By Debby Schwartz, OTR/L, CHT

Nearly 100 hand surgeons and hand therapists gathered in Caracas, Venezuela last week to attend the Tenth Anniversary Congress of Hand Therapy and 25th Anniversary Congress of Hand Surgery sponsored by the Venezuelan Societies of Hand Surgery and Hand Therapy. I had the distinct honor of presenting on hand therapy topics with Shrikant Chinchalkar, OTR/L, CHT from Canada. Dr. Joseph Imbriglia, a hand surgeon from Pittsburgh, Pa. and two hand surgeons from San Paola, Brazil, Dr. Rames Mattar and Dr. Luis Angelini, also presented. All talks were presented in English or Spanish with simultaneous translation.

Jose Manuel Pineda of Caracas, the vice president of the Sociedad Venezolana de Mano, was our extremely friendly and charming host. He took care to prepare all of our travel arrangements with great detail, including hotel stay, rides around Caracas, and our delicious meals. Rosa Marina Perez, the president of the Sociedad Venezolana de Mano, also took great care of us and attended to all of our requests. Many other members of the Venezuelan Hand Therapy Society accompanied us on all of our outings and made sure we felt right at home. I have never met so many affectionate and friendly people who hug you, kiss you on both cheeks, and smile at you, and thank you warmly for sharing information with them. Our efforts were so appreciated!

Our conference topics were wide and varying. We presented on topics of interest to therapists and surgeons alike: anatomy, patho-mechanics of arthritis, X-rays and fracture stabilization, tendon transfer protocols, splinting, sports injuries, overuse tendinopathies, mutilating injuries and brachial plexus injuries. We also participated in a panel discussion on Focal Hand Dystonia, although it is a rare diagnosis in Venezuela, as well as in the United States, Brazil and Canada. Participants really enjoyed a DVD presentation on Orfit Industries products and splinting, and loved my quick and easy splinting demonstration. Splinting is one topic with which Venezuelan hand therapists have little experience. Orfit Industries graciously and generously provided each participating therapist with a sample kit, including an excellent splinting book by Paul Van Lede, OT, MS, and sample Orfit splinting materials. All the therapists were eager to go home and practice splint making on family members.

Along with the intense teaching and learning experiences, we also enjoyed coffee, pastries and chatting with the Venezuelan therapists. We discussed patients, work schedules, educational opportunities and the differences and similarities between our countries.

Visit to Hand Therapy Clinics in Caracas
The day before the conference, we visited two rehabilitation facilities and observed hand therapy as practiced in Venezuela. We were also able to sit with one particular patient and problem-solve issues regarding his treatment plan. This patient, who spoke perfect English, and his therapy team were thrilled with our advice, and eagerness to help. They were particularly interested in the joint mobilization techniques and self stretching maneuvers demonstrated by Shrikant. I was able to add some ideas to improve on the splinting design for increasing passive supination. At the time of our session, I was unaware of how little exposure the therapists have to thermoplastic materials.

Hand Therapy Practice in Venezuela
The information I gathered on hand therapy practice in Venezuela today came from informal discussions with conference attendees, chatting during our shared meals, and from a short survey which I had the therapists fill out at the end of the conference.

Educational Background
Hand therapists in Venezuela are either occupational or physical therapists and I met an equal number of both disciplines. I don't know about the Physical Therapy program; however, occupational therapists receive a certificate as Technician of Occupational Therapy after a three year course of study. Just recently a fourth year of class work was introduced to allow therapists to get a degree of Occupational Therapy and national licensure. Many practicing Occupational Therapists are now devoting Fridays and Saturdays to studies in order to pass the coursework and examination and become licensed to practice with a degree. However, ten years ago, the Venezuelan Society of Hand Therapists was created with a core group of 17 therapists. They have since created a certification examination in order to become a certified hand therapist in Venezuela. Only six therapists have passed the examination so far. So the process of becoming a certified hand therapist with a degree in Venezuela takes a slightly different course than in the United States.

Splinting
There is little experience with splinting in the Occupational Therapy educational program and little access to thermoplastic products in the hospital systems, most likely due to lack of funding. It seems that some therapists working in private clinics may have access to thermoplastic splinting products. The hospitals rely heavily on the prosthetic departments to fabricate splints with therapy input. We did observe two patients with static progressive splints utilizing turnbuckles to increase motion. But thermoplastic static progressive splints, blocking splints and exercise splints are neither readily available nor utilized.

Treatments
The emphasis in the clinics appears to be on functional use of the extremity, with modalities such as paraffin, infrared, ultrasound and magnetic therapy. As we observed treatment in the National Rehabilitation Hospital of Caracas, all patients appeared independent in their use of the many handmade activities spread around the room. Therapy student projects included wooden mazes, sanders and dangling macrame hangers to encourage finger dexterity and upper extremity range of motion.

All the therapists expressed familiarity with the modalities common to American hand therapy clinics, except for fluidotherapy. Therapists commonly use hot and cold packs, paraffin, contrast baths, infra red treatments, ultrasound and iontophoresis. A few therapists stated that they use standardized functional tests like Jebsen, Moberg, and the Purdue Pegboard test as well as performing Functional Capacity Evaluations (FCE). Only a few therapists mentioned using the DASH (Disabilities of the Arm, Shoulder and Hand) or PRWE (Patient Rated Wrist Evaluation) which I emphasized in my talks.

Diagnoses
The diagnoses that hand therapists see in Venezuela are very much the same as what we treat here in the United States. In addition to the wide variety of fractures, tendon injuries, nerve injuries and work related accidents, they also treat Carpal Tunnel Syndrome, CRPS, Cumulative Trauma, and Arthritis. And I was surprised to learn, even Dupuytren's Disease. Unfortunately, we did not have enough time to discuss protocols, or share treatment techniques and methods.

National Health Care
Citizens of Venezuela are covered in a socialized health care system. There is a lot of controversary regarding the Government's initiatives in health care reform including the rising number of Cuban physicians now practicing in Venezuela. Treatment at public hospitals is free, but private health care insurance can be purchased, and private doctor and therapy facilities are increasing in number. Patients typically come three times a week for forty-five minute sessions. Most of the therapists reported working full time; This ranged from forty-five hours per week to seventy hours per week as several therapists told me they work at two different jobs. The salaries are much lower in Venezuela.

Support for Hand Therapy
There seems to be a very good relationship between the hand therapists and the hand surgeons. Most therapists reported that they feel their efforts are appreciated and supported by the surgeons. Over half of the therapists indicated that they meet with the surgeons on a regular basis to discuss patient care.

The therapists did describe professional difficulties with lack of funding for equipment and increasing numbers of patients to be treated. Other issues of concern to therapists include lack of continuing educational opportunities, lack of experienced hand therapists, and lack of clinical research studies. Many therapists indicated that they are members of the Venezuelan Hand Therapy Society, read the Journal of Hand Therapy, attend conferences regularly and have access to literature on the internet. They appear to be a highly motivated and enthusiastic group of professionals!

Our forays in Caracas included a terrifyingly long and steep cable car ride up the Avila Mountain for a fondue dinner as well as a stroll through the peaceful arts and craft stores of El Hatillo, a suburb of Caracas. It was an incredibly wonderful visit to Caracas, Venezuela, and I want to sincerely thank my hosts for the opportunity to visit and teach. I hope to visit again in the near future!

About the Author
Deborah A. Schwartz has been an Occupational Therapist for 21 years, specializing in hand therapy for 18 years. Her specialty is working with tendon transfer patients. In 2004, she presented two talks on Tendon Transfer Rehabilitation at the International Federation of Societies of Hand Therapy conference in Edinburgh, Scotland. She has also presented on this topic at the Philadelphia Hand Meeting and at the ASHT meeting in Charlotte, N.C. in 2005. Her article, "Tendon Transfers for Enhanced Wrist Extension: A Case Report" was recently published in the British Journal of Hand Therapy. Ms. Schwartz is the 2004 recipient of the Evelyn Mackin Traveling Hand Therapist Award. She traveled to Norway and Great Britain where she visited hand therapy clinics and presented on tendon transfers and hand therapy in America. An article about her experiences was recently published in the Journal of Hand Therapy.

Ms. Schwartz currently works at a private hand center in Marlton, N.J. She is very committed to international hand therapy topics and has recently joined the ASHT's international committee.