Lessons Learned: Understanding the Hand Therapy Knowledge Gap & Filling It.

by: Mirella Deisher, OTD, MS, OTR/L, CHT

Virtual Hand to Shoulder Fellowship, LLC

Faculty & Founder

I have always been acutely aware that my OT education did not equip me to be as effective as a physical therapist to work at the impairment level, and it’s always bothered me. As a new clinician who aspired to work in hand therapy, it bothered me when a colleague told me that PTs are equipped to treat at the impairment level, while OTs are equipped to treat the resultant disability. It bothered me, but I knew they were right. I knew they were right because even as a patient six years earlier, I found myself asking my PT, who was treating my lower limb and gait, to help me with my upper limb.

My OT was wonderful, but I wanted every chance at a full recovery, and my PT seemed to know more about the mechanics of the body. My PT also coached me towards using normal movement patterns, which was naturally in line with my goals at twenty-one years of age. I didn't want compensation, and I didn't want adaptive strategies because it just felt like giving up. So I'm sure you're wondering why I became an OT instead of a PT. I did apply to both programs, but ultimately OT seemed to be the best of both worlds. I had read that OTs address the upper limb and hand but also consider the whole person. That resonated with me because, by then, I understood that disability is influenced by many variables, not just physical impairments. I felt OT offered a framework that would allow a clinician to identify these variables and integrate them into a holistic approach to care.

However, once I found myself working side by side with PTs I could appreciate the knowledge gaps that would limit my ability to serve my patients at the highest level for remediation of upper limb and hand impairments. So, just a year into my OT career, I did something about it and enrolled in a physical therapy certificate program for upper quarter & hand therapy. That was in 2000, and since then, most of my professional growth as a hand therapist has come from the opportunity to work alongside surgeons in orthopedic practices. Ultimately, the foundational knowledge gained from completing the PT certificate program enabled me to do so effectively and successfully.

For many years I grappled with why OTs do not get the needed education to think critically within a biomechanical approach with equal emphasis to other practice paradigms, at least for the physical rehabilitation of the upper extremity. After all, being holistic should include competency in all areas, particularly to support remediation. I wanted to fill an educational need for other OTs so that they would have the opportunity to think more independently based on a comprehensive understanding of anatomy, biomechanics, pathomechanics, and the physiology of healing. I gained this knowledge through the certificate program and then through 22-plus years of interactions with surgeons and reading the literature they were reading.

Then through the years, as I began to serve in various leadership roles within hand therapy departments, it provided a platform to advocate for and develop hand therapy fellowship programs. I ran these programs for roughly eight years. Finally, in 2020, I transitioned to academia to understand the disconnect from education to practice, particularly in upper extremity and hand therapy, and to identify strategies to enable competency within this highly specialized area of practice.

As part of the founding faculty for an entry-level doctoral program, I learned that our educations were never designed to equip us in this manner. They are designed to prepare us as generalists. The scope of occupational therapy is so broad that it cannot prepare us as specialists within any given specialty without significantly extending the program's length and, thus, the student's costs. Quite frankly, the same is true for physical therapy. However, their curriculum is focused, and they develop the type of critical thinking that more effectively translates into the practice of hand therapy.

As part of the OTD faculty, I was tasked with teaching anatomy and neuroanatomy, so now I had to put my money where my mouth was. While I made great effort to connect the relevance of anatomy to clinical practice, I needed to do this for the entire musculoskeletal system in one semester. We spent a third of the semester, roughly five weeks, on the upper extremity. As a comparison, the Virtual Hand to Shoulder Fellowship is a year in length and could easily be longer. So, I realize now that unless a university offers a specialty track, which may lengthen the program’s duration and cost, not much can change in the OT curriculum and still meet the required standards to obtain accreditation.

So now I stand even firmer on the need to bridge an inevitable knowledge gap. I believe our professions recognize this need, and for this reason, we’ve seen tremendous growth in the development of residency and fellowship programs. However, not all clinicians can relocate for a clinical fellowship. Not all clinicians can afford a reduction in pay to participate in fellowships, and not all clinicians can afford to pay for postgraduate certificates. Thus, Virtual Hand to Shoulder Fellowship comes from 22 years of clinical practice, the eight years invested in developing and running clinical hand therapy fellowships, and more recently, working in academia and understanding curriculum design for occupational therapy programs and its limitations.

Virtual Hand to Shoulder Fellowship, LLC is now in its 3rd year providing access to the advanced knowledge and skills required to effectively practice within the specialty of upper extremity and hand rehabilitation. Since its launch, we've refined and expanded our core curriculum and identified strategies to support experiential learning even within this online format. We have also collaborated with organizations such as the Rothman Orthopedic Institute to provide entry-level clinicians with the VHSF didactic curriculum and mentorship from their highly skilled CHTs.

VHSF has also created a 16-week curriculum, Intro to Hand Therapy, designed to support fieldwork students in upper extremity and hand therapy settings. Our pilot cohort consists of my former students at Cedar Crest College's entry-level doctoral OT program. As their anatomy and neuroanatomy instructor and as a certified hand therapist, I understood the gaps in their knowledge. I appreciated that they completed those courses a year prior to starting their fieldwork experiences. Thus, in addition to the curriculum, we created video tutorials on various needed clinical skills and also offered supplemental mentorship. We have since opened the Intro to Hand Therapy program to assistant clinicians or generalists that want to broaden their skills but not necessarily specialize.

As VHSF continues to evolve, we are primarily driven by serving as advocates for both the clinician and the patient. Our goal is to create an accessible means to achieve the highest level of competency in upper limb and hand therapy, regardless of local resources. A clinician's "zip code" should not create barriers to achieving clinical excellence in their chosen specialty. VHSF has been developed so that therapists, and subsequently their patients, feel confident they are optimizing rehab outcomes within the specialty of upper limb and hand rehabilitation.