Hand, Wrist and Upper-Limb Rehabilitation: What Hand Therapy Involves

After a fall, a surgery or months of night-time tingling, buttoning a shirt can feel clumsy, and nobody has said how long that will last. This page describes how hand, wrist and arm rehabilitation generally works: common conditions, what a hand therapist does, splints and movement, and published recovery timelines. It is general education from named public sources, not a diagnosis, and it does not replace the plan from your own surgeon, doctor or therapist.

What upper-limb rehabilitation is

The American Society of Hand Therapists (ASHT) describes hand and upper extremity therapy as the art and science of evaluating and treating injuries and conditions of the shoulder, arm, elbow, forearm, wrist and hand, using a number of therapeutic interventions to help return a person to their highest level of function. The aim is less a perfect-looking hand than one that can open a jar, hold a pen and do the tasks of a particular job or household.

The wider profession is covered in what occupational therapy is and who it helps, and the overlap with physical therapists is explained in occupational therapy versus physical therapy.

Who hand therapists are

According to ASHT, a hand therapist is an occupational or physical therapist who, through advanced continuing education and clinical experience, has become proficient in treating upper extremity conditions that result from trauma, disease, or congenital or acquired deformity. It is a specialty within two existing professions, not a separate license. ASHT notes that a prescription from a physician may be necessary before you can see one.

A formal credential exists as well. The Hand Therapy Certification Commission (HTCC) says its Certified Hand Therapist (CHT) credential is a voluntary program, established in 1989, for occupational and physical therapists in the advanced clinical specialty of upper limb rehabilitation. Its 2020 exam brochure lists these requirements: a current professional license or registration, at least three years since it was issued, a minimum of 4,000 hours of direct practice in hand therapy, and a 200-question multiple-choice exam. Certification lasts five years, after which the therapist must recertify. The brochure is a few years old, so check current requirements with the HTCC. Not every capable hand therapist holds the credential.

Conditions that commonly lead to hand therapy

Carpal tunnel syndrome

The American Academy of Orthopaedic Surgeons' patient site, OrthoInfo, explains that carpal tunnel syndrome occurs when the median nerve is squeezed as it passes through the wrist, causing numbness, tingling, burning and pain, mainly in the thumb, index, middle and ring fingers. It often wakes people at night. OrthoInfo adds that in most people it gets worse over time, and that left too long it can cause permanent loss of feeling and weakness. The NHS says symptoms often come and go.

Tendon injuries

Flexor tendons run along the palm side of the fingers and let them bend. OrthoInfo's flexor tendon page says these tendons are usually injured by a cut on the palm side of the fingers, hand, wrist or forearm, and that a cut tendon often cannot heal on its own because the ends pull apart. Surgery is usually performed within 7 to 10 days.

Trigger finger

In trigger finger, a thickened tendon catches as it passes through a tunnel at the base of the finger, producing a catching or locking feeling. OrthoInfo's trigger finger page says it affects about 2% of the general population, and is stiffest after inactivity such as on waking.

Wrist fractures

A distal radius fracture is a break of the forearm bone near the wrist. OrthoInfo reports that in the United States about 1 out of every 6 broken bones treated in the emergency room is a distal radius fracture, and that the most common cause is a fall onto an outstretched arm.

Arthritis

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) states that rheumatoid arthritis is more common in the wrists, hands and feet and often affects both sides of the body. Hand swelling can make everyday tasks hard, such as making a fist or buttoning clothes. ASHT adds that people with arthritis can benefit from education on joint protection and energy conservation and from adaptive equipment.

How the assessment works

For carpal tunnel syndrome, OrthoInfo lists tapping over the nerve to see if tingling spreads into the fingers, holding the wrist bent, light-touch testing of the fingertips with eyes closed, checking for weakness in the muscles at the base of the thumb, and looking for wasting of those muscles. For a flexor tendon injury, the doctor asks the patient to bend and straighten the fingers, tests finger strength, and checks sensation and blood flow.

Recovery is tracked in the same terms: OrthoInfo notes that after carpal tunnel surgery grip and pinch strength usually return by about 2 to 3 months. The exact tests a therapist uses vary by clinic and condition, and the sources reviewed do not list them, so this page does not either.

Splints and orthoses

A splint, also called an orthosis, holds or supports a body part in a chosen position. ASHT lists custom orthotic fabrication among the tools hand therapists use, and the sources show how differently splints are used:

• For carpal tunnel syndrome, OrthoInfo says a brace worn at night keeps the wrist from bending during sleep, and the NHS says relief can take time: you may need to wear a splint for up to 6 weeks before it starts to feel better.
• For trigger finger, OrthoInfo lists a night splint that keeps the affected finger or thumb straight as a first-line option.
• After flexor tendon repair, OrthoInfo says a protective splint is usually worn for approximately 6 to 8 weeks, removed only to do the exercises prescribed by the doctor and therapist.
• After a wrist fracture, a splint is usually used for the first few weeks to allow for swelling, and the cast usually comes off about 4 to 6 weeks after the injury.

Position, hours and duration depend on the problem. OrthoInfo stresses that after a tendon repair, splint wear and exercise exactly as prescribed are as important as the surgery itself.

Movement, exercise and activity changes

Rest and movement both have a place, and the balance changes with the injury. After a distal radius fracture, OrthoInfo says to work on moving the fingers as soon as possible, and to tell the doctor if you cannot fully move them within 24 hours. After flexor tendon surgery, the surgeon often refers the patient to a hand therapist within days to start protected exercises.

OrthoInfo lists gentle stretching for trigger finger and nerve gliding exercises for carpal tunnel syndrome, which help the median nerve move more freely, adding that a doctor or therapist may recommend specific ones. The NHS is more cautious, saying there is a small amount of evidence that hand exercises ease carpal tunnel symptoms. Because the right movements depend on the diagnosis and stage of healing, this page gives no exercise program. Do the exercises your own surgeon or therapist chooses.

Activity changes matter too. For carpal tunnel syndrome, OrthoInfo says modifying aggravating activities can help slow or stop progression, sometimes by changing the workstation, and the NHS suggests cutting back on activities that bend the wrist or need hard gripping. For desk work, see workstation ergonomics, and for the home, adapting the home and daily routines.

Swelling and scar care

ASHT includes management of pain and swelling and wound and scar care among hand therapy techniques. For a serious cut, OrthoInfo advises a compression wrap, ice and keeping the hand lifted above the heart. After carpal tunnel surgery, some soreness is expected, and elevation helps with pain and swelling.

Scar tissue can become the next problem. OrthoInfo explains that after tendon surgery, scar tissue may make the tendon stick to its sheath. Stiffness is common but usually responds to therapy, and if it does not, a second operation called tenolysis may be considered at about 4 to 6 months from the repair. Specific scar techniques are for a therapist to choose after seeing the wound, so none are described here.

How long recovery takes

Timelines differ widely. These published figures are examples from OrthoInfo and the NHS, not predictions:

• Distal radius fracture: full use of the hand for all activities in about 3 months, full recovery up to 1 year. OrthoInfo adds that it keeps getting better for at least 2 years, and that some people have lasting stiffness or aching.
• Flexor tendon repair: about 3 to 4 months for the tendon to heal before the hand is strong enough to use without restrictions.
• Carpal tunnel release: the NHS says return to normal activities can take about a month. OrthoInfo says complete recovery may take up to a year, and that if the nerve was in poor condition before surgery, grip and pinch strength may not improve for about 6 to 12 months.
• Trigger finger release: OrthoInfo says the incision usually heals within a few weeks, but swelling and stiffness can take 4 to 6 months to go away completely, and on average people feel fully recovered 6 months after surgery.

OrthoInfo adds that arthritis can slow recovery after carpal tunnel surgery.

Returning to daily tasks and work

Return is usually gradual. After carpal tunnel surgery, OrthoInfo says driving, self-care and light lifting and gripping may be permitted soon after, and the doctor will say when you can go back to work and with what restrictions. After a wrist fracture, light activities such as swimming are listed at about 1 to 2 months after the cast comes off, and demanding ones such as skiing or football at about 3 to 6 months after the injury.

ASHT notes that a hand therapist can also act as a consultant in the industrial world, training employees and recommending modifications of workstations and alternative work methods. Fatigue is a factor too, and pacing ideas are covered in energy conservation and fatigue.

When to see a doctor

The sources name several points where waiting is not advised:

• After a wrist injury, OrthoInfo says if your fingers feel numb, go to an emergency room right away.
• For a cut on the palm side of the hand or fingers with a finger that will not bend, OrthoInfo says to see a doctor as soon as possible, and that a finger with no blood supply needs immediate surgery.
• For carpal tunnel symptoms, the NHS says to see a GP if symptoms are getting worse or not going away, or if home treatment is not working.
• After surgery, OrthoInfo says significant pain and weakness lasting more than 2 months after carpal tunnel release may lead to a hand therapist referral.

If you are unsure whether something counts, ask your own doctor. Choosing a therapist is covered in choosing a therapist and what to ask, and other hands-on approaches are compared in hands-on therapies compared.

Honest limits

This page draws mainly on United States and United Kingdom public sources, and practice varies by country, clinic and surgeon. Many conditions are not covered, including burns and amputations. Needs differ from person to person, and your own surgeon, doctor or hand therapist has the final word on splints, exercises and timing.

The short version

Hand therapy is rehabilitation for the shoulder to fingertips, delivered by occupational and physical therapists with extra training, and it combines evaluation, splints, guided movement, swelling control and task practice. Recovery ranges from weeks to a year or more, and the splint hours and exercises differ by injury. Numb fingers after an injury, a cut palm with a finger that will not bend, or symptoms that keep worsening are reasons to see a doctor promptly.