Original Article

Hand Therapy
2018, Vol. 23(4) 121–129
Occupational performance problems ! The Author(s) 2018
Article reuse guidelines:
identified by 507 patients: An insight that sagepub.com/journals-permissions
DOI: 10.1177/1758998318784316
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Helle S Poulsen1 and Alice Ø Hansen1,2

Abstract
Introduction: Several barriers challenge the use of occupation-based interventions in hand therapy. An outpatient
clinical setting can be prepared in such a way as to address the most common occupational performance problems which
might promote an occupation-based intervention. To this end, more knowledge is needed about which problems
patients with hand-related disorders consider most important.
Methods: Interviews using the Canadian Occupational Performance Measure (COPM)were conducted with 507
patients. Data were entered into Microsoft Excel in the COPM categories: Self-care, productivity and leisure and analysed
using descriptive statistics. Data concerning main problem areas were categorized according to the Taxonomic Code of
Occupational Performance (TCOP). The analysis included the number of prioritized occupational performance prob-
lems (NPOPP) in each COPM category/subcategory; the NPOPP in each category is relative to gender and age and the
most frequent problems.
Results: The total NPOPP was 2384. Problems within productivity and self-care constituted the largest proportion,
respectively, 46% and 40%. Gender or age affected the NPOPP in each category to a limited extend. Problems were
expressed at all levels in the TCOP, except the lowest level. The most frequently expressed problem was use of utensils
when eating.
Conclusion: The problems mostly concern productivity and self-care, regardless of gender or age. Patients consider
problems at the levels of occupation, activities, tasks and actions to be important and meaningful to address in their
intervention. This study provides useful knowledge that can be applied when preparing a setting to address the most
common problems, which could lead to the promotion of occupation-based interventions.

Keywords
Canadian Occupational Performance Measure, hand injuries, hand therapy, occupation, occupational therapy
Date received: 13 April 2018; Revised received 26 May 2018; accepted: 30 May 2018

Introduction rehabilitation to manage their activities of everyday

Hand-related disorders are quite common and affect 1,2
people of all ages.2–4 Patients with hand-related disor-
ders report that the disorder impacts on their perfor-
mance of activities of everyday life, such as dressing,
meal preparation, toileting and driving.5–9 The disorder
can continue to have an impact on paid work, domestic
work, leisure activities, and health-related quality of
life many years after the injury has taken
place.7,8,10–15 At Odense University Hospital,
Denmark, where this study was conducted, about
10,000 patients are treated at the accident and emer-
gency department each year.1 Several are in need of
life, both during and after recovery.
A focus in occupational therapy is to enable
patients’ engagement in occupations they want to do,
1
Department of Rehabilitation, Odense University Hospital,
Odense, Denmark
2
Department of Clinical Research, Research Unit for Rehabilitation,
University of Southern Denmark, Odense, Denmark
Corresponding author:
Helle S Poulsen, Department of Rehabilitation, Odense University
Hospital, Kløvervænget 8, Odense C 5000, Denmark.
Email: helle.s.poulsen@rsyd.dk
122
need to do or are expected to do – by improving their
occupational performance.16 Occupational perfor-
mance is the dynamic interaction between a person,
occupation and environment.17 The problems to be
addressed in an intervention are identified through a
client-centred approach, which includes a proviso that
the patient and therapist collaboratively select the
occupational focus for the intervention.18
One way of gaining insight into patients’ priority
issues is by applying the Canadian Occupational
Performance Measure (COPM).19 COPM is a stan-
dardized outcome measure designed to identify
occupational performance problems. During a semi-
structured interview performed by an occupational
therapist (OT), the patient identifies their problems
within the areas of self-care, productivity and leisure.19
The patient rates the importance of the problems on a
scale from 1 to 10. At the end of the interview, the
patient prioritizes up to five problems that are most
important to them and rates them on a scale from 1
to 10 in terms of performance and satisfaction with
performance. The psychometric properties of COPM
have been investigated in a number of countries and
populations,20–28 including patients with hand-related
disorders.24,25,27,29,30 Adequate levels of reliability and
validity have been reported, together with a strong
responsiveness and utility.20–28,31
Occupation-based interventions have been shown to
be effective in several patient groups, from paediatric
to geriatric, in increasing patients’ occupational perfor-
mance,32–38 and it is reported that this intervention is
more meaningful, motivating and satisfying for the
patient.39 To practise an occupation-based interven-
tion, the occupational performance problems experi-
enced by the patient must be analysed in detail, since
occupations can be complex and consist of several
underlying activities and tasks. The different levels in
the Taxonomic Code of Occupational Performance
(TCOP) can be used to distinguish the different com-
plexity of the chosen problems. TCOP describes occu-
pational performance on five levels, with increasing
complexity.17,40 At the top level, occupation is defined
as: ‘An activity or set of activities that is performed with
some consistency and regularity that brings structure,
and is given value and meaning by individuals and a cul-
ture’ (p. 19).17
Thus, only the individual patient can decide if an
activity is an occupation or not. An activity is described
as a set of tasks with a specific endpoint; a task is
described as a set of actions, while voluntary move-
ments are placed at the lowest level of the taxonomy.17
According to the literature, occupation-based inter-
ventions are sparsely used in hand therapy,39,41 despite
the fact that OTs working as hand therapists have
acknowledged the value of this intervention.39,42
Hand Therapy 23(4)
Several explanations and barriers are reported that
challenge the use of occupation-based interventions in
hand therapy.39,42 The main challenge is that hand
therapy is dominated by the biomedical approach and
its focus on body impairments.39,43,44 Logistical issues
are also mentioned, such as limited time, space and
available supplies for all the different occupations in
which people are engaged.39,45 By meeting the logistical
barriers, it might be easier to change the focus and
increase the use of occupation-based interventions in
hand therapy. Thus, clinical settings need to be pre-
pared in such a way as to address the most common
occupational performance problems that arise when
using the COPM.
The aim of this study was to explore occupational
performance problems that patients with hand-related
disorders in need of rehabilitation consider to be the
most important at the beginning of their rehabilitation
at an outpatient hand therapy clinic. The insights
gained may increase the chances that occupation-
based interventions are included in rehabilitation of
hand-related disorders.
Methods
This study was an explorative and descriptive cross-
sectional study using baseline data from a randomized
controlled trial investigating the effectiveness of an
occupation-based intervention versus a physical
exercise-based and occupation-focused intervention,
for patients with hand-related disorders.46 All partici-
pants were informed about the project verbally and in
writing before enrolment of the main trial46 and they all
gave their written consent. The main trial was approved
by the Regional Scientific Ethical Committee for
Southern Denmark, Project-ID 20120123.
Participants
Participants were recruited into the trial between
February 2014 and December 2016 reported else-
where.46 Enrolment was at the time of referral to reha-
bilitation at the specialized outpatient hand therapy
clinic at Odense University Hospital (OUH) in
Denmark. Patients were referred to rehabilitation by
the hand surgeons, based on clinical evaluation. They
had a broad spectrum of hand-related disorders, such
as fractures of the wrist and fingers, tendon and nerve
injuries, dislocations, wounds, arthrosis, arthritis,
Dupuytren’s, pain and infections. Patients were exclud-
ed from the main study if they had a shoulder disability
with <100 degree flexion or abduction, epicondylitis,
or burn injuries. They were also excluded if they had
trivial injuries with minor influence on occupational
performance, such as impaired extension in fifth
Poulsen and Hansen
finger of the non-dominant hand or hyper-sensitivity of
a scar as the only disability, or if they had no described
or prioritized occupational performance problems.
This was done to maintain the internal validity of
the main study. In this study,46 56.4% of the 507
participants were women (n ¼ 286), (mean age
47.2 year, range 18–92). Most participants had a
vocational education or medium-length, third-level
education; however, they were educated along a
spectrum from elementary school to long-term,
third-level education.
Data collection
Data used in this study were derived from COPM inter-
views collected at baseline in the main trial.46 The day
the patients started occupational therapy, COPM inter-
views were conducted in accordance with the Danish
manual,31 by specialized hand therapists experienced in
using the COPM. In the trial, patients had to select
three to five occupational performance problems and
rate them.
Data analysis
The three to five prioritized occupational performance
problems of each patient were entered into Microsoft
Excel and divided among the three COPM categories:
Self-care, productivity and leisure, as described in the
Danish version of COPM.31 Problems that could be cat-
egorized within more than one category, e.g. “using a
computer,” were categorized according to the patient’s
decision during the interview. Descriptive statistics were
used in the analysis. Included in the analysis were the
number of prioritized occupational performance prob-
lems (NPOPP) in each COPM category/subcategory, the
NPOPP in each category relative to gender and age and
the most frequently expressed problems. Furthermore,
Figure 1. The number of prioritized occupational performance problems (NPOPP) per patient in each age group and within each
COPM category.
123
data concerning the most commonly mentioned occupa-
tions, activities, task or actions were categorized accord-
ing to the TCOP.
Results
The total NPOPP formulated by the 507 patients were
2384. Each patient prioritized, on average, 4.7 prob-
lems. Problems within productivity and self-care consti-
tute the largest proportion, respectively, 46% and 40%.
The proportion of problems identified in leisure
amounted to 14%.
Occupational performance problems in relation to
gender and age
Women accounted for 56.4% (n ¼ 286) of the patients,
and 57.6% of the NPOPP identified. The proportion of
problems in relation to women and men was, respec-
tively: self-care (38.7%, 41.9%), productivity (47%,
43.5%) and leisure (14.3%, 14.5%). The main differ-
ences within the categories were: Within productivity,
76.6% of the problems expressed by the women con-
cerned household management and 20.9% were about
paid/unpaid work. For the men, 55.9% of the problems
were about household management and 42.3% con-
cerned paid/unpaid work. Within leisure, 28.6% of the
problems expressed by the women were about quiet
recreation, e.g. needlework. By comparison, 12.9% of
the problems expressed by the men were about
quiet recreation.
The NPOPP in relation to age is shown in Figure 1.
The dispersions of NPOPP per patient for all the
age groups were, respectively, 1.83–1.92 (self-care),
1.88–2.28 (productivity) and 0.53–0.92 (leisure).
124 Hand Therapy 23(4)

Occupational performance problems in COPM In detail, the most often expressed problems in self-
categories and subcategories care were using utensils when eating (NPOPP ¼ 149),
driving a car, within transport (NPOPP ¼ 73), doing up
The NPOPP in each of the three COPM categories and buttons when dressing (NPOPP ¼ 58) and washing
their subcategories is shown in Table 1. Occupations one’s hair – under grooming/personal hygiene
that represented the majority of a subcategory are spe- (NPOPP ¼ 44), as shown in Table 2. In productivity,
cifically mentioned in the table. the most frequently expressed problems were cutting
In self-care, 443 participants (87.4%) prioritized 1 to
while cooking (NPOPP ¼ 115) and wringing a cloth
4 problem(s), giving an NPOPP of 955. The problems
when cleaning (NPOPP ¼ 101). In the subcategory
especially concerned dressing, grooming/personal
paid/unpaid work, problems related to the use of a spe-
hygiene and eating, within the subcategory personal
cific tool, such as a screwdriver, were common
care and about transport, within the subcategory com-
(NPOPP ¼ 48). In leisure, the most frequently
munity management.
expressed problem was doing physical exercises, in
In productivity, 475 participants (94.7%) prioritized
the subcategory active recreation (NPOPP ¼ 42).
1 to 5 problem(s), giving an NPOPP of 1086. Most
Furthermore, three problems were mentioned in more
problems were about cooking and cleaning, within
than one COPM category, respectively, lifting/carrying/
the subcategory household management. The subcate-
holding heavy objects (NPOPP ¼ 135), using a computer
gory paid/unpaid work showed a big variation in prob-
(NPOPP ¼ 97) and writing by hand (NPOPP ¼ 84). The
lems, which reflects the fact that the patients had
first problem was especially represented in the subcate-
different professions, e.g. within the care, retail, skilled
gories household management in relating to cooking
or manual work sectors.
(NPOPP ¼ 73) and in the subcategory paid/unpaid work
The category with the lowest NPOPP was leisure,
(NPOPP ¼ 46). The occupational performance problems
where 239 participants (47.1%) chose to prioritize 1
with an NPOPP >40, shown in Table 2, represent 55.1%
to 3 problem(s), giving an NPOPP of 343. The largest
of the total number of problems.
subcategory was active recreation: NPOPP ¼ 153
(45%), e.g. physical sport such as fitness, handball
and horse-riding. Twenty-five per cent of the 507 par- Occupational performance problems and the TCOP
ticipants (131 participants) prioritized 1 to 2 problem(s) The occupational performance problems that patients
in active recreation. found most important to them are expressed at all

Table 1. Number of prioritized occupational performance problems (NPOPP) within the COPM
categories, the subcategories and the most commonly mentioned occupations within a subcategory.

Canadian Occupational Performance Measure, COPM

Category Sub-category Most mentioned occupation NPOPP

Self-care 955
Personal care 637
Dressing 237
Grooming/personal hygiene 216
Eating 173
Functional mobility 108
Community management 210
Transport (car, bike) 144
Productivity 1086
Unpaid/paid work 321
Household management 741
Cooking 445
Cleaning 214
School 24
Leisure 343
Quiet recreation 75
Active recreation 153
Sport (physical) 101
Socialization 115
NPOPP: number of prioritized occupational performance problems.
Poulsen and Hansen 125

Table 2. The most frequently expressed problems In this study, patients with hand-related disorders
(NPOPP > 40). primarily considered occupational performance prob-
COPM lems within productivity and self-care as most impor-
Occupational performance problems category NPOPP tant to regain in their rehabilitation. However, 46%
and 40% of the expressed problems concerned these
Using utensils when eating S 149 categories. These findings indicate that both categories
Lifting/carrying/holding heavy objects S/P 140 are important to address at the beginning of the reha-
Cutting bread/meat/fruit/vegetables P 115
bilitation which is supported by Nielsen and Dekkers.47
Opening can/milk carton/bottle/ P 103
Since OTs in hospitals or clinics often focus on
screw cap
Wringing a cloth P 101 self-care,20,48 attention must be paid to the fact that
Using computer S/P/L 97 problems within work, cooking, shopping and trans-
Writing by hand S/P/L 84 portation are just as important.
Car driving (changing gear, etc.) S 73 Women accounted for 56.4% (n ¼ 286). Since 57.6%
Cycling (holding handlebars, using the S 62 of the NPOPP were mentioned by women, the number
brake, etc.) of prioritized problems appears to be fairly equal
Peeling/holding fruit/vegetables P 61 between the two genders. Furthermore, the distribution
Doing up buttons S 58 of NPOPP between the genders is almost the same in
Gardening P 49 the three main COPM categories. In the subcategories,
Using tools (e.g. screwdriver, hammer) P 48
a bigger variation between the genders was found
Tying shoelaces S 46
regarding the prioritized problems. Women typically
Washing hair (opening/squeezing S 44
shampoo bottles) found that problems to do with household management
Physical exercises (fitness, L 42 and quiet recreations were more important to them.
strength training) Men typically prioritized work-related problems more
Shopping (payment, placing items on S 41 than the women did. The dispersion of NPOPP per
the conveyor belt) patient is small for all age groups in each COPM cat-
egory. However, there was a slight tendency for
Note: Some problems were represented in more than one
COPM category. patients in the youngest age group (18–29) to weight
S: self-care; P: productivity; L: leisure; NPOPP: number of prioritized problems in leisure higher and problems in productivity
occupational performance problems. lower than do the other age groups. These considera-
tions need to be kept in mind for practice.
levels in the TCOP, except the lowest level – voluntary According to Killian,49 the availability of treatment
movement. Examples are shown in Table 3. In the self- areas where occupations can be performed in a
care and productivity categories, a few patients expressed common natural environment is important when
their problems at the level of occupation, e.g. dressing implementing occupation-based practice, e.g. a house-
(NPOPP ¼ 10) and cooking (NPOPP ¼ 16) or cleaning keeping area.50 In the two largest categories, productiv-
(NPOPP ¼ 4). The problems are mostly expressed at the ity and self-care, the most expressed problems concern
activity, task and actions levels. The action level is typ- cooking, cleaning, dressing, grooming/personal
ically represented in occupations involving handling hygiene, eating and transportation (car driving and
instruments or tools, e.g. eating, cooking and cleaning. cycling). These findings indicate that the setting must
Some problems are expressed accurately: ‘Holding a be organized with functional stations (as far as possi-
fork when eating’ and others are expressed more ble) where these types of problems can be addressed. In
widely: ‘Lifting something heavy, e.g. a pan’. In the lei- relation to functional stations, the five most expressed
sure category, the problems are mostly expressed at the problems in Table 2 can be addressed in a kitchen area
activity level, e.g. playing the guitar and knitting. (using utensils, lifting/holding heavy objects, cutting,
opening something and wringing a cloth). Activities
like spreading butter on bread and making coffee are
Discussion easily accessible and accommodate the issues men-
The aim of this study was to explore occupational tioned. A station where patients with problems using
performance problems that patients with hand-related a computer or writing by hand can practise would be
disorders considered to be the most important at the appropriate. Furthermore, an area for personal care
beginning of their rehabilitation. This insight can be where problems like doing up buttons and tying shoe-
used when preparing an outpatient clinical setting in laces can be addressed. For these issues, patients could
order to address the most common problems which be asked to bring some of their own belongings.
might promote an occupation-based intervention in Performing tasks or activities in areas prepared for
hand therapy. this will make it easier for the patient to transfer the
126 Hand Therapy 23(4)

Table 3. Examples of expressed performance problems at each level in the TCOP.

Activity Task Action

Self-care
Dressing Putting on a shirt Doing buttons
Putting on shoes Tying laces
Putting on trousers Pulling up trousers
Personal hygienea Taking a bath Drying the body/back
Washing hair Squeezing a tube
Brushing teeth Squeezing a tube
Eatinga Using utensils Holding a knife/fork
Shoppinga Paying Putting credit card in/taking
credit card out
Open/close wallet Receiving change
Transportationa Driving a car Holding the steering wheel
Putting on seat belt
Turning the ignition key
Shifting gear
Riding a bike Fastening a cycle helmet
Holding the handlebars
Shifting gear
Productivity
Cooking Baking buns Forming the buns
Knead dough
Peeling potatoes Lifting a pot
Cutting bread Keeping a grip on bread
Opening cans and jars
Cleaning Vacuuming Holding the vacuum cleaner handle
Wringing a cloth
Doing laundry Taking laundry out of machine Lifting the laundry basket
Hanging up laundry Squeezing a clothes peg
Folding laundry Folding socks
Leisure
Needleworka Knitting
Sewing Sewing a button in trousers Holding a needle
Sport (physical) Fitness training Lifting weights
Communicationa Using a mobile Writing a test message
Writing by hand
a
Not expressed by the patients. Applied when categorizing data.

treatment to their own environment, which in turn will
support their rehabilitation.
An important finding in this study is that patients
with hand-related disorders prioritize problems at all
levels in the TCOP, apart from voluntary movement, in
choosing their most important problems. This finding
is supported by a study by Larsen et al.,20 in which it is
reported that patients with orthopaedic conditions
identify tasks or actions when describing their most
important occupational performance problems.
The fact that problems are expressed on several levels
in the TCOP indicates that occupation-based interven-
tions do not necessarily have to consist of performing
occupations at the highest level in the TCOP – given
that patients also highlight problems at the level of
activities, task and actions to be meaningful and impor-
tant. This might reflect that they are able to analyse
their occupations themselves and distinguish which
activities, tasks or actions are the main ones before
being able to perform the occupations they would
like to do. This assumption is supported by Dekkers
and Nielsen.5
The described tasks and actions (Table 2) can guide
the preparation of boxes as suggested by Killian49 to
support an occupation-based intervention. Boxes are
collections of supplies and equipment that are com-
monly used in an occupation or activity42 and that
can be used right away in the interventions without
spending time on preparation. When preparing the
boxes, the context – where the activity, task or action
is typically performed – should be taken into consider-
ation. For example, wringing a cloth is not just about
wringing a dry cloth. It is about wringing a wet cloth
and wiping a table. Furthermore, it can be noted that
Poulsen and Hansen
some problems at the action level are specifically linked
to an activity or occupation, e.g. to be able to hold a
fork. Other problems are more generally formulated,
e.g. to be able to squeeze a tube – an action which is
required in a wide range of self-care activities, such as
hair washing, applying lotion and brushing teeth.
In this study, it has also been seen that problems in
the leisure category often are described at a higher level
than those involved in self-care or productivity. It may
be due to the fact that, at the beginning of their reha-
bilitation at the outpatient hand therapy clinic, the
patients only have had to perform the occupations
that they used to doing every day. Through these occu-
pations, they learn their limitations and from this expe-
rience they can express their problems at lower levels in
the TCOP, while as yet they have not tried to perform
their leisure occupations.
Limitations
There are some potential limitations to this study. The
COPM interviews were conducted by several OTs,
which might have introduced variation in interview
style and thereby affected the level of occupational per-
formance problems mentioned. Furthermore, the data
were entered and categorized only by the first author
and therefore could be at risk of being biased.
However, any questions in doubt were discussed with
the co-author. It might also be a limitation that the
patients were asked to fill in the COPM at their first
visit to the outpatient clinic, since the chosen occupa-
tion performance problems might have been different if
they had had time to reflect on them. However, the
results show what they found important on the day
they started rehabilitation.
Conclusion
This study has provided insight into which occupation-
al performance problems that 507 patients with hand-
related disorders in need of rehabilitation consider as
most important at the beginning of their rehabilitation
at an outpatient hand therapy clinic. It turns out that
the prioritized problems mostly concern productivity
and self-care, irrespective of gender or age.
Furthermore, the problems are expressed at all levels
in the TCOP, apart from voluntary movement, which
indicates that occupation-based interventions do not
necessarily have to involve performing occupations.
For patients, it is also meaningful and important to
perform activities, task and actions.
Finally, this study provides useful knowledge that
can be used when preparing a clinic setting, addressing
the most common occupational performance problems
which will promote an occupation-based intervention.
127
Acknowledgements
We would like to thank all patients and occupational thera-
pists who participated in this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: The main trial was supported by the University of
Southern Denmark, the Region of Southern Denmark, the
Danish Occupational Therapist Association, Bevica
Foundation and Odense University Hospital. Funding sour-
ces did not have any role in the design of this paper.
Ethical approval
The main trial was approved by the Regional Scientific
Ethical Committee for Southern Denmark, Project-
ID 20120123.
Guarantor
HP.
Contributorship
The data used in the present study were collected in a main
trial,1 led by AOH. HP and AOH researched the literature
and planned the present study. HP entered, categorized and
analysed the data; and wrote the draft of the introduction,
results and discussion section. AOH wrote the draft of the
method section. Both authors reviewed and edited the article
and approved the submitted version.
Informed consent
All patients were informed about the project orally and in
writing before enrolment in the main trial. Written informed
consent was obtained from the patients for their anonymized
information to be published in articles.
Note
a. Sourced from the Accident Analysis Group, Department
of Orthopedic Surgery, Odense University Hospital,
May 2017.
ORCID iD
Helle S Poulsen http://orcid.org/0000-0001-7956-1238
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