burns 48 (2022) 1645–1652

Available online at www.sciencedirect.com

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The investigation of the effects of occupation-

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based intervention on anxiety, depression, and

sleep quality of subjects with hand and upper
extremity burns: A randomized clinical trial
⁎
Mahnoosh Khanipour a, Laleh Lajevardi b, , Ghorban Taghizadeh b,
Akram Azad b, Hooman Ghorbani c
a
School of Rehabilitation Sciences, Iran University of Medical Sciences (IUMS), Tehran, Iran
b
Rehabilitation Research Center, Department of Occupational Therapy, School of Rehabilitation Sciences, Iran
University of Medical Sciences (IUMS), Tehran, Iran
c
Department of Occupational Therapy, Shahid Motahhari Specialized Burns Hospital, Iran University of Medical
Sciences (IUMS), Tehran, Iran

a rt i cl e in fo ab strac t

Article history: Aim: This study aimed to investigate the effects of occupation-based intervention on
Accepted 21 February 2022 psychological factors and sleep quality of subjects with hand and upper extremity burns.
Methods: In this randomized controlled intervention trial, a total of 20 patients were ran­
Keywords: domly assigned to one of the control group or intervention group. The control group only
Burns received traditional rehabilitation. However, the intervention group received traditional
Psychological factors rehabilitation and Cognitive Orientation to daily Occupational Performance (CO-OP), re­
Sleep disorder spectively (during 18 sessions, 45 min/day in both groups). Occupational therapy sessions
Occupational therapy were held three times a week for a six-week duration. Occupational performance and sa­
Occupational performance tisfaction, anxiety, depression, and sleep quality were measured before the intervention
and in weeks 2, 6, and 14 (follow-up) using Canadian Occupational Performance Measure,
Beck Anxiety Inventory, Self-rating Depression Scale, and Pittsburgh Sleep Quality Index,
respectively.
Findings: The results of the present study show that there were significant changes in all
the studied variables in the two groups. However, these changes (P ≤ 0.05) were not sta­
tistically significant between these two groups.
Conclusion: The results of this study show that occupation-based interventions are as ef­
fective as traditional therapeutic interventions on improving the anxiety, depression, and
sleep quality in patients with hand burn injuries.
© 2022 Elsevier Ltd and ISBI. All rights reserved.

⁎
Corresponding author.
E-mail address: lajevardi.l@iums.ac.ir (L. Lajevardi).

https://doi.org/10.1016/j.burns.2022.02.014
0305-4179/© 2022 Elsevier Ltd and ISBI. All rights reserved.

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1646 burns 48 (2022) 1645–1652

and IRCT code (IRCT20180908040970N1). The study started

1. Introduction
recruiting in December 2018 and ended with the last follow-
up in May 2020.
Burn injuries can create numerous barriers and have many
consequences such as physical, psychological, social, and
2.2. Participants
emotional subsequences for these patients [1,2]. These chal­
lenges could endanger the patients’ health and compel them
A total of 25 patients with hand and upper extremity burns
to experience multiple difficulties [2,3]. In addition to the
were referred to the rehabilitation center by the surgeon
negative effects of burns in almost all aspects of daily func­
during the first week following the skin graft surgery, of
tions in patients with burn injuries, mental health is known
whom 20 subjects participated in the current study. All of the
as a main concern for these patients, especially in whom
participant have a debridement and application of dressing
Post-Traumatic Stress Disorder (PTSD) is very common [1].
during the course of treatment. The inclusion criteria were
According to the previous study by Khanipour et al., sleep
the followings: age range of 18–65 years old, one week has
quality, pain, and psychological factors are correlated with
passed since the skin graft surgery [12], having an acceptable
disability and interfere with occupational performance and
level of cognitive function as a score of 21 or higher based on
meaningful occupations [4]. The authors recommended that
the Mini Mental Status Examination (MMSE) [13], the depth of
rehabilitation specialists consider the therapeutic interven­
burn was deep second degree or third degree and consisted of
tions to improve these factors in patients with burn injuries
2.5–3% TBSA (total body surface area) burns according to the
[4]. Previous studies have identified the need for a multi­
modified Lund and Browder chart [14]. The exclusion criteria
disciplinary approach to burns rehabilitation [3,5,6]. The
was existence of accompanying injuries such as fractures,
study by Jagnoor et al. highlighted the value of occupational
tendon injuries or wound infections.
therapy services aimed at the patient returning to their pre­
vious functional level and participating in meaningful occu­
2.3. Data collection procedure and outcome measures
pation [7]. As part of a multidisciplinary approach,
occupational therapy plays an essential role in the re­
After receiving ethical approval and registering in the IRCT
habilitation of patients with hand burn injuries [5].
system, we introduced the research project to the surgeons
One of the most common interventions that occupational
and occupational therapists and obtained permission to
therapists use to facilitate a sense of power and well-being is
commence. The study began after introducing and summar­
occupation-based intervention [8], in which they use mean­
izing the research project and its purpose to the surgeons and
ingful activities to improve disabilities and impaired capa­
occupational therapists, and obtaining permission. After ad­
cities [9]. In this regard, one of the occupation-based
mitting the patients in rehabilitation center, the interven­
interventions is Cognitive Orientation to daily Occupational
tion’s objectives and the study method were fully explained
Performance (CO-OP). Accordingly, CO-OP is a cognitive ap­
to the participants, and if they agreed to participate, they
proach that directly focuses on occupational performance
filled out an informed consent form. Thereafter, using a
with aim of solving occupational performance problems.
random-numbers table, the included participants were as­
Since a complex interaction among the individual, the en­
signed into the two groups, including control group (n = 10)
vironment, and the action leads to occupational perfor­
and intervention group (n = 10). The occupational therapy
mance, this approach tries to improve occupation capacity
sessions were held three times a week for a six-week dura­
and occupational performance by focusing on strengthening
tion (during 18 sessions, 45 min/day) in the two studied
the relationship between these three factors and use of pro­
groups. The control group received traditional rehabilitation,
blem solving strategies [10].
including motor exercises, muscle strengthening, mobiliza­
Din et al. reported that patients with burn injuries ex­
tion, stretching, scar massage, edema control, and graded
perienced cultural stigmatization, which could lead to the
stretching exercises [1]. Additionally, the required splints,
loss of their social network [11]. Based on the previous study
pressure gloves, burns clothes or silicone sheets were pre­
highlighting the correlation between psychological factors
scribed according to each patient's condition. Traditional re­
and disability [4], and the study by Jagnoor et al. that iden­
habilitation was provided to participants in the intervention
tified the need for further research on burn rehabilitation in
group in weeks 1 and 2 for two reasons: due to observing
low and middle-income countries [5], this study aims to in­
physical limitations in these patients after graft surgery such
vestigate the effects of occupation-based intervention on
as range of motion restrictions, severe hand swelling, lack of
anxiety, depression, and sleep quality in subjects with hand
muscle strength, and possible sensory problems, therefore
and upper extremity burns.
they were unable to perform adequate movement to begin
the CO-OP treatment protocol. Secondly, motor pre-requisites
2. Material and methods had to be met, and this was only possible by performing
traditional rehabilitation. The steps of the CO-OP protocol are
2.1. Study design and setting presented in Table 1 [10].
The Canadian Occupational Performance Measure (COPM)
This study was a randomized controlled trial, performed at a was used to determine the participant's current occupational
specialized burns hospital in Tehran, Iran. The study protocol performance level and satisfaction [15]. The Beck Anxiety
was approved by the Ethics Committee of the Iran University Inventory (BAI) was used to determine the participant's self-
of Medical Sciences with ethics code (IR.IUMS.REC.1397.293) reported anxiety level [16]. Depression and sleep quality were

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 burns 48 (2022) 1645–1652 1647

Table 1 – Sessions structure: the CO-OP intervention protocol.

Prior to Therapy (Preparation) 1. Establish contact with caregivers
2. Orient caregivers to Cognitive Orientation to daily Occupational Performance (CO-OP)
3. Contract with caregivers to ensure resources and support
4. Provide Daily Activity Log
5. Check for participant/caregivers and therapist prerequisites
Session 1 (Assessment) 6. Review participant's completed Daily Activity Log
7. Administer Canadian Occupational Performance Measure (COPM) and identifying
three goals
8. Baseline participant's performance using the Performance Quality Rating
Scale (PQRS)
Session 2 (Introducing Global Cognitive 9. Introduce Global Cognitive Strategy: Goal-Plan-Do-Check
Strategy) a. Therapist introduces the puppet, Commander Goal-Plan-Do-Check
b. Therapist maps Goal-Plan-Do-Check (GPDC) to a familiar task
c. Participant map Goal-Plan-Do-Check to a familiar task
d. Caregivers observe session and discuss the application of GPDC at home
Sessions 3–11 (Acquisition) 10. Conduct Dynamic Performance Analysis: Ongoing
11. Facilitate the participant’s acquisition and application of the Global Cognitive
Strategy: Goal-Plan-Do-Check
12. Guide discovery of Domain Specific Strategies (DSS) and mediate their application to
skill acquisition
13. Apply Enabling Principles
14. Teach caregivers about Goal-Plan-Do-Check and applicable Domain Specific
Strategies
15. Educate caregivers about their ongoing role in facilitating cognitive strategy use, in
order to promote skill acquisition
Session 12 (Consolidation) 16. Re-administer COPM
17. Re-administer baseline, using PQRS
18. Probe participant for generalization and transfer of Global and Domain Specific
Strategies: GPDC and DSS
19. Review and reinforce CO-OP approach, and cognitive strategy use with caregivers

evaluated using the Self-Rating Depression Scale (SDS) [17],
and the Pittsburgh Sleep Quality Index (PSQI) [18], respec­
tively. These evaluations were conducted with both groups
before the rehabilitation program commenced, and in weeks
2, 6, and 14 (follow-up).
2.4. Statistical analysis
The normal distribution of the obtained data was in­
vestigated using the Shapiro-Wilk test. None of the outcome
measures data was normally distributed according to the
results of the Shapiro-Wilk test. Comparisons between tra­
ditional and CO-OP groups at each time point were done
using the Mann-Whitney U test. Changes within each group
were analyzed with Friedman's test for multiple time points.
3.2. Demographic and clinical variables
The results show no difference between the study groups in
terms of the participants’ baseline characteristics and clinical
data. No side-effect was observed in each groups. The results
indicated that, in both traditional and CO-OP groups, COPM-F
(P < 0.0001) and COPM-S (P < 0.0001) scores were sig­
nificantly increased. Further, in both traditional and CO-OP
groups, BAI (P < 0.0001) and SDS (P < 0.0001) scores were
significantly decreased. PSQI score was significantly de­
creased in the traditional group (P < 0.0001) while it did not
significantly change in the CO-OP group (P = 0.16). No sig­
nificant difference was observed between the traditional and
CO-OP groups at pretreatment and weeks 2, 6, and 14 eva­
luations (Table 4) (Fig. 2).

3. Results
3.1. Patient selection
The participants' recruitment flowchart is presented in Fig. 1.
A total of 25 patients with hand and upper extremity burns
were identified as eligible. Of them, three cases were ex­
cluded due to non-attendance at more than two therapy
sessions and two of them were declined to participate.
Therefore, only 20 patients voluntarily participate in the
current study. The baseline characteristics of the participants
are presented in Table 2. The mean and standard deviation of
outcome measures in both groups at different times are
summarized in Table 3.
4. Discussion
Previous studies have reported that patients with burn in­
juries experience anxiety, which can lead to decreased phy­
sical and emotional performance [19], and sleep disorders
[20,21]. Masoodi et al. highlighted the important role of sleep
quality in the mental health and quality of life in patients
with burn injuries [22]. Additionally, psychological adjust­
ment to a burn injury affects patients' recovery [23] and loss
of social networks may cause significant social problems for
individuals [11,24]. Therefore, addressing the psychological
problems and sleep disorders in patients with burn injuries is
highly important.

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1648 burns 48 (2022) 1645–1652

5 cases were eligible but

Assessed for eligibility (n=25)
did not participate:

3 cases were excluded due

Registration to non-attendance at more
than two therapy sessions,

2 cases declined to
Randomized (n=20) participate

Intervention group (n=10) Allocation Control group (n=10)

Traditional rehabilitation Traditional rehabilitation

(Week 1 and 2) + CO-OP Assessment (before
protocol (Weeks 3 - 6) the intervention,
at the 2nd, 6th,
and 14th weeks
(follow up))

Analysis

Fig. 1 – Participants' recruitment flowchart.

CO-OP protocol is a cognitive and verbal approach to ac­
quisition of occupational skills and the growth of occupa­
tional adequacy also improves the existing skill [10]. Since
this therapeutic approach focuses on the individual and
meaningful occupations [25] and the evaluation of this model
includes the COPM, this therapeutic approach is considered
effective to improve the patients' ability to perform mean­
ingful activities and to reintegrate into their community [3].
Indeed, by considering that occupational performance and
psychological characteristics such as depression and anxiety
as different dimensions of the person [3], it is understood
that this therapeutic approach can be used to achieve better
improvement in mental dimensions, as well as facilitating
individual's return to the society. This study was the first that
aimed to determine the effects of occupation-based inter­
vention on psychological factors and sleep quality in patients
with hand burn injuries. The findings of this study showed
that CO-OP protocol along with traditional rehabilitation
could be an effective intervention on improving anxiety, de­
pression, and sleep quality. Although statistical data on sleep
quality in the CO-OP group did not show a significant differ­
ence at different times, but the trend of improving sleep
quality in this group has been observed and the lack of sig­
nificant difference can be considered due to the small
number of samples in the CO-OP group. Indeed, CO-OP was
shown to be as effective as traditional intervention.
It should be noticed that the results of this study show
that all changes in psychological characteristics and sleep
quality had no significant difference between the two study
groups. In this study, CO-OP in combination with traditional
rehabilitation programs, including range of motion training,
muscle strengthening, mobilization, stretching, scar mas­
sage, edema control, and graded stretching exercises
(during the initial 6 session), were provided to the inter­
vention group. The reason for providing traditional re­
habilitation to the intervention group was mobility
requirements prior to commencing the next phases of the
treatment (CO-OP protocol). Changes in occupational per­
formance and satisfaction as well as some subsequent
changes in psychological factors and sleep quality were

Table 2 – The baseline characteristics of the participants.

Characteristics Intervention Group Control Group P Value
Gender 8 men/2 women 7 men/3 women 0.61
Age (years old) 43 (11.47) 40.50 (12.14) 0.64
MMSE score 26.90 (1.52) 27.80 (0.78)
Total Body Surface Area 3% 6 3 0.37
(TBSA) 2.5% 4 7
Depth of burn Deep partial thickness 4 5 1.00
Full thickness 6 5
3%: lower arm burns; 2.5%: hand burns.

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 burns 48 (2022) 1645–1652 1649

Table 3 – Comparison of the functional outcome measures at different times of the assessment between the control and
intervention groups.
Outcome Measure Assessment Time Control Group Intervention Group

Mean ± SD Mean ± SD
COPM Function Pre-treatment 2.01 ± 1.70 1.62 ± 1.96
2nd week 4.73 ± 2.72 5.49 ± 2.24
6th week 8.03 ± 1.97 8.82 ± 1.51
14th week 9.49 ± 0.94 9.73 ± 0.65
Satisfaction Pre-treatment 0.99 ± 1.45 2.19 ± 3.31
2nd week 4.19 ± 2.83 0.20 ± 2.72
6th week 7.64 ± 2.68 8.72 ± 1.52
14th week 9.55 ± 0.93 9.72 ± 0.62
BAI Pre-treatment 2.30 ± 8.42 14 ± 4.94
2nd week 8 ± 7.87 10.10 ± 7.12
6th week 4.20 ± 4.59 8.50 ± 10.65
14th week 2 ± 1.56 4.20 ± 4.39
SDS Pre-treatment 41.10 ± 5.02 43.70 ± 5.85
2nd week 39.40 ± 5.10 39.30 ± 6.73
6th week 38.10 ± 6.85 36.20 ± 6.03
14th week 30.50 ± 6.18 29.80 ± 5.78
PSQI Pre-treatment 5.80 ± 3.88 7.50 ± 4.30
2nd week 4.80 ± 3.32 6.20 ± 3.35
6th week 3.30 ± 2.49 6.40 ± 5.64
14th week 2 ± 1.56 6 ± 5.41
COPM: Canadian Occupational Performance Measure; BAI: Beck Anxiety Inventory; SDS: Self-rating Depression Scale; PSQI: Pittsburgh Sleep
Quality Index.

observed in both study groups, with no significant difference
between the groups, which is not consistent with the study
by Tang et al. [1]. However, the results related to the
improvement in sleep quality and the decreased depression
and anxiety levels in their study were similar to those of the
current study. While in their study, the control group
only received initial nursing treatments at the time of their
hospitalization stay and specific rehabilitation treatments
were not offered to them. Correspondingly, the results show
a significant difference between the two groups.

Table 4 – The results of the within-group comparison of the group (control and intervention) and time (before treatment,
second week, sixth week and follow-up period) for COPM-F, COPM-S, BAI, SDS, and PSQI.
Variable Mean (Std. Deviation) Within-group comparison

Pre Post 6 s Post 18 s Follow X2 P (V)

F-COPM Traditional 2.01 (1.70) 4.73 (2.72) 8.03 (1.97) 9.49 (0.94) 29.45 0
CO-OP 1.62 (1,97) 5.49 (2.24) 8.82 (1.51) 9.73 (0.65) 28.7 0
Between-group comparison Z 0.54 0.49 1.15 0.89
P(V) 0.59 0.62 0.25 0.38
S-COPM Traditional 0.99 (1.45) 4.16 (2.84) 7.64 (2.68) 9.55 (0.93) 28.41 0
CO-OP 2.19 (3.32) 5.02 (2.72) 8.72 (1.52) 9.72 (0.63) 28.08 0
Between-group comparison Z 0.43 0.76 0.97 0.53
P(V) 0.67 0.45 0.33 0.59
BAI Traditional 12.30 (8.42) 8.00 (7.87) 4.20 (4.59) 3.00 (1.56) 17.26 0
CO-OP 14.00 (9.94) 10.10 (7.12) 8.50 (10.66) 4.20 (4.39) 15.03 0
Between-group comparison Z 0.3 0.8 1.18 0.04
P(V) 0.76 0.43 0.24 0.97
SDS Traditional 43.70 (5.85) 39.30 (6.73) 36.20 (6.03) 29.80 (5.79) 19.53 0
CO-OP 41.10 (5.02) 39.40 (5.10) 38.10 (6.85) 30.50 (6.17) 13.36 0
Between-group comparison Z 0.9 0.04 0.72 0.19
P(V) 0.36 0.97 0.47 0.85
PSQI Traditional 5.80 (3.88) 4.80 (3.33) 3.30 (2.50) 2.00 (1.56) 13.74 0
CO-OP 7.50 (4.30) 6.20 (3.36) 6.40 (5.64) 6.00 (5.42) 5.14 0.16
Between-group comparison Z 0.95 0.72 0.92 1.72
P(V) 0.34 0.47 0.36 0.09
COPM-F: Canadian Occupational Performance Measure-Function; COPM-S: Canadian Occupational Performance Measure-Satisfaction; BAI:
Beck Anxiety Inventory; SDS: Self-rating Depression Scale; and PSQI: Pittsburgh Sleep Quality Index.

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1650 burns 48 (2022) 1645–1652

Fig. 2 – The interaction plot of the two study groups (intervention and control) by time (pretreatment, at 2nd and 6th weeks
after the treatment and follow up) of COPMF, COPMS BAI, SDS, and PSQI outcome measures. *P < 0.05.

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 burns 48 (2022) 1645–1652
4.1. Limitations
In the present study, there were some limitations. Lack of
performing the evaluations at shorter intervals led to the
failure to record early positive results in the intervention
group. Unfortunately, we did not performed the evaluations
at short intervals, so we cannot document that the patients
enrolled in the intervention group achieved occupational
performance and satisfaction earlier than the control group.
Emphasizing the desired activities of patients in CO-OP pro­
tocol [10] appeared to lead to achieving occupational perfor­
mance and satisfaction faster than the control group.
Subsequently, their satisfaction, Function, and psychological
factors improved earlier. Being different in the time acquisi­
tion of occupational performance and satisfaction between
the two groups is the most important issue that was not
documented, but it was observed only experimentally by the
researchers. Therefore, future studies are recommended to
perform the evaluations at shorter intervals.
Although this study showed that the occupation-based
interventions are as effective as traditional therapeutic in­
terventions on improving psychological factors and sleep
quality, this study indicated no significant difference be­
tween the two groups, possibly due to the similar protocol
use during the first 6 sessions of the intervention in both
study groups. So, we recommend that future studies should
use different treatment methods in the initial treatment
sessions in both groups. As well, due to the problems caused
by the corona virus and stopping the procedure of the study;
the current study was conducted on a total of 20 patients. A
small sample size in both groups (10 people in each group)
was recognized as one of the most important reasons for the
bias in the results of this study, so it is suggested that further
studies be performed with a larger sample size.
5. Conclusion
This study showed that the occupation-based interventions
using the CO-OP approach can reduce both depression and
self-reported anxiety levels. Therefore, these interventions
could be used in rehabilitation clinics to improve the above-
mentioned outcomes in patients with hand and upper ex­
tremity burn injuries.
Funding
The authors received no financial support for the research
and/or authorship of this article.
Author contributions
This study was designed by L.L, GH.T, and A.A. Intervention
and data collection were performed by M.KH. GH.T per­
formed the statistical analysis. H.GH as a blinded assessor
performed all evaluation trials. L.L and M.KH wrote the ar­
ticle. L.L, GH.T, A.A, and M.KH read and approved the final
manuscript.
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1651
Declaration of interest
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Acknowledgments
We would like to thank all the patients and the Shahid
Motahhari specialized burns hospital.
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