Bridging Gaps in Pediatric Hand Therapy: A Capstone Project
Capstone Preparation
I recently had the privilege of completing a Capstone rotation with the Hand and Upper Extremity (UE) Rehabilitation Department at Children’s Hospital in St. Louis. I feel very fortunate to have had this opportunity, as I am the first Capstone student hosted by this department. Hand therapy is a specialized niche within the OT/PT realms, but pediatric hand therapy is an even further subspecialty. I have always been curious about what pediatric hand therapy entails, as I have wanted to explore occupational therapy’s role when working with this population. Because hand therapy is such a niche specialty, many students feel averse to fieldwork rotations in this area.
To prepare for this rotation, I completed one Level 2 fieldwork rotation in pediatrics and one Level 2 rotation in adult hand and UE rehabilitation. My first experience in pediatrics was a school-based occupational therapy rotation at an elementary school. This rotation helped me learn the documentation basics and, most importantly, play! Integrating play with school-readiness occupations was the most important skill I took away from this rotation, which came in handy for my rotation at Children’s Hospital. I had a blast with my kiddos creating crafts, addressing handwriting, and making obstacle courses! My second fieldwork rotation was at a fast-paced outpatient hand and UE clinic where I was exposed to hand issues across the gamut from finger fractures to nerve transfers. During this rotation, I learned the basics of orthosis fabrication, management of UE conditions, and interpersonal connection. So much of my intervention planning centered around supporting my clients to return to their beloved or required occupations: whether it be the ASL interpreter who broke their wrist, the golfer who broke his pinky, the cross-fitter post-breast reconstructive surgery due to cancer who wishes to return to exercising; all of my clients shared a level of grief associated with their injury. Being able to see progress over time in each of my clients and slowly return to their desired occupations in the clinic was the most salient point of my hand therapy rotation.
I feel fortunate that my Capstone rotation was a beautiful mix of the high points of both of my Level 2B fieldwork rotations. During my Capstone rotation, interventions were centered around play, and I could support my clients to return to their desired occupations like pitching and ballet class. Clients ranged from 9 days to 30 years old and had a wide variety of conditions. One large population that we worked with is infants who experience birth brachial plexus injuries. Our role as therapists is to monitor for native recovery and provide parent education around how the family can help promote nerve healing (if appropriate), and support the infant to reach their appropriate developmental milestones. Translating the clinical knowledge of adult brachial plexus injuries to pediatrics was a great way for me to develop my clinical reasoning and deepen my understanding of the UE.
For my project component of the Capstone rotation, I created department resources for the therapy team to share with therapists who work in remote locations. Many clients travel far for their therapy and physician visits, and many of the conditions that we see require continued therapy. By creating templates for detailed therapy referrals and mini-lectures on the most common hand conditions that we see, our department can easily refer clients to therapists who work at more remote locations and enable those therapists to feel more confident treating these UE conditions. This project has been a great learning tool for me, as it has allowed me to delve into recent research on common pediatric UE conditions, providing me with a better understanding of the involved anatomy and interventions.
Common Myths and Misperceptions About Hand Therapy
As a student, I have greatly enjoyed my hand therapy rotations and would encourage more students to consider completing a rotation in hand therapy, even if it’s just a Level I rotation. Hand therapy rotations can be daunting, as many students report feeling unprepared. Let’s break down some common misperceptions about hand therapy that I have compiled throughout my time in occupational therapy school:
Myth 1: Hand and UE Rehabilitation is not Occupation-Centric.
I wholeheartedly disagree with this sentiment! While a foundational knowledge of anatomy and biomechanics is essential for interning in a hand therapy clinic, having the personal skills to connect with your clients and administering a thorough occupational interview to guide an intervention is key to a successful client interaction. While it may be easy to leave occupation out of hand therapy, our UE is essential for most ADLs and IADLs. Even a P1 pinky fracture can inhibit a person’s ability to engage in their required and desired tasks, as the pinky is an important contributor to grasp.
Myth 2: I Don’t Remember Enough Anatomy to Complete a Level 2 Fieldwork in Hands!
As a student, and even a clinician, you are never expected to know everything. Hand therapy is a specialty where you will be required to continuously learn and grow as a clinician. While I definitely recommend refreshing your anatomy before this rotation, give yourself grace and know that your caseload will scaffold appropriately. I felt more prepared for my pediatrics rotation than my hand therapy rotations, which is a very normal feeling!
A resource I recommend using is the ASHT Student Guided Workbook. I used portions of this workbook to study anatomy and get acquainted with common conditions seen in the clinic. This workbook is challenging but can be used as a tool to help gauge learning needs. If you’re stuck, great! Bring that page(s) to your hand therapy rotation and ask your clinical instructor (CI) about it. My favorite textbook that I used as a student is Cooper’s Fundamentals of Hand Therapy, which I could check out from my school library. See who else from your school is doing a fieldwork rotation in hand therapy and set up a study group!
Myth 3: My Splinting Needs Help!
I struggled with orthosis fabrication in class, and I still struggle. My program had only given me the opportunity to complete two splints prior to my hand therapy rotation. Communicate this worry to your CI on your first day of the rotation, and they will help you learn! As with everything, mastery comes with time and practice.
A splint that I made for a 2-month-old, with help from my CI
I hope every occupational therapy student gives hand therapy a try. Consider completing one of your Level 1 fieldwork rotations in hand therapy to get a better sense of what these practitioners do in the clinic. If you like pediatrics and anatomy, consider a rotation with the hand and UE rehabilitation unit through one of your local children’s hospitals. You may be surprised by how much fundamental knowledge in hands will guide your treatment in other OT specialties.
Carley Yanuck, MM, OTD, completed her degree at Washington University in St. Louis in July 2024. Carley is currently applying for hand and upper extremity rehabilitation opportunities, seeking to utilize her OT knowledge with her past music performance career. Prior to OT school, Carley performed with many different orchestras in the United States and Europe and continues to perform as a member of the St. Louis Philharmonic Orchestra. Carley holds a master's degree in Music Performance from DePaul University in Chicago. Outside of OT school, Carley also serves as the Editor-in-Chief for the AOTA Student Pulse and is passionate about supporting the arts in St. Louis.