therapy patients is different. I think it’s much more personal working so closely with a patient, touching their hand and trying to improve how they feel. Even a small amount of progress can result in improved function.’
Ms Desai’s advice for those thinking about a move into hand therapy is to first consider where you would like to work and identify some clear goals. Then, she says: ‘if you’re interested, give it a go!’. fl
Fast facts on hands
- There are 27 bones in the hand.
- Phalanges are the bones in the fingers.
- The palms of your hands are made up of five metacarpal bones.
- Wrists consist of eight carpal bones (held together by ligaments).
- The carpal bones are arranged in two rows – proximal (scaphoid, lunate, triquetral and pisiform) and distal (trapezium, trapezoid, capitate and hamate).
So, you want to be a hand therapist?
What clinical skills do I need?
A strong knowledge of the anatomy of the upper limb, assessment skills, wound management skills, management of scars and the ability to make splints.
Do you have to be practical?
It helps, as the making of splints is also about patterns and you often need to think on your feet to create a bespoke splint. You may also be required to stabilise fractures or make a splint in order to stretch a hand. Tools such as scissors and Stanley knives are used regularly so hand therapists need to be fairly dextrous.
How do I become a hand therapist?
People often move into hand therapy via rotation, as they build a career after graduating as a physiotherapist or occupational therapist (OTs). There are also openings via graduate rotational positions within larger tertiary centres.
Some trusts also have static band 5 positions. If you are interested in a career as a hand therapist, it is advisable to spend some time shadowing a hand therapist or doing your clinical placement within the field if you are currently studying.
The British Association of Hand Therapists (BAHT) also offers training options for physiotherapists and OTs.
Who would pay for my training?
In the majority of cases, training would be paid for by the individual. Within the NHS, funding may be available on a trust by trust basis. Funding would be offered to applicants already working in a particular speciality, such as musculoskeletal. Sometimes employers pay, but usually trainees cover their own costs. BAHT offers annual education bursaries for members.
Are many physiotherapy posts available?
Most employers are looking for either a physiotherapist or an OT, but some posts are open to both professions. Trusts and boards will be looking for a specific profession to provide cover while rotational work is carried out elsewhere. When looking for hand therapy posts – particularly within the NHS – be sure to search for both physiotherapist and OT opportunities, as a job description may state that your profession is eligible to apply.
Answers supplied by Christy Fowler, chair of the British Association of Hand Therapists
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