"There is a shortage in general of hand therapists," said Cindy Johnson, PT, DPT, CHT, president of the hand rehabilitation section for the American Physical Therapy Association. "But PT hand therapists are sought after. They are never wanting for a job."
Hand therapy certification is one of the most demanding programs offered to PTs. Five years of experience as a PT and documentation of 4,000 hours or more in direct practice in hand therapy is required before a candidate can sit for a rigorous half-day written exam, which has only a 50% pass rate.
"CHT has meaning," Johnson said. "PTs with a CHT are taken seriously because it denotes a certain level of expertise."
But along with a difficult certification program is a rewarding career, Johnson said. "If you really want to make a difference for somebody, take care of their hands," she said. "Hands are so foundational for taking care of yourself on a very basic level — dressing, bathing, feeding yourself — and at the same time you couldn’t do many jobs without your hands."
Low numbers
Only around 750 PTs are certified hand therapists, making up only 14% of the almost 5,400 therapists with CHT designations, Johnson said. The vast majority of CHTs are occupational therapists, she said.
Julianne Howell, PT, MS, CHT, who works at Samaritan Health Services in Corvallis, Ore., and lectures about the CHT designation across the country, sat for the first CHT exam in 1991. "The number of PTs with a CHT has gone up only a couple of percentage points since I took the exam," she said. "OTs are traditionally upper body, I think that’s why PTs have not taken it on."
Mark Walsch, PT, DPT, CHT, clinical director at Hand and Orthopedic Physical Therapy Associates in Levittown, Pa., and an assistant clinical professor at Drexel University in Philadelphia, agreed the upper body has been the domain of OTs. "But [the number of] PTs in hand therapy is growing," he said. "Nine of the CHTs that are in our practice are PTs. Another reason for the low number of PTs is logistics. In some states, regulations say we can’t cross lines. So if we have a hand OT that wants to go on vacation or is out sick, we have to use an OT to take her place. The same with a PT hand therapist. Logistically, it’s a bit of a problem."
CHT treatments
CHTs actually treat a lot more than the hand. The Hand Therapy Certification Commission, which offers the certification, defines hand therapy as the rehabilitation of the upper limb, including the hand, wrist, elbow and shoulder girdle.
Johnson, who works in the trauma center and is a senior instructor at the University of Colorado in Boulder, said CHTs treat a wide variety of issues in their caseload including burns, nerve compression syndrome, overuse problems such as tennis elbow or carpal tunnel syndrome, and distal radius fractures.
Walsch said physicians, particularly hand surgeons, now routinely request a CHT when writing their prescriptions for therapy. He said he sees four areas that a CHT can treat with their higher level of skill: multiple trauma with fractures or nerve damage requiring surgery, total joint replacements, flexor tendons and complex regional pain syndrome. "Some of our PT colleagues think that they can take care of hand issues as well as a CHT," he said. "But it does require a certain amount of knowledge and experience to do it correctly."
OT, PT & CHT
Johnson said new research suggests a strong link between the spine and conditions of the upper limb, which could fuel a growth in PT interest in the certification. "Research is coming out stating you can’t treat the hand without treating the spine," Johnson said. "That is not part of an OT practice, but it is part of a PT practice."
For example, a study by Joshua Cleland, DPT, OCS, and others in the Journal of Manual and Manipulative Therapy (Vol. 13) shows that patients with lateral epicondylalgia (tennis elbow) show greater improvement in all outcome measures when including manual therapy aimed at the cervicothoracic spine along with local treatment directed at the elbow.
Research also is showing the development of a concept called "regional interdependence," which involves thoracic spine manipulation to treat symptoms in regions adjacent to the spine, such as the shoulder, according to Ronald Walser, PT, DPT, in the same journal (Vol. 17.) "Apart from what is exactly happening as a result of spinal manipulation/TSM, regional interdependence is a concept that experts agree occurs and that should be considered in clinical decision-making," he wrote.
While occupational and physical therapists approach hand therapy in different ways, most see it not as a competition, but as a way to combine the best of both practices. "It made me a much better therapist to work with OTs," said Ann Porretto-Loehrke, PT, DPT, CHT, COMPT, at the Head and Shoulder Center in Appleton, Wis. "Once you become a CHT, it doesn’t matter if you are a PT or OT. The CHT is a common bond."
PTs typically have more background in biomechanics, posture and anatomy, said Sharon Andruskiwec, PT, CHT, the hand program manager at Orthopedic Specialty Group in Fairfield, Conn. "We’re taught to appreciate the entire body as a whole." she said.
OTs, on the other hand, focus treatment around functional activities, Andruskiwec said. "It took me a long time to embrace functional activities," she said. "OTs start with that."
Howell said after becoming a CHT and working alongside OTs she now thinks about function every day. "I think it’s a compliment when someone can’t tell if I’m an OT or a PT," she said.
Billing issues/rewarding outcomes
One challenge for CHTs is there is no licensing board established at the state level to recognize the specialty, Poretto-Loehrke said. "It would take so much to get each state set up for licensing," she said. "It’s not practical for the CHT commission to take on."
She said insurers are not consistent in approving care for CHTs across the board. In her practice in Wisconsin, she frequently sees patients from nearby Michigan. "For example, Blue Cross Blue Shield of Michigan says outside of state there is no OT coverage, only PT coverage," she said. "Golden Rule also will only take PT coverage out of state. You have to learn to live with the rules."
Some insurers, like Blue Cross and United Healthcare, allow direct access to the PT CHT, while others do not, she said.
Also, Medicare, which is the insurer for many hand patients, will not allow both OT and PT CHTs to work on the patient without separate plans of care, Johnson said. "It’s a barrier in some cases," she said. "Medicare rules keep us from sharing a caseload."
On the other hand, CHT may very well be the only specialty certification for PTs that is recognized by physicians and insurers. "You don’t see a prescription for PT OCS [orthopaedic clinical specialist], but you will see a prescription for a CHT from a hand surgeon," Walsch said. "And a lot of referrals come with CHT."
Despite billing issues, PT hand therapists do not hesitate when asked if their jobs are rewarding. "You develop a really close relationship with your patients," Andruskiwec said. "They are very motivated and really appreciative to you."
(Source: todayinpt.com)
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