The Four Pillars of Hand Therapy

Occupational therapists lead the way in this essential rehabilitation specialty.

Hand therapy is a unique specialty for which I have a lot of respect and much enjoy. I learned about certified hand therapy during the second semester of my occupational therapy assistant program.

I have been interested ever since, and continue to work toward fulfilling the requirements to take the certified hand therapist (CHT) exam.

To become a certified hand therapist, a list of criteria must be met before you can even test. Historically, the certification exam has had a pass rate percentage in the high 50s, with the last three exams having pass rates of 55%, 62% and 62%. Testing takes place twice per year.

Currently, there are approximately 6,000 CHTs worldwide (mostly in the United States and Canada). Of those, 85% are occupational therapists. As occupational therapists, we realize how special our hands are; but generally, people take them for granted.

Complex Anatomy

The hand is one of the most complex components in our bodies, with 27 bones and intrinsic muscles including the lumbricals and the interosseous, which are both volarly and dorsally located. Extrinsic muscles include the extensor and flexor masses.

Annular ligaments work as pulleys holding tendons in place, and ligaments in various places stabilize the wrist and digits. For example, the ulnar collateral ligament in the thumb is commonly injured, making grasp and grip painful and weak.

Sagittal bands hold the extensor tendons in place. There are three nerve distributions in the hand: radial, ulnar and median. (This is not an all-inclusive list of hand anatomy.)

With a solid understanding of the structures in the hand and forearm, it becomes much easier to understand how many things can go wrong.

Carpal tunnel syndrome, trigger finger, tendon injuries, and broken bones are just a few of the most common. Though there are many considerations when treating patients who have suffered a hand injury, there are few things that should be constantly considered. I call them “the four pillars.”

These four pillars go hand-in-hand, but the first three are directly connected to each other. We manage edema and swelling first while we address scar tissue.

While managing these two factors — reducing scar tissue adhesions and edema — we will increase range of motion to a point. Lastly, we work on returning strength. This is the final pillar of treatment and recovery.

Edema Management

Edema is not only painful but limits motion and functional use of the hand. Edema must be addressed for a number of reasons including pain, decreased sensation and limited range of motion.

There are several treatment techniques to reduce edema. The most common are retrograde massage, compression groves, therapeutic taping techniques, bandage wraps and education for elevation.

Modalities can also address edema such as contrast baths, TENS units and cold packs. Edema can be measured by a volumeter or through circumferential measurements to document progress on a regular basis.

Scar Tissue Management

Scar tissue begins to form during the second phase of the wound healing process (fibroplasia). This can start as early as three days after trauma, and can last up to six weeks.

During this time, collagen is produced in excess, but doesn’t form in an organized fashion due to immaturity. Scar tissue binds to tendons and other structures, subsequently preventing movement through a joint, which limits range of motion and ultimately function.

Scar management will address the functional and cosmetic aspects of recovery. Therapeutic application of modalities, such as thermal ultrasound combined with stretch, helps increase range of motion.hand therapy occupational therapy

Functional electrical stimulation facilitates tendon gliding through scar tissue. Scar massage helps break up immature collagen and realign the collagen fibers, helping to flatten out the scar and reduce possible adhesions, which also improves the overall appearance of the scar.

Range of Motion

OT081015_NET_program_JL_CoverWithout the return of range of motion, we cannot start increasing strength; therefore, it’s imperative to maximize range of motion before we address strength.

Prior to addressing range of motion, modalities are often applied to heat the joint and improve elasticity. Therapists often use joint mobilization techniques and increase motion.

Range of motion is addressed in many ways: gravity-assisted stretch, passive stretch, active motion and loading the joint. Hand therapists routinely take measurements for active and passive range of motion to demonstrate progress and justify services.

Generally speaking, following post-surgical interventions, hand therapists work to return passive range of motion (PROM) first, then active range of motion (AROM). While progressing both at the same time, PROM leads the way.

Recently, I treated a patient with a Colles’ fracture. Her original measurements were 25 degrees of active flexion and 35 degrees of active extension.

After treatment consisting of soft tissue mobilization, passive range of motion and stretch, her motion improved to 35 degrees of active flexion and 45 degrees of active extension.


Without strength, we cannot open a jar, start the car, pick up a bag of groceries, or perform other tasks necessary for independence. Like range of motion, strength will slowly return. Strength gives us the ability to complete activities of daily living and instrumental activities of daily living.

Strengthening is addressed through graded activity and exercise through the use of hand exercisers, therapeutic putty and progressive repetition exercises, as well as gravity-assisted and other forms of resistive exercise.

Generally speaking, we measure strength with grip and pinch testing. Grip strength is tested with a dynamometer. There are multiple ways to complete this standard grip test.

The five-level grip test uses each rung of the dynamometer, while the rapid exchange test provides the most accurate results, especially if you suspect the patient is self-limiting.

Pinch is tested in three positions: lateral pinch, 2-point and 3-point. Additional measurements are taken through manual muscle testing. Recently, it’s become difficult to continue treating patients who have only strength deficits. To continue strengthening after the patient is discharged home, exercise programs have become increasingly important.

Learning More

This article does not represent an all-encompassing treatment protocol for any specific condition. For instance, sensation is also an important consideration when evaluating and treating hand therapy patients as edema, inflammation and scar tissue can impact the nerves and their function.

However, this article does serve as a basic foundation to establish assessment and evaluation of this unique subset of patients seeking occupational therapy services.


  1. Burke S. (2006). Hand and upper extremity rehabilitation: A practical guide (3rd ed.). St. Louis: Elsevier Churchill Livingstone.
  2. Cooper C. (2013). Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity (2nd ed.). St. Louis: Mosby.
  3. Hand Therapy Certification Commission. Who is a CHT? Accessed via Retrieved Oct.29, 2015.

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