CRITICALLY APPRAISED TOPIC

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1 TITLE CRITICALLY APPRAISED TOPIC Occupation-based treatment may be beneficial for improving participation in occupational performance for people with hand injuries. AUTHOR Prepared by Kallie Pennel, OTS and Carrie A. Ciro, PhD, OTR/L, University of Oklahoma Health Sciences Center Date 8/26/12 address Review date 10/1/12 CLINICAL SCENARIO Man is an active being whose development is influenced by the use of purposeful activity (AOTA, 1979). As occupational therapists, our profession is based on the emphasis to use meaningful, occupation-based treatment. Occupation-based intervention incorporates meaningful activities chosen by the patient to be used as goals and practiced as intervention within treatment to allow improved performance of these meaningful activities in their daily lives. However, in the late 1980s, due to the medical model s influence on occupational therapy and documentation requirements for reimbursement by health insurance companies, many occupational therapists transitioned from using traditional functional activities as treatment to using exercises, sensory re-education, cognitive retraining, and physical agent modalities. Occupational therapists felt that results from improvement in measurable components of treatment were more justifiable and reimbursable than improvement of functional outcomes (Neistadt & Seymour, 1995). While Neistadt & Seymour (1995) found an improvement of occupational therapists use of functional activities as treatment in a wide scope of occupational therapy facilities, it is unclear why occupational therapists are not currently incorporating occupation-based treatment within hand clinics. As clinicians, we must reflect on the research to analyze the most effective interventions to use in hand therapy. Treatment should not be guided by what is most commonly or traditionally practiced, but what is found to be most beneficial for improved patient functional outcomes. Therefore, the purpose of this CAT was to explore the effectiveness of occupation-based treatment for people with hand injuries. FOCUSED CLINICAL QUESTION For people with hand injuries, is occupation-based treatment beneficial for improving perceived areas of occupational dysfunction? SUMMARY OF SEARCH Three articles were analyzed in this review, one randomized control trial, one nonrandomized control trial, and one single group with pre/post study design. The samples included adults with various acute or chronic hand injuries. The first two

2 studies compared a control group with an experimental group that received therapeutic activities, while in the single group study, most participants received therapeutic activities. The randomized control trial used a list of common activities that all participants completed, while the other two studies used patient occupational goals to lead the therapeutic activities. All three articles used the DASH with additional outcome measures. Though the studies lacked in design strength and validity, each study had statistically significant positive results toward the inclusion of occupation-based activities. CLINICAL BOTTOM LINE There is limited, yet promising evidence to promote inclusion of occupation-based treatment as a credible intervention for treatment of people with hand injuries. Important note on the limitation of this CAT This critically appraised topic has been peer-reviewed by only one other faculty member. SEARCH STRATEGY Terms used to guide the search strategy Patient/Client Group: People with hand injuries Intervention (or Assessment): Occupation-based treatment Comparison: none Outcome(s): Improved perceived areas of occupational dysfunction Databases and Sites Searched OVID- Ovid MEDLINE, Embase, AMED, ALL EBM Reviews, ERIC, OUHSC Full text@ovid Search Terms Occupational therapy, hand therapy, hand injuries, occupationbased, occupation, hand, treatment Limits Used English only, humans INCLUSION and EXCLUSION CRITERIA Inclusion Criteria Participants with hand injury, acute or chronic Participants of any age Studies focus on and include occupations as part of the intervention Studies either list specific occupations and/or describe part of the intervention as including occupations chosen by the participants Studies use the DASH as outcome measure Exclusion Criteria

3 Samples focus on other bodily injury, not a hand injury Studies do not focus on occupation for intervention and/or in outcomes RESULTS OF SEARCH A total of 10_ relevant studies were located and categorized based on an adapted version of the American Occupational Therapy Association Literature Review Project for OT outcomes research: Design Level I=Randomized control trial, systematic review or meta-analysis II= Non-randomized control trial, two groups III= Non-randomized control trial, one group, pretest-posttest IV=Single-subject design NA=Narratives, case studies Sample Size Level A= n 20 B= n < 20 Table 1: Summary of Study Designs of Articles Retrieved Study Design/Methodology of Articles Retrieved Level Number Located Author (Year) Randomized control trial, Systematic Reviews 1A 4 Guzelkucuk, Duman, Taskaynatan, & Dincer (2007); Omar, Hegazy, & Mokashi (2011); Amini (2011); Snodgrass (2011) Non-randomized control trial, two group 2A 1 Harth, Germann, & Jester (2008) Single group, pre/post design 3A 1 Case-Smith (2003) Single-subject design 4B 4 Chan & Spencer (2004); Toth- Fejel, Toth-Fejel, & Hedricks (1997); Earley & Shannon (2006); Jack & Estes (2010)

4 BEST EVIDENCE The following studies/papers were identified as the best evidence and selected for critical appraisal- (Guzelkucuk, Duman, Taskaynatan, & Dincer, 2007), (Harth, Germann, & Jester, 2008), & (Case-Smith, 2003). Reasons for selecting these studies were: All examined the effects of occupation-based intervention for people with a variety of hand injuries All used the DASH as well as other credible outcome measures SUMMARY OF BEST EVIDENCE Table 2: Description and appraisal of a randomized control trial by Guzelkucuk, Duman, Taskaynatan, & Dincer (2007). Aim/Objective of the Study: This study tested the efficacy of including therapeutic activities in rehabilitation versus traditional hand therapy for young adults with a variety of hand injuries. Study Design: Randomized control trial where participants were randomly assigned to groups by a random number generation method. Outcome measures were performed at baseline, after treatment, and two months following treatment. Setting: This study was completed at a hand rehabilitation unit in Turkey. Participants: The sample used in this study included 36 patients with hand or wrist injury of the bone, tendon, and/or peripheral nerve, which impaired hand function. The injury had to occur within 1.5 to 6 months of being admitted to the hand rehabilitation unit. The study used prospective recruitment and a convenience sample as the patients were admitted. The mean age of the patients was 23 years old, which authors stated may have been due to the department usually serving young military recruits. The mean time after injury to surgery was 7 days, while the mean period between the injury and rehab was 102 days. The dominant hand was injured in 23 of the 36 patients. Types of injury include nerve lesions, tendon lesions, and fractures, caused by gunshot, traffic accident, work accident, or laceration by knife or glass. There were no dropouts reported. Intervention Investigated: Both groups received a rehabilitation program consisting of physical therapy and therapeutic exercises for 30 minutes daily, 5x/wk, for three weeks, then participants were given a home exercise program. Description of the physical therapy was not given. The therapeutic exercises included passive, active-assistive,

5 and active ROM as well as strengthening exercises, based on lack of motion in certain movements and impairment. Description of who provided treatment was not given. Control (N=16) The control group received the above rehabilitation program twice daily for the allotted amount of time (two 30 minute sessions of physical therapy). Experimental (N=20) The experimental group received the above rehabilitation program once daily (30 minutes of physical therapy) as well as one 30 minute session of therapeutic activities. Therapeutic activities included using a spoon, using scissors, writing, carrying a bag, buttoning, opening and closing a door by the handle, etc. These activities used appropriately constructed materials, and each activity was performed for three repetitions in a therapy session. Outcome Measures: (Primary and Secondary) The Disabilities of Arm, Shoulder, and Hand (DASH) Questionnaire includes 30 questions that are ranked on 5 levels. The levels range from 1- easily done to 5- cannot do. According to Beaton et al., the DASH exhibited excellent test-retest reliability (ICC=0.96) and correlated with other measures of pain and functional limitations (r>0.69). The DASH was found to be valid for both proximal and distal arm disorders (Beaton et al., 2001). The Jebsen Test of Hand Function contains seven subtests, which were all performed. These subtests include: 1- turning over cards, 2- picking up small objects and placing them in a can, 3- picking up beans with a teaspoon and placing them in a can, 4- stacking checkers, 5- moving large light cans, 6- moving heavy cans, and 7- writing. Scoring is based on length of time to complete each activity. This assessment ranged from 0.60 to 0.99 test-retest reliability (Jebsen, Taylor, Trieschmann, Trotter, & Howard, 1969). Information on test examiners was not provided. Grip strength, pinch strength, total active movement, opposition, abduction, and finger pulp-distal palmar crease distance were also measured. Main Findings: Posttreatment versus baseline results found statistically significant improvement for all tests in the study group and inconsistently for the control group (P<.05). Followup evaluation versus baseline also found statistically significant improvement for all tests in the study group and inconsistently for the control group (P<.05). Increased statistically significant improvement was found in grip strength, pinch strength, all the Jebsen subtests and the DASH for the study group in posttreatment versus baseline as well as follow-up evaluation versus baseline (P<.001). Statistically significant improvement was found for the study group over the control group in the difference of mean changes between groups at follow-up evaluation for all tests with the exception of total active movement and abduction (P<.001).

6 (Guzelkucuk, Duman, Taskaynatan, & Dincer, 2007, p.1423) Original Authors Conclusions: These authors concluded that based on their results, the inclusion of therapeutic activities resembling ADLs in hand rehabilitation may improve hand function more than physical therapy and therapeutic exercises alone. Critical Appraisal Validity: Threats to internal validity: possible experimenter bias because those who conducted the outcome measures were not blind to the experiment lack of specified training or protocol used for therapy lack of testing for patient adherence to home exercise program practice of therapeutic activities may be individually irrelevant or no longer problematic for the patient did not specify patient levels in recovery process and if prior therapy was given Threats to external validity: bias due to convenience sample lack of patient demographic information given (gender, ethnicity, comorbidities, socioeconomic class) patient age only included young adults, may not generalize to older adults Aspects of study which strengthen validity: no drop-outs reported concise list of therapeutic activities that mimic ADLs specified use of therapeutic activities in rehabilitation multiple outcome measures outcome measures given not only before and after treatment, but two months after treatment

7 control and experiment group were equivalent at baseline control and experiment group were given the same amount of treatment variety of hand or wrist injuries higher level of evidence, using randomization of participants into either control or experiment group Interpretation of Results: The results consistently exhibited greater outcomes in the study group over the control group. Statistically significant improvement was demonstrated in each Jebsen subtest and in the DASH scores for the experimental group (P<.001), while there was inconsistent statistically significant improvement for the control group. The study group exhibited improvement at the end of treatment and two months following treatment. The study group had statistical significance over the control group at the two-month evaluation (P<.001). These results interpreted with the validity of this study, including higher level of evidence using randomization, concise list of therapeutic activities that mimic ADLs, and multiple outcome measures, point to the benefits of therapeutic activities for intervention. Summary/Conclusion: This study found incorporation of therapeutic activities mimicking ADLs with physical therapy and therapeutic exercise to be beneficial to increase hand function. While the activities were not chosen by the patient as perceived areas of occupational dysfunction, they are common activities that a person post-hand injury may have difficulty doing, such as writing, using a spoon, opening a door, tying their shoelaces, cutting with scissors, etc. The practice of these therapeutic activities in rehabilitation not only improved patients ability to complete these activities, but also showed greater improvement in grip strength and pinch strength than the control group. Table 3: Description and appraisal of a non-randomized control trial, 2 group by Harth, Germann, & Jester (2008). Aim/Objective of the Study: The objective of this study was to examine the impact of patient-oriented rehabilitation versus standard rehabilitative care for patients with hand injuries by analyzing functional outcomes, return to work, patient satisfaction, and costs. Study Design: This two cohort, longitudinal study with consecutive sampling recruitment for the standard program, from June 2003 and July 2004, and a patient-oriented group, from December 2004 and January With the exception of satisfaction questionnaires, each outcome measure was given at the beginning of treatment, the end of treatment, and six months after discharge from treatment. Setting:

8 This study was conducted in an inpatient setting within a regional trauma center in southwest Germany. This hospital commonly receives patients who have had workrelated hand injuries. Participants: There were 150 participants with varying diagnoses, including injuries to: one digit, multiple digits, palmar/dorsal aspect of the hand, wrist, varying structures caused by crush or explosion, and areas affected by CRPS (complex regional pain syndrome). Patients were prospectively recruited as they entered rehabilitative care. This convenience sample had to meet the inclusion criteria of: adequate knowledge of the German language, between 18 and 65 years old, and no observable psychiatric conditions. For the standard program group, the mean age was 46 years old and 67 of the 75 were male. For the patient-oriented group, the mean age was 41 and 63 of the 75 patients were male. The male-dominated patient population represents the general population of this hospital. The hospital is in a wine-growing region and all the patients came from work-related injuries in manual labor jobs. Majority of the patients were not initially treated in this hospital, but previously received rehabilitation and were referred to this hospital due to unsuccessful therapy outcomes. There were no drop-outs reported; one patient refused to participate in the study in the first cohort and no patients refused in the second. Intervention Investigated: Both groups received two individual physiotherapy and occupational therapy treatment sessions per day, as well as participating in a group sport and gym activities. Other members of the rehabilitation team included: doctors, sport therapists, clinical psychologists, social workers, and vocational rehabilitation managers. Details of individual treatment session duration and number of days patients received therapy were not given, as well as specific details about their treatment except that it was standard treatment for their department. The average length that patients stayed in the inpatient rehabilitation center was 5-6 weeks. Also, patients identified work activities that were important to them as well as areas of possible functional limitation based on the 30 DASH questionnaire items and prioritized these based on importance. Control (n=75) The participants in the control group received the above treatment between June 2003 and July The prioritized relevant activities were not incorporated into therapy intervention or goals for this group. Experimental (n=75) Based on data analysis from the control group, the researchers identified several areas to change in the patients treatment for the patient-oriented group, from December 2004 to January These changes included: integration of the WHO s biopyschosocial model into team practice inclusion of prioritized relevant activities as treatment goals and transition from interdisciplinary to a multi-disciplinary team approach addition of a pain therapist to the rehabilitation team

9 clinical psychologist incorporated earlier based on SF-36 scores and addition of a questionnaire for screening purposes at admission team/patient discussion group meet weekly to incorporate patient-oriented rehabilitation rehabilitation professionals were integrated into the weekly team meetings and obtained information from employers as needed occupational therapy focused more exclusively on work-related activities Additional specifications about this adapted program were not given. Outcome Measures: The Disabilities of Arm, Shoulder, and Hand (DASH) Questionnaire scores vary from 0-100, with 0 indicating no limitation and 100 indicating extreme limitation of upper extremity function. This questionnaire includes 21 physical function items and 9 symptom items, for a total of 30 items that are ranked on a 0-4 scale with 0 being unable to perform or extreme symptom to 4 being no difficulty in performance or not-a-all symptoms. For the purpose of this study, the DASH scores were divided up into 5 categories: disability, impairments, activity limitation, sport/music, and work. According to Beaton et al., the DASH exhibited excellent test-retest reliability (ICC=0.96) and correlated with other measures of pain and functional limitations (r>0.69). The DASH was found to be valid for both proximal and distal arm disorders (Beaton et al., 2001). Other outcome information included: grip and pinch strength active range of motion of the fingers and wrist self-reported pain- visual analogue scale health-related quality of life- German version of the Short Form-36 (SF-36) upper extremity functioning- German DASH questionnaire psychological parameters- Health-related Locus of Control-KKG and Attitude to return to work-iri patient s satisfaction with service delivery via German version of the Client Satisfaction Questionnaire patient s satisfaction with functional results six months after discharge via questionnaire number of days receiving treatment and the number of days off work to indicate cost The satisfaction questionnaire given six months after discharge asked patients to rate the questions on a four-point scale from 1- very dissatisfied to 4- very satisfied. The questions were: All in all, how satisfied are you with your hand function? All in all, how satisfied are you with your hand strength with regard to your work activities? All in all, how satisfied are you with your range of motion with regard to your work activities? Patients were also assessed to see if they were able to return to their original job.

10 Information on test examiners was not provided. Main Findings: While the patient-oriented, or adapted, group showed greater improvement for all categories of the DASH six months after discharge, only the DASH-score (total functioning) and DASH-sport/music (activities/participation) subtests exhibited statistically significant improvement (P<.05). The adapted group exhibited statistically significant satisfaction at the end of treatment over the control group on the Client Satisfaction Questionnaire on all questions (P<.0001), with the exception of better able to cope with problems, which the adapted group still rated higher than the control group. The adapted group ranked their satisfaction with functional results higher than the standard group six months posttreatment (statistically significant, P<.01). There was no statistically significant differences for the control group six months post-treatment for the DASH scores or questionnaires. (Harth, Germann, & Jester, 2008, p ) Original Authors Conclusions: The authors concluded that the adapted treatment group was more cost-efficient (7.3 day shorter stay) and effective. Participants in the patient-oriented group had overall better vocational abilities and patient satisfaction with functional outcomes than the control group.

11 Critical Appraisal Validity: Threats to internal validity: the adapted program implemented multiple changes in intervention, rather than solely an increased focus on the patient s prioritized, work-related goals possible experimenter bias because those who conducted the outcome measures were not blind to the experiment unknown patient time spent in therapy and other programs lack of explanation of what standard program was for the control group lack of explanation of amount of time spent on work-related tasks in therapy lack of specific, uniform treatment protocol for therapists to follow for both groups possible variation in treatment and hand injuries for groups due to receiving treatment at different times Threats to external validity: study was performed with a consecutive non-randomly drawn convenience sample in one location unknown time from patient s injury, previous rehabilitation, and to current rehabilitation at this site Aspects of this study that strengthen validity: only one patient refused to participate, and no drop-outs reported patients identified and prioritized important work-related activities to focus on in therapy (adapted group) multiple outcome measures outcome measures given not only before and after treatment, but also six months after treatment variety of hand or wrist injuries large quantity of participants Interpretation of Results: In two of five DASH scores, there was statistically significant improvement for the adapted group six months post-treatment in total functioning and sport/music (P<.05). In seven out of eight questions from the Client Satisfaction Questionnaire, as well as all three satisfaction questions about functional results, the adapted group six months post-treatment fared better (P<.0001). While these results indicate better outcomes for the patient-oriented group, it cannot be attributed solely to the addition of work-related goals and interventions, due to threats in internal validity. Summary/Conclusion: Due to the adapted program including multiple changes, one aspect of the changes cannot solely be given credit for improving patient outcomes. While the adapted

12 program was referred to as patient-oriented and this was a major goal for changing treatment, other implemented changes may have also increased patient s overall improvement. While flawed, this study provides support for focusing on relevant occupations/activities in a team-based environment which is relevant to this CAT. Table 4: Description and appraisal of Single group, pre/post design by (Case- Smith, 2003). Aim/Objective of the Study: The aim of this study was to implement functional outcome assessments, especially the Canadian Occupational Performance Measure (COPM), in patients with hand injuries and/or surgery. Study Design: This single group, pre/post design study included patients with hand injuries that received outpatient hand therapy from an occupational therapist. Participants received a mean of 13 hours (54 units) of outpatient occupational therapy. The COPM, DASH, and SF-36 were administered at the beginning and end of therapy services. The Community Integration Questionnaire (CIQ) was administered 2-3 months after discharge by phone. Setting: This study occurred at five different sites in Ohio. This included two hand outpatient centers, two hospital outpatient centers, and one rehabilitation center. Participants: Thirty-seven participants began this study, and 33 completed the end of treatment tests. Of these four that dropped out, two were discharged early, one developed severe medical problems, and one was lost when an occupational therapist transferred. Of these 33 participants, only 28 were reached by telephone 2-3 months after discharge for the post-treatment questionnaire. The mean age of participants was 44 years old, and the majority of the patients were female (61%). Prior employment status included 22 that were employed, 3 full-time students, and 8 were retired or unemployed. Diagnoses ranged from contusions, infections, soft tissue trauma, fractures, and crush injuries, to surgeries following a condition, such as ligament repair, arthritis, arthroplasty, and carpal tunnel syndrome. Participants were prospectively chosen by the occupational therapists if they met the following requirements: Direct referral for occupational therapy services due to upper-extremity injury within previous 30 days and was not immobilized No significant secondary diagnosis involving the central nervous system Hand injury did not involve burn injury or major nerve injury, due to the recovery process usually requires more than 8 weeks of rehabilitative services (8 weeks was the intervention period selected for this study) Only received occupational therapy services and standard medical care for the

13 duration of the study Intervention Investigated: Control (none) Experimental (N=33) The five site coordinators were trained by the principal investigators, then three of these site coordinators trained another occupational therapist at their facility to assist in data collection. The five site coordinators were taught: orientation to the project, informed consent procedures, instructions to administer the assessments, participant inclusion criteria, and how to record data. Therefore, the site coordinators selected patients who met the inclusion criteria, compiled data, and submitted their notes, evaluation reports, and billing records for each participant. Participants received a mean of 13 hours of hand therapy; therapy for the 33 participants lasted 6-8 weeks. Percentages were given of most commonly used therapy services, which in descending order was: therapeutic activities (received by 20 patients), therapeutic exercise (15), splinting (13), manual therapy (7), and activities of daily living (2). When patients completed the COPM, they identified goals to work on in therapy, such as driving, typing, writing, cooking, child care, gardening, doing laundry, tennis, and biking. Outcome Measures: In this study, the trained site coordinators and three other occupational therapists that were trained by the site coordinators administered these assessments: The Canadian Occupational Performance Measure (COPM) is useful to guide clientcentered care by patients and therapists together identifying occupational performance problem areas with level of performance and satisfaction ratings for those areas. The various sections of the COPM includes: personal care, functional mobility, community management, work, household management, and leisure. The client rates each problem area on a 1-10 point scale, with 1 being not able or not satisfied and 10 being able to do well or extremely satisfied. Then the therapist and patient prioritize the top five areas to use as goals for therapy. Testretest reliability ranged from 0.63 to 0.84 (Sanford, Law, Swanson, and Guyant, 1994). Validity was measured by comparing COPM with other assessments, which highly relates to life satisfaction (McColl et al, 2000) and to the SF-36 (Law et al., 1994). The Disabilities of Arm, Shoulder, and Hand (DASH) Questionnaire includes 21 physical function items and 9 symptom items, for a total of 30 items that are ranked on a 0-4 scale with 0 being unable to perform or extreme symptom to 4 being no difficulty in performance or not-a-all symptoms. Scores vary from 0-100, with 0 indicating no limitation and 100 indicating extreme limitation of upper extremity function. According to Beaton et al., the DASH exhibited excellent testretest reliability (ICC=0.96) and correlated with other measures of pain and functional limitations (r>0.69). The DASH was found to be valid for both proximal and distal arm disorders (Beaton et al., 2001). Main Findings: Participants overall documented positive change from the beginning of treatment of end of treatment. For COPM Performance, the mean improvement change was

14 4.21 (p<.001). For COPM Satisfaction, the mean improvement change was 5.04 (p<.001). On the DASH, the participants mean improvement change for Part 1 (ability to perform activities) was 26.6 (p<.001), and for Part 2 of the DASH (decreased symptoms present) was 10 (p<.001). (Case-Smith, 2003, p.503) Original Authors Conclusions: As shown by gains in the COPM, DASH, and SF-36, patients with hand injuries made significant gains following client-centered occupational therapy. Critical Appraisal Validity: Threats to internal validity: All patients did not participate in therapeutic activities, even though it was the most common intervention, and there was no distinction in the results between clients based on which interventions they used possible experimenter bias while administering the COPM, though the assessment is typically used through a team effort between the patient and therapist for goal setting unknown patient appointment frequency lack of specific, uniform treatment protocol for therapists to follow Threats to external validity: no control group the inclusion criteria is more restrictive than other studies for types of injuries moderate number of participants Aspects of this study that strengthen validity: data collected at five different sites reported number of drop-outs, which were minimal and had understandable reasoning all completed COPM and designed goals from the COPM multiple functional outcome measures moderate variety of hand injuries included rates of prior and post work status

15 specific training for the site coordinators to allow uniformity in collecting data Interpretation of Results: Overall, the results showed statistically significant improvement in the COPM and the DASH. Of the 22 participants that were previously employed, 17 returned to work and 2 had plans to return to work within the next few weeks. While these results are positive, lack of fidelity in intervention delivery restricts the generalization of these findings. Summary/Conclusion: While this study demonstrates use of the COPM to design functional goals, this study is limited because not all of the therapists used therapeutic activities as part of their intervention to reach these goals. To address to goal of this CAT, the inclusion of occupation-based treatment was a frequently used intervention, but not always used. We are unable to assess the benefits of occupation-based treatment in this study due to lack of intervention fidelity. Table 5: Characteristics of included studies Study 1 Study 2 Study 3 (Guzelkucuk, Duman, Taskaynatan, & Dincer, 2007) (Harth, Germann, & Jester, 2008) (Case-Smith, 2003) Intervention investigated Therapeutic activities that mimic ADLs Patient-oriented program Client-centered outpatient hand therapy Comparison intervention Traditional therapeutic exercises Standard program none Outcomes used DASH, Jebsen hand test, ROM, grip & pinch strength DASH, SF-36, satisfaction questionnaires, ROM, pain, grip & pinch strength COPM, DASH, SF- 36, community integration questionnaire Findings Inclusion of therapeutic activities led to greater improvement in hand function Adapted group was more cost effective and had better functional ability Participants made significant improvement in functional performance IMPLICATIONS FOR PRACTICE, EDUCATION and FUTURE RESEARCH According to the compiled evidence, occupation-based treatment for clients with hand injuries has the potential to be an effective intervention. However, due to the

16 strength and validity of these studies, definite conclusions are difficult to draw. The study conducted by Guzelkucuk, Duman, Taskaynatan, & Dincer (2007) gives the best example through research of including occupation-based intervention. However, this study systematically used therapeutic activities mimicking ADLs as intervention, not meaningful occupations chosen by the patients. These activities are common activities that a person post-hand injury may have difficulty doing, such as writing, using a spoon, opening a door, tying their shoelaces, cutting with scissors, etc., which allows this study to still be applicable and supportive for the inclusion of occupation-based intervention. The study conducted by Harth, Germann & Jester (2008) is a good example of problem-solving and making multiple improvements within a rehabilitation unit. Yet, due to including occupation-based intervention as one of many changes between patient groups, it cannot be deducted that the improvement seen in the patient-oriented group was solely influenced by the inclusion of occupation-based intervention. While flawed, this study does provide support for focusing on relevant occupations/activities in a team-based environment. The study conducted by Case-Smith (2003) was limited by the lack of intervention fidelity, because all patients did not receive therapeutic activities as part of their treatment, and due to a lack of randomization. Therefore, this study is unclear in determining the benefits of occupation-based treatment. Given this evidence, it may be beneficial to incorporate occupation-based treatment in our hand clinics. Clients that received occupation-based intervention, in conjunction with more typically used interventions appear more able to perform valued occupations, as well as enjoying improvements in client factors such as improved range of motion and strength. Occupational therapists do not need extra education in order to deliver this intervention but educational programs should provide guidance in how to conceptualize this intervention with other interventions emphasized in education such as splinting and physical agent modalities. The feasibility of blending this intervention in with traditional therapy methods should be quite seamless for an occupational therapy practitioner. By collaboratively choosing meaningful goals, we establish priority areas and the course for our occupation-based hand interventions. Considering the occupationbased intervention part of the exercise of the session, occupational therapy practitioners can continue incorporating all of the necessary orthopedic interventions normally provided without an increase in treatment time. These occupation-driven activities will serve to improve all client factors normally addressed, such as strength and range of motion if graded appropriate the client diagnosis. In future research, researchers should advance the rigor within their studies. To advance rigor, researchers must improve fidelity measures by standardizing intervention protocols, give specific training for interventionists, use randomization and blinding of examiners, as well as operationally defining occupation-based versus traditional treatment. This would allow stronger evidence to assess the efficacy of using occupation-based intervention in the hand clinic.

17 REFERENCES American Occupational Therapy Association. (1979). Policy The philosophical base of occupational therapy. In Policy manual of the American Occupational Therapy Association, Inc. Bethesda, MD: Author. Amini, D. (2011). Occupational therapy interventions for work-related injuries and conditions of the forearm, wrist, and hand: A systematic review. American Journal of Occupational Therapy, 65, doi: /ajot Beaton, D. E., Katz, J. N., Fossel, A. G., Wright, J. G., Tarasuk, V., & Bombardier, C. (2001). Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand Outcome Measure in different regions of the upper extremity. Journal of Hand Therapy, 14(2), Case-Smith, J. (2003). Outcomes in hand rehabilitation using occupational therapy services. American Journal of Occupational Therapy, 57, Chan, J., & Spencer, J. (2004). Adaptation to hand injury: An evolving experience. American Journal of Occupational Therapy, 58, Earley, D., & Shannon, M. (2006). The use of occupation-based treatment with a person who has shoulder adhesive capsulitis: A case report. American Journal of Occupational Therapy, 60, Guzelkucuk, U., Duman, I., Taskaynatan, M. A., & Dincer, K. (2007). Comparison of therapeutic activities with therapeutic exercises in the rehabilitation of young adult patients with hand injuries. Journal of Hand Surgery, 32A, Harth, A., Germann, G., & Jester, A. (2008). Evaluating the effectiveness of a patient-oriented hand rehabilitation programme. Journal of Hand Surgery, 33E(6), Jack, J., & Estes, R. I. (2010). Documenting progress: Hand therapy treatment shift from biomechanical to occupational adaptation. American Journal of Occupational Therapy, 64, Jebsen, R. H., Taylor, N., Trieschmann, R. B., Trotter, M. J., & Howard, L. A. (1969). An objective and standardised test of hand function. Archives of Physical Medicine and Rehabilitation, 50(6), Law, M., Polatajko, H., Pollock, N., McColl, M., Carswell, A., & Baptiste, S. (1994). The Canadian Occupational Performance Measure: Results of pilot testing. Canadian Journal of Occupational Therapy, 61, Lieberman, D., & Scheer, J. (2002). AOTA s evidence-based literature review project: An overview. American Journal of Occupational Therapy, 56(3), McColl, M. A., Paterson, M., Davies, D., Doubt, L., & Law, M. (2000). Validity and community utility of the Canadian Occupational Performance Measure. Canadian Journal of Occupational Therapy, 67, Neistadt, M. E., & Seymour, S. G. (1995). Treatment activity preferences of occupational therapists in adult physical dysfunction settings. American Journal of Occupational Therapy, 45(5), Omar, M., Hegazy, F., & Mokashi, S. (2011). Influences of purposeful activity versus rote exercise on improving pain and hand function in pediatric burn. Burns, 38, Sanford, J., Law, M., Swanson, L., & Guyant, G. (1994). Assessing clinically

18 important change on an outcome of rehabilitation in older adults. Paper presented at the Conference of the American Society of Aging. San Francisco, CA. Snodgrass, J. (2011). Occupational therapy interventions for work-related injuries and conditions of the forearm, wrist, and hand: A systematic review. American Journal of Occupational Therapy, 65, 7-9. Toth-Fejel, G.E., Toth-Fejel, G.F., & Hedricks, C.A. (1997). Occupation-centered practice in hand rehabilitation using the experience sampling method. American Journal of Occupational Therapy, 52(5),