The OT Guide to Hand Therapy Interventions

I quickly learned in graduate school (in my physiology and neuroscience courses) that I learn best with flow charts – when I can form a plan and visualize what steps come next. The same is true for me now when treating a patient in my hand therapy setting.

Regardless of how simple or complicated the diagnosis or treatment plan, I try to have a “road map” in my head planned out. The plan is built from a thorough understanding of protocols, personal experience, and collaboration with fellow hand therapists.

What is really exciting about hand therapy (but also challenging at times) is how many different “road maps” exist for treating the same diagnosis since each patient presents with unique problems and issues.

This article will focus on common diagnoses seen in hand therapy (and possibly in your setting) with typical hand therapy interventions and treatment protocols in an easy to read list form. It is by no means an exhaustive list, but hopefully will provide you with a direction to take when seeing an unfamiliar diagnosis.

1. Carpal Tunnel Syndrome (Conservative & Post-Surgical)

Carpal tunnel syndrome is in the top 5 most common diagnoses I see. However, I tend to see more orders for post-surgical treatment than conservative.

In regards to post-surgical carpal tunnel releases (and actually all post-surgical diagnoses), it is important to read the operative report in detail prior to treatment. There are differing surgical techniques (open versus endoscopic release) which may determine what treatment interventions and outcomes are most appropriate.

Conservative Treatment:

• Night-time splinting – prefab volar wrist cock-up splint
• Education – pathophysiology, purpose of splint, ergonomics, activity modifications
• Nerve glides – proximal and/or distal median nerve glides (these must be completed pain-free!)
• Modalities (if applicable) – ultrasound or iontophoresis with dexamethasone

Post-surgical Treatment:

1-2 weeks post-op:

• Wrist active range of motion (4-6x/day x 10 reps MINIMUM)
• Tendon glides (4-6x/day x 10 reps MINIMUM)
• Edema management

3 weeks post-op:

• Gentle grip strengthening (3-4x/day x 10 reps)

4-6 weeks post-op:

• Progress strengthening as tolerated

2. Distal Radius Fracture & Open Reduction Internal Fixation (ORIF)

This is likely the most common post-surgical diagnosis I see, especially with the winters we have here in Minnesota. Due to the advancements in surgical techniques, we are now mobilizing distal radius ORIF’s 3-5 days after surgery. Not too long ago, these patients would have been casted for 4-6 weeks and been extremely stiff afterwards, with long recoveries likely.

In general, patients who undergo a distal radius ORIF have great outcomes with minimal complications. The key is to mobilize the wrist aggressively (as pain allows) the first few weeks to avoid scar adhesions, reduce swelling, and minimize stiffness. Special considerations must be made for some patients depending on quality of fixation/bone, pain, edema, work requirements, or psychosocial factors.

This protocol is a guide and is commonly accelerated or decelerated depending on therapist or physician’s discretion.

Post-surgical Treatment:

3-5 days post-op:

• Fabricate custom volar wrist cock-up (~30 degrees wrist extension) removing only for hygiene and home exercises
• Wrist active range of motion within tolerable ranges (4-6x/day x 10 reps MINIMUM)
• Tendon glides (4-6x/day x 10 reps MINIMUM)
• Edema management (elevation, compression, active range of motion, icing)

2 weeks post-op:

• Begin active-assist and passive wrist range of motion as tolerated (4-6x/day x 10 reps)
• Wrist and forearm isometrics within pain-free ranges (2-3x/day x 5-7 reps)
• Light grip strengthening with sponge or theraputty (throughout day as pain allows)
• Monitor edema

3 weeks post-op:

• Begin weaning from splint with light functional activities (dressing, cooking, folding laundry, house cleaning)
• Continue wearing splint with heavy activity, lifting, and community mobility

4 weeks post-op:

• Wrist and forearm isotonic strengthening (2-3x/day x 15-20 reps with 1# dumbbell or lightest theraband)
• Discontinue use of splint except heavy lifting or when in crowds

6 weeks post-op:

• Discontinue use of splint
• Progress strengthening as tolerated
• Activities as tolerated
• Typically discharge patients at this point

3. Lateral & Medial Epicondylitis (Tennis & Golfer’s Elbow)

Lateral or medial epicondylitis (epicondylosis) can be a very challenging diagnosis to treat, as there are varying opinions on best treatment practices. Patients present with palpable pain over the lateral epicondyle due to micro/macroscopic tears within the fiber origin of the common extensor mass, primarily involving the extensor carpi radialis brevis (ECRB) and secondarily the extensor digitorum communis (EDC) or extensor carpi radialis longus (ECRL) (Cannon, 2001, p. 224).

Below, I will describe techniques I have found that lead to the best outcomes, although it truly varies from patient to patient. Length of symptoms and work responsibilities/requirements must be considered as they will likely effect therapy outcomes.

My treatment plan consists of two stages – first reduce pain and then increase strength. In my opinion, pain-free strengthening of the wrist extensors leads to the best long-term outcomes.

Special Tests:

• Resisted wrist extension
• Resisted long finger extension
• Limited or painful grip strength (especially noted with elbow extended and forearm pronated)

Conservative Treatment Stage 1 – Reduce pain

Home Exercise Program:

• Splinting
  – Counter-force bracing with activity
  – Night time wrist brace (if applicable)
• Transverse friction massage (2-3x/day x 2-3 minutes)
• Ice (acute) or heat (chronic)
• Stretching: Wrist extension and flexion stretch (hourly x 5 repetitions x 5 second holds)

Treatment:

Manual techniques

• Graston – I am certified in this tool-assisted myofascial release technique and it is my “go to” treatment option

Modalities

• Iontophoresis – this is my “go to” modality. I apply this at the end of the session. In my clinic, I commonly use the 4-6 hour patch with dexamethasone
• Ultrasound – I will use this if iontophoresis does not seem to be reducing pain, but rarely combined the two.

Conservative Treatment Stage 2 – Increase Strength

Wrist & Forearm Strengthening:

• Isometrics – within pain-free ranges, 50% resistance with 3-5 second holds. In my experience, it is important to thoroughly educate patients on the appropriate way to complete isometrics as it is very common for patients to apply too much resistance and actually cause further damage.
• Isotonics – high repetitions with low weight (2-3x/day x 20-25 repetitions with 1# dumbbell or lightest theraband)

4. Thumb Carpometacarpal (CMC) Osteoarthritis (Conservative)

CMC osteoarthritis, also commonly called basilar joint arthritis or CMC degenerative joint disease, is essentially “wear and tear” of the trapezium and base of first metacarpal (Cannon, 2001, p. 8). Patients commonly report localized pain at the base of the thumb, which increases with activity.

Conservative treatment is common and typically consists of 1-3 visits of skilled hand therapy depending on the stage and presenting symptoms. Treatment usually focuses on splinting, pain management, activity modifications, and adaptive equipment.

Conservative Treatment

Splinting:

There are many different options available. Depending on the severity and/or doctor order, I tend to lean more towards prefabricated splints which tend to be more functional than the classic hand-based thumb spica.

Hand-based Thumb Spica

• Immobilizes the CMC and metacarpophalangeal (MCP) joint
• Provides the most support through immobilization, but can limit function
• Positions CMC joint in palmar abduction with interphalangeal (IP) joint free

Metagrip

• Immobilizes CMC joint only
• Very functional splint, but typically comes in three sizes which may not appropriately fit the patient

Hand-based Comfort Cool brace

• Provides good support, but does not completely immobilize the CMC or MCP joints
• Very functional and durable

Pain Management:

Due to the chronicity of CMC osteoarthritis, I find heat to be more beneficial for patients than ice. Another technique that patients tell me is very beneficial is a contrast bath, completing 1-2x/day as time allows. Splinting should also help with pain management, along with activity modifications and adaptive equipment.

Activity modifications:

One of the most important aspects of conservative CMC osteoarthritis treatment, as it has shown to lead to improved long-term outcomes.

• Avoid sustained pinching, especially with torque, pushing, pulling or repetitive motions
• Avoid sleeping on thumb without splint
• Avoid putting your thumb “on an island” as I like to describe it (ex. pushing down on hand sanitizer or lotion dispenser, holding coffee cup)

Adaptive equipment:

At my clinic we have a great adaptive equipment magazine which I give to each patient and educate on various self-help devices, which may reduce pain and increase function. Here are some examples of adapted items:

• Jar lid openers
• Car key holders
• Playing card holders
• Ergonomic tools (scissors, knives)

5. DeQuervain’s Tenosynovitis (Conservative & Post-Surgical)

Patients with DeQuervain’s tenosynovitis commonly present with pain over the first dorsal compartment, especially with thumb flexion and ulnar deviation (also known as Finkelstein’s test). The first dorsal compartment consists of two tendons – extensor pollicis brevis (EPB) and abductor pollicis longus (APL).

Conservative treatment is simple, mainly focusing on splinting and pain management. If conservative treatment fails, patients commonly undergo a first dorsal compartment release.

Conservative Treatment

Splinting:

forearm-based thumb spica (positioned with thumb midway between palmar and radial abduction and able to oppose the small finger) worn full-time and only removed for hygiene and gentle wrist/thumb AROM daily.

Post-surgical Treatment:

1-week post-op:

• Active and passive range-of-motion wrist and thumb exercises initiated at least 4-6x/day x 10 repetitions as pain allows
• Desensitization techniques for incision

3-4 weeks post-op:

• Progressive strengthening initiated to wrist and thumb
• Return to normal activities as tolerated

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My Go-To Resources for Hand Therapy Interventions

Below are a few resources that I lean heavily on for treatment protocols and hand therapy interventions. There are many more resources, but these are my personal favorites.

1. The “Diagnosis and Treatment Manual for Physicians and Therapists – 4th Edition” (commonly referred to as the Indiana Hand Manual) is the gold standard for treatment protocols and something I use on a daily basis.

2. Rehabilitation of the Hand and Upper Extremity – 6th edition is used by everyone in my clinic for treatment planning and understanding various diagnoses. We also pick a chapter bi-weekly, read & review, and discuss to further progress understanding of diagnoses and ensure research-based interventions are being used.

3. Orthobullets is also one of my favorite resources to use because of how easy it is to use and read. Diagnoses are described in bullet-form and are directly to the point without fluff or frills.

Additional Readings For Those Interested in Hand Therapy

Yes, You Can Splint With Confidence! Neuro Splinting Tips for the “Non-Splinter” (My OT Spot)

A Day in the Life of an Outpatient Hand Therapist (My OT Spot)

Learn The 5 Steps To Become A Certified Hand Therapist (My OT Spot)

References:

Cannon, Nancy M. (2001). Diagnosis and treatment manual for physicians and therapists: upper extremity rehabilitation.