Hand & Upper Extremity Protocols with Author Elizabeth de Herder
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[00:00:00] Hey, it's Hoang here with Hand Therapy Secrets. Welcome to my show today. I've got a special guest. Her name is Elizabeth De Herder. Not only is she an occupational therapist and a certified hand therapist that has her own private practice. She's been running for 20 years. 20 years she's been running this private practice.
It's amazing. Not only that, how does she have time to write a book? So she. The Author of Evidence-Based Hand and Up Extremity Protocol Book, and this is her second edition she just released this year. We are going to talk to Elizabeth and get some of her insights into some of her story of how she became a certified hand therapist and how she got into private practice.
And how she started writing this book. So this is one of the go-to books for if you are looking for a protocol book and you're just like, I'm new to hand therapy. I've been working in hand therapy for a while, and it's nice to have a protocol book that you can just. Look at the content and then you [00:01:00] like find out where your particular injury is and you can get answers right away versus going into a textbook and reading all that stuff.
That's something for later. But these protocol types of books are really awesome because you can get help from them really fast, especially when you're on the go in the clinics. This is her book that she just released, so listen to her story.
Hey everybody. It's Hoang With Hand Therapy Secrets. Today I have Elizabeth De Herder. She is a practice owner, private practice owner, and also the author of Evidence Base Hand and Upper Trim Protocol. We see her book right next to her, so welcome to my show. Thank you so much for joining us. Thank you for having me.
I wanted to have you on because as myself, as a business owner, I'm always interested in seeing and sharing other private business owners. And not only are you a private business owner of 20 years, but you also have written a book. And this is your second edition, am I correct? Yeah.
Your second [00:02:00] edition. Okay. So I wanted to have you on the show, and I know that a lot of people do approach me because I have private practices and stuff like that, and I think a lot of people do look for some inspiration. In terms of can I do this myself too? Can you share a little bit about your story of going into private practice?
Sure. So I was actually always worked in big medical complexes, trauma centers worked at UAB B for a while at M U S C. and one of the hand surgeons that I was really close to and I still work with, I've worked with him for 27 years. He was going into private practice at that time. Now he's back hospital based.
But asked me to come work with him and I said I'd rather you know if you'll let me do my own thing. And they did. So that's how it evolved, although I didn't know a whole lot about that because being in hospitals, I didn't know about all the contracts and all the, that I've learned and sometimes I learned the hard way.
I made a lot of mistakes the first year for sure and probably lost a lot of money. [00:03:00] But , I worked really hard and I was very frugal. I made a lot of my own equipment and. , now I've got four OTs that are working for me and three office staff, and I have two locations and I've been the surgeons have grown and so my practice has grown.
And so it's been a really amazing journey and I'm very grateful. To probably 80% of my business comes from hospital-based surgeons and they had their own OTs, but they and hand therapists, cht. Yeah. But they like my practice and they know I get good results and they also know how I train my therapist.
All three of the therapists that work for me were students under me. That's awesome. That's awesome. So tell us, you've been in private practice for a while. What? You said you made some mistakes. I know that my first year I didn't know what I was doing. , you just throw yourself out there and be like, I can [00:04:00] do it.
And what would you say was like a huge mistake of. , probably the contracts. I didn't realize that you had to go through all the contracting and what all you had to do. It's really hard to get started because you have to have a physical location before you can bill, and then you can't bill really. It is a catch 22.
Yeah. Especially with Medicare and with Blue Cross. And those are your first ones you usually go after. So we started out slow and then just built on it, and then revisiting those, So about every three to five years, I go back to the insurance companies. And that's something that probably OTs and PTs don't do.
And I work my own contracts. I don't let my office manager who's awesome do it. Yeah. But I've done PowerPoints, I've proved that I'm not the. Because I'm in such a specialty. Yeah. And but I've proved that I'm a little bit different animal and I treat really traumatic injuries and get good results, right?[00:05:00]
So I've proved my worth and they tend to listen a little bit better when you've, when you actually do the talking and not absolutely somebody who doesn't know. So I think that's s advice if you're gonna do it. Run your practice. That's great advice for anyone who's coming and looking to open their own practice.
Because we do tend to, when we don't know credentialing, right? We don't know credentialing. You do pass the bucket to someone who does, and you're essentially saying, Don't pass the bucket. Don't pass the bucket. , do it yourself. Does some of that especially with the new therapists coming in.
But as far as the contracts go, yeah, the contract, you need to go in there and you need to specify, and you need to show up and say why, with the specialty. Why they should be paying you more. That's much what [00:06:00] you're saying. I'm Elizabeth, I have this, I know how to get people better.
You need to pay me more to get your people better. Yes. Oh, that's good stuff. That's really awesome. One of my things with being on this journey of being in private practice is I've learned a lot about myself, in these last couple. that I didn't really think I would, like you go on this journey, you're just creating like a job, building your career.
What would you say that you like really learned about yourself as a person that you didn't really. No, before. I like the business aspect. I love the therapy. Yeah. But I really like the business aspect. And two years ago I graduated with my mba. Congratulations. At 50, I was 56. Yeah. Actually I was 58 when I went to school, so I graduated when I was 60 and I was the oldest one in the class[00:07:00]
But you know what, we're like the more studious ones, right? When as you get a little older, a little bit more mature, like you're just more serious, like you just study a different way. What didn't you say? Yes. And also I'd owned a business, so I had a little bit of a leg up on, especially the entrepreneur part of it.
Yeah. Some of the finances and learning a cruel accounting about killed me and economic, but you know what I, I feel so much better now about making my decisions business wise because I know how to do do the math, work it out. Do scenarios, make sure I'm right, making the right calls. So if you're gonna own your own business, I think you've really got to make sure you're running the business and it's someone else.
You're not relying on somebody else to do it. Now somebody does do my billing and all that, but I keep on top of it. You have to. Yeah. I'm. . I'm learning so much about numbers and I always used to say that I was not good at [00:08:00] math, and the only thing I do nowadays is math . Because everything comes down to numbers.
So you started your business, you've been in business for a while. When did you decide to write this evidence-based protocol book? . Okay. When did you have time? Elizabeth . I know. Really? So in nine, I think in 2000 and 15 I I go back to actually 1985. , when I. Alabama and also at M U S C, we treated all the trauma, so flexor tendons, extensor tendons, anything and everything came through our clinic with the doctors.
The doctors would immediately send them, to us to get 'em started, and then we would. Would refer them out to other places. So closer to home if they were three hours away or two hours away. So my surgeons were like, we want a protocol written up that we like, we approve and base it on research.
So I've been doing this my whole career. Wow. About [00:09:00] 2015, one of my surgeons that was a very big referral source, retired. And it left a big hole in my practice till they replaced him. And so I had all this time and I thought, no, I need to go back and, revisit because they're not updated. So I started doing 'em, then I started adding to 'em and one of my therapists looked at me and said, you need to publish this.
And I said, you know what? I think I do. So I contacted an attorney that I'd worked with before. He gave me some, anybody in his office. I looked into publishing. through a publishing company, but they wanted to put it in Barnes and Noble. And I'm like, that's not my niche market. Yeah. So I looked into self-publishing and I wrote the book.
I paid a self-publishing company to put it into a format for me and to print it. I did it spending money not knowing if I was gonna get any return on how I. She received. And then in 2015 it took me, it takes me a year to write [00:10:00] this. This took a year to redo it, and the first one took a year to even do it.
The amazing thing isn't, it's not, is more than a year, Elizabeth, you're like for five, you've been like pieces of paper. Pieces of paper, and then you took all the papers, not just written down, but the ones that are in your head filed out, put it out. So like a whole career. It took you a year to put it in print
It took a hundred copies of books and suitcases to the Afh T meeting, rented a booth and I sold all a hundred that first year. Wow. So word of mouth, I worked with some other people that helped me get. Started, which is good. This next version though, I decided I wanted to do it all myself.
I went to school to learn how to do a lot of this stuff, and I said, you know what, I, and I love the self-publishing because if somebody asked me, say they're going on a mission trip and they are looking for some donations or something, I. Privilege to [00:11:00] give them that book. Yeah. If I choose and to donate that book to a very good cause to people that really don't have access to anything and I like the control that I have over it.
Yeah. That I can share it without having a publisher, yeah. It's definitely different when you have it like published by a big publishing company. Yeah, it's a lot of work. I published a book, but not, nothing nearly like yours, . This one was this one I loved. The first one was scary and this one I actually really enjoyed it.
It added that new clinical pearls section. Yes. That is my favorite part because it, there were so many things in reading the research that I would go, oh my gosh, that's cool to know, but it really doesn't fit into a protocol. Yeah. And so I decided to add that to each one so that I gave a glimpse of research that's out there and little tidbits and outcomes and maybe [00:12:00] future things that are going on in other countries, but not really proven.
And I said that in the book. So all these little things that people will read, and maybe I'm just such a nerd, but I really enjoyed finding those little things and then sharing 'em. So I had to pour over stacks of research each one. But you guys get the privilege of me teasing out what's That's right.
That's why we should buy your book. So we love the fact that you have a paper. . And I love the fact that you have an E online version as well. Yes. And I have a lot of people who started watching what I was doing on Instagram or Facebook, and I put out a free 30 day hand therapy training, and I've been getting a lot of people enter that program world.
And I think that a lot of people who come from other countries they're telling me the same things. I'm getting on calls with people from all around the [00:13:00] world and they're telling me the same thing that we hear here in the United States, which is, I really wanna specialize in hand therapy and upper extremity management, but I have no one to like really help me or mentor.
And so I'm like, I'm really proud and honored to like to mention your book and to send them to your website really to purchase it because they're overseas, they can get the e version of it. And one of the things that I really liked about it was if you are beginning in it, , you've got those clinical pearls like you've gotten, like you did, tease out all this information and compartmentalize 'em in these little bite size, I call 'em bite size pieces that are easy for people to consume and to learn really quick when they're, most of the time they're going to a protocol book because they're like, oh my God I have this case coming in this afternoon, , I don't read a whole chapter.
I'm gonna read this one little tidbit. It's gonna help me get started and it's [00:14:00] gonna help me carry through. And then if I want to read more to, to fortify my understanding of why, then I'm gonna go into the textbook. Yes. So that's what I really enjoyed about your protocol book. I've had a lot of people.
Ask me, Ship International, the printed book. But there's some really problems right now with suspended shipping in several countries like South Africa I couldn't ship to. That's where I'm getting people. Calling from, so somebody in South Africa, there was somebody in I just shipped.
I, I was able to ship to Turkey. I just got one out. But there's a whole list of countries that you know, so now at least if they want it, they can get the e-version. I also did a. Bundle that if you buy the printed, then you also can get the ebook for half off. So I think it's, I forgot how much it is now.
It's 2 64, but it's, you get both. Okay. And when you get the e version, you get it two ways. [00:15:00] And you have unlimited downloads as long as you are personally downloading it and not sharing it with computer on your phone. Yeah. So I have it on both also, which sometimes if you go to another clinic, you don't have the, how the book, you can just look it up.
Yeah, I like that. I like that. We're gonna get the e-version for mine as well, but I've had people from Brazil, I'm actually gonna lecture at a conference in Brazil, like virtually. . But definitely when I posted about the book I had a lot of people interested , and I like the fact that you, they can get it, if they can't get a shift.
I I'm a. person that loves like the physical book. Me too. Not everyone can get , the physical book, but I do like even as I'm teaching and helping OTs pass the CHT exam, the rehab of the handbook. Like I, I love that book home with me. I'll go home and I'll read and I'll study.
I love the fact that you have it both. Yeah. Who doesn't like options? . Exactly. [00:16:00] Awesome. I'm really excited to share in the link below, I'm gonna share your website so people can, as they find this show over time, go and be able to purchase it from you. Now, you have been practicing for a really long time in hand therapy.
I was hoping that you could share with the audience. , maybe one thing that you do really well or that you teach your own staff so that someone who's watching this can take away right away and apply to something they're gonna do with their patient. I've been really thinking, cuz you gave me a heads up on that question, and one, I love tendon repairs.
That's actually one of my favorite things and I think I'm very good at it. But I think it's also so much that what I see now is that I put some things out there that I actually did a physician ask for a kliner because there was a reason and the patient did fantastic. I've had several of those.
I'm not afraid to do that and I think they moved very well , I know the move is to go early [00:17:00] active, and we do that too. In fact, we do it a lot. But that doesn't always fit the person. Yeah. It doesn't fit, their age, their lifestyle whether they can't come into clinic as much as you want 'em to.
Yeah. One thing I'd like to just share is that really be open to not thinking that, the book actually gives you several options. Yes. And. They all are good. Yeah, Duran, I've gotten some great stuff from them. I do think that one thing that I do that's a little bit different with my tendons is that, especially with a Kliner and the Duran, is I tell 'em they need to do it every 15 minutes.
You can put fingers in Traction E, even if you've got a Palmer Bar and you keep 'em like that for an hour, are they gonna get a contracture? Yeah, probably. But if they do it every 15 minutes, you're actually doing it more often. They don't mind, don't end up, if they do end up with the small contracture, I easily can work that out.
Even in the. And I'm being real careful. Yeah. And [00:18:00] I get really good results because they're the client getting that excursion and not letting it sit on an album. Yeah. So I'm gonna explain what the client heart is, just in case somebody doesn't know. But basically the position is the risk. In slide flexion, the mps in slide flexion, the ips are straight and they have the the hooks here on the nails, right?
, and then the rubber bands pull them down. And then what they do is they go into active extension, and then the rubber bands pull them into flexion and they go into active extension. So when they have that on, you're telling them to exercise, going to active extens. Every 15 minutes. Every 15 minutes, and then at night you take them off the rubber bands and you have a plate bar there to hold them.
Their ips are straight. Yes, except for when I have an F D P repair, I actually don't cross the ftp. I want that F DP to sit in a little bit of flexion. Okay. And I find that if they got a flexion contractor, I usually can work that out easier than a [00:19:00] lag. So why don't I let it sit in a little bit of flexion.
Yeah. And you're not putting pressure on it. And I get better results that way too. Okay. That's definitely in my book. Those are little things that Yeah. Seen that written in research. No, . But that's why you're sharing it here. So people. No, like definitely is research based, but there's a little bit of me in there.
Yes, of course. Not everyone can come work for you. You only have four spots, , thousands of therapists that are like clamoring to come work with a hand therapist like you, and they're gonna watch us. They're gonna be like, oh my God. Yes. . I always tell therapists that they need to understand the positioning and all that stuff, but then know the different protocols because you are right Elizabeth, that not everyone fits the same protocol.
Yes. Right now there's a early active that's really huge, a couple years back it was Duran, right before that was the Klein heart, but I don't [00:20:00] have too many doctors that order that anymore. Who do you think. That fits best. the client heart. What kind of patient would benefit from that?
Based on my surgeons make that call, but like the last one I did that did beautifully, she was started with us, but she went down to a smaller town where there is a C H T, but the doctor's not as familiar, right? And so she couldn't go to therapy, but maybe once or twice a week. And I think he just felt like that was a little bit safer and it ended up that she was supposed to stay down there.
but she decided to come back cuz she just liked our clinic and her parents were happier up here. So I met her about a week later, but it was too, we, it was too long a period to start that early active, cuz you have to do that really between three and five days. Yeah. So we we just did, continued the way we were doing and did a lot of tenodesis and really worked out stiffness and, yeah.
[00:21:00] She pretty much has almost near, she is three and a half weeks and she has a composite fist. She's probably lacking maybe 15 degrees of d i p flexion and that's it. That's amazing. Three and a half weeks. That's really great. So if someone does if the doctor doesn't ask for a client heart, but you really thought I'm a big believer in.
Asking the surgeons, Hey, I think this, , I want this . Sometimes you get in, sometimes you don't, but I'm a big believer in Hey, if you know your stuff, ask for it. Would you ask for Aline Heart on somebody? Who was potentially, they were younger and they wouldn't necessarily come to therapy that often or would you ask for it based on if they were really stiff or swollen?
If you had to go to the surgeon and ask for it? That's a good question. If they were really stiff. See we don't get too many swollen and stiff hands. We get stiff but not [00:22:00] swollen. Cuz my surgeons are really good about that. But I probably would ask for that if there was somebody young. Probably they would lean more toward the Duran if they didn't trust them, knowing that they're gonna probably cheat a little bit anyway.
and knowing that maintenance, there definitely is a maintenance issue with Kleiner, with all the, the rubber bands and the issues. Yeah, all that kinda stuff. But my doctors are really aggressive, so if they feel like there's a reason, like the one person that we did that I remember who was very intelligent, came in, he would've been good for early acta, but.
Skills saw injury, which takes a honk out of the tendon. The tendon, when they put it back together was a little bit shortened. Yeah. In fact, he almost had his finger amputated so it wasn't just, know, a very clean cut. He really did wonderful. Other than he did get a p I P joint contracture. But has excursion was great.
Yeah. As long as their excursion is excursion . And then he went back and got that, that , released and he did beautifully. [00:23:00] Yeah. And then we've got a couple of early actives right now that are doing wonderful. So the surgeons are pretty good that I work with. Yeah, they're very aggressive and if they think they're being safe, then there's reasons usually.
Yeah. Yeah. So that's such a great point. So not everyone works with hand surgeons, and not all hand surgeons are created. Just not all therapists are created equal. So do you have any great tips for someone who is a flexer that comes in and they're really swollen? I am asking you all the tough questions.
I want people to get your benefit . So I elevation, I mean you can't put a glove on 'em. It's almost impossible to do that because you can't position 'em safely and get a glove on. So I think just elevation and you can, if you're doing passive arrange, you can coba and rap, but you can't really coban rap if they're doing any kind of active, cuz you're putting drag on the Tinder.
Yeah. Yeah. I probably would [00:24:00] just work it out my cell. Yeah, you can do a little bit of lymphedema stuff, which I do some of that. Yeah. I haven't seen one of those in so long, honestly. You're lucky. I know. We see 'em all the time and sometimes it's. due to delay. Sometimes it's due to the nature or the severity of the injury.
But yeah, sometimes people come delayed. We'd love to see all of our cases really early, but we don't always get to see 'em really early. I usually, one of the things I do is I'll do the retrograde massage, but I'll do the coban wrapping at night. Okay, yeah, I'll do the covid wrapping at night.
Cuz during the day you want them to move, like during the day they're gonna do the passive range motion and they should be doing some retrograde on the, on themselves. And then just doing some once they get started with active and stuff like that. . Yeah. And I do understand therapists that maybe get frustrated because their doctors are old school.
But I think then you go and what I've done in my past, cuz I was doing early active with two strand repairs. Yeah. So that [00:25:00] was, way back when before we're getting into the 4 6 4 strand. Yeah. , and that was pretty scary. And I did it and I talked my surgeon into it, but I showed him the research.
So I pulled up all the articles and said, listen. I highlighted 'em and said, what do you think? And he goes, okay. And we didn't rupture any we learned a lot during that process. God, wood . Yeah. But now it's safer to do it. Yeah, it is safer. Yeah. The big thing I think is patient education.
Just tell 'em, do not do this. Yeah. You have some knucklehead that takes it off and ruptures. You can't have those . Yeah. Yeah. I had somebody who, she was much older and she was already with underlying. , but the family didn't really know when she went under anesthesia for her surgery and stuff like that.
She, by the time she came in, and this was a great hand surgeon I worked with, and he sent her three to five days, but she came in, she was already, she had already fought her splint off, like her post-op, it was post-op. Things are huge, and it was [00:26:00] like half hanging out. She was like coming in and carrying.
I'm like, what happened? Who are you fighting with? And the family was like, we don't know what happened. She woke up like this , and turned out she had ruptured her tendon fighting, fighting it off. I of suspected and told him right away I'm suspecting I don't feel anything from day one.
and it was like it's too late, we can't really do anything. So we waited and stuff like that. And she did the rod placement. Then she went and had the the reconstruction came in the second time after reconstruction fighting her splint. And she ruptured it was feeling some kind of way claustrophobic or whatever but that dementia that was underlining that the family was like not telling us about.
As we spend time with our patients, we. Think there's some underlying dementia stuff. Is she forgetful? And they're like, yeah, we think so. We've just been in denial . So yeah, it was, that was my only, knock on wood, only wrecker, but , she came like that. , [00:27:00] that's, that, you I don't know.
That's an awful lot. That's a huge surgery to do. The sec. This two stage. Yeah. And then go through all that and rupture again. Yeah. Knowing what you knew the first time, I don't know. . Yeah. Yeah. What I think we didn't, they didn't, they were, they were really in denial about the first time that she was starting on this path.
Even though it wasn't successful, they were, in the end, they were we tried to get her like the most that we could, and then sh in the end she was like, okay, I'm fine. Exactly finger sticking, straight up like that. And , but oh, thank you so much for coming on, sharing your stories.
Sharing your protocol book with us. I'm gonna include the link where anyone can, whether you're starting out in hand therapy or you've been in hand therapy. This is a great protocol book for you to have not only in your clinic, but if you. Have it for yourself, then no matter what [00:28:00] clinic you go to, you can take it with you.
There's a physical book that you can purchase and an online version. So I'll include that link for everyone who comes on and is interested in getting your book. Thank you so much for sharing everything, Elizabeth. Thank you very much. It was very nice to meet you.
Hey, thanks for listening to Hoang's world podcast. If you are brand new to the hand therapy world, head over to my website, www . Hand therapy secrets.com, where you can get started with some of our free guides and paid programs for both OTs and PTs diving into the world of hand therapy. Or if you've been listening for a while watching on our YouTube channel and you think you could benefit from developing and moving your career further along in hand therapy, reach out to me and my team at info @ Hand therapy.secrets.com and tell us exactly what you're looking for, By the way, if you know someone who could benefit from today's show, please share.
Thanks. See you on the [00:29:00] next episode.
