Accepted Manuscript

The Use of Occupation-based Assessments and Intervention in the Hand Therapy

Setting – A Survey

Kimatha Oxford Grice, OTD, OTR, CHT, Associate Professor

PII: S0894-1130(15)00023-X
DOI: 10.1016/j.jht.2015.01.005
Reference: HANTHE 901

To appear in: Journal of Hand Therapy

Received Date: 30 June 2014

Revised Date: 5 January 2015
Accepted Date: 12 January 2015

Please cite this article as: Grice KO, The Use of Occupation-based Assessments and Intervention in the
Hand Therapy Setting – A Survey, Journal of Hand Therapy (2015), doi: 10.1016/j.jht.2015.01.005.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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 ACCEPTED MANUSCRIPT

The Use of Occupation-based Assessments in the Hand Therapy Setting

Kimatha Oxford Grice, OTD, OTR, CHT

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Associate Professor

Department of Occupational Therapy

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The University of Texas Health Science Center

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7703 Floyd Curl Drive, MC 6245

San Antonio, Texas 78229

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210-567-8886 (phone)
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210-567-8893 (fax)

Oxford@uthscsa.edu
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This has not been presented at a meeting and did not receive any grant support

ASHT provided support by waiving the fee for the email list of members to be used for the
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survey
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The Use of Occupation-based Assessments and Intervention in the Hand

Therapy Setting – A Survey

Abstract

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Study Design: Descriptive survey

Introduction: This study specifically explored the use of occupation-based

assessments and intervention in the hand therapy setting, but also more generally,

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current practice trends about all assessments being utilized in this setting,
frequency of their use, and therapists’ perceptions about them.

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Methods: An online survey was distributed via email to members of the American
Society of Hand Therapists (ASHT). The survey consisted of ten questions and was
administered via Survey Monkey.

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Results: Responses were received from 22% of those surveyed. A descriptive
analysis was completed of the results and indicated that over half use occupation-
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based assessments on a daily basis; most are related to ADL function and used for
the development of goals. The primary reason for not utilizing occupation-based
assessments is time limitation. Seventy-nine percent believe these measures are
important for the services provided in the hand therapy setting.
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Conclusion: Occupation-based assessments and intervention are not utilized as

much as therapists would like in the hand therapy setting, primarily due to time
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constraints. While not formally assessed, the majority of those who responded
indicated that they do address occupation in their assessments and interventions.
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Level of evidence: Not applicable

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The Use of Occupation-based Assessments and Intervention in the Hand

Therapy Setting – A Survey

In recent years, there has been concern and discussion that occupational

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therapists have deviated from using occupation as a means, or “occupation based”

treatment.1-5 This observation has been made across all settings, but especially for

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the practice setting of “hand therapy.”

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“Hand Therapy” is defined as:

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the art and science of rehabilitation of the upper limb, which includes the
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hand, wrist, elbow and shoulder girdle. It is a merging of occupational and

physical therapy theory and practice that combines comprehensive

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knowledge of the structure of the upper limb with function and activity.

Using specialized skills in assessment, planning and treatment, hand

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therapists provide therapeutic interventions to prevent dysfunction, restore

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function and/or reverse the progression of pathology of the upper limb in

order to enhance an individual’s ability to execute tasks and to participate

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fully in life situations.6

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While the definition states that this practice area is a combination of occupational
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and physical therapy theory and practice, current statistics show that 86% of all

certified hand therapists are occupational therapists,6 who have been trained in the

use of occupation-based assessment and intervention.

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In an article titled, “Can Occupational Therapists be Hand Therapists?”,

Fitzpatrick and Presnell7 stated “occupational therapists working in the field of hand

therapy tend to follow a reductionist biomedical approach in their practice. This

emphasis means that there is the potential to lose the occupational focus in

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interventions with this client group.” They go on to explain that when this happens,

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therapists are reinforcing diagnosis over person and risking the creation of a

perception that clinical practice is primarily technical in nature.

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Occupation as a “means and an end” is core to the basis of occupational therapy

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as a profession. The “means” is the use of occupation as a process or method of
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intervention; the “end” is the outcome or product being facilitated by intervention.8,9

Over the years, “occupation” has been defined in many ways:

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Continuous activity having a purpose.10

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Doing culturally meaningful work, play, or daily tasks in the stream of time
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and in the contexts of one’s physical and social world.10

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The ordinary and familiar things that people do everyday.10

Activity that is both meaningful and purposeful to the person who engages in
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it.11
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Why has the profession veered so far away from these core tenets for intervention?

The reasons that occupational therapists in the hand therapy setting have become

less “occupational” have been explored and seem to be primarily related to cost

containment measures such as limited visits, decreased treatment duration, and

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reimbursement capitation.3 Other reasons found have included reliance on

protocols and prescribed treatment methods, the effects of specialization, and

higher caseload demands.1 Jack and Estes12 contend that in the past 20 years, the

profession has become aware of the need to return to “our ‘caring’ roots to include

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“more holistic, client-centered approaches that supplement the strong manual skills

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of more biomechanical approaches. In this era of managed care, hand therapy is

increasingly perceived as a practice area in which mechanical skill must often over-

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shadow client-centered approaches to meet health insurer demands.”

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Having been an occupational therapist for over 30 years, and a certified hand
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therapist for over 20 years, I followed these observations and discussions with

interest. I had to agree that I was observing the same trends. In my opinion, we
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were using occupation-based treatment to a much greater extent 20 years ago.

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Another trend that I began to notice was a decrease in the use of formal

assessments. It seems that if any formal assessment was done, it was primarily for
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impairment deficits. Assessment is the first contact a therapist has with a client and
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is the initial step in the clinical reasoning process. For occupational therapists,

assessment should focus on occupational performance (function) and involve

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analyzing tasks, activities, and occupations. “Best practice assessment (in O.T.) is
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centrally focused on occupational performance in everyday life.” 13 Were these

components of evaluation actually being done in the hand therapy setting? Since the

use of occupation-based intervention had seemingly declined in the hand therapy

setting, it would seem to follow that the use of occupation-based assessment had

also declined.

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The 2008 practice analysis of hand therapy14 revealed that hand therapists

reported spending 27% of their time in “evaluation of upper extremity and relevant

patient characteristics.” Included in this domain of evaluation is: “assess and

document psychosocial, functional and ergonomic factors and status” and “identify

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impairments, functional limitations, and disabilities based on the result of the

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assessment.” Which assessments were being utilized to achieve this?

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The purpose of this study was specifically to explore the use of occupation-based

assessments and intervention in the hand therapy setting, but also more generally,

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current practice trends about all assessments being utilized in hand therapy
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settings, frequency of their use, and therapists’ perception about them. For the

purpose of this survey, occupation-based assessments were defined as

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including:13,15,16
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-measurement of occupational performance (function) that involves assessment of

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self-care, work, other productive pursuits, play and leisure

-focus on both the subjective experience and the observable qualities of

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occupational performance
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-problems identified by the client and his/her family, not the therapist
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-take into account what people do in their daily lives, what motivates them, and how

the environment influences successful occupational performance

While focusing primarily on occupation-based assessment, the survey presented

the opportunity to also gather information about the use of occupation-based

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intervention, possibly adding to existing literature and the discussion already in

progress within the field, on this topic.

Method

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An online survey was created by the author, who has had previous experience in

developing surveys, has been an occupational therapist for 34 years, and a certified

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hand therapist for 23 years. The survey was informally piloted among the author’s

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co-workers to check for clarity and necessary edits. The survey consisted of a total

of ten questions. The first two questions addressed demographic information; the

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next four questions were about the use of occupation based assessments; the next
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two asked about impairment based assessments; the last two addressed perceptions

and opinions about occupation based assessment and intervention. Nine items
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were multiple choice questions and one was an open ended question. The survey
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received IRB approval from the University of Texas Health Science Center, approval
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from the American Society of Hand Therapists (ASHT) research division, and was

administered via the Survey Monkey platform. An invitation and consent to

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participate in the electronic survey was sent to all current members of ASHT via

email. The message contained a link to the survey. Three weeks later, a reminder
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email was sent. The survey remained open for an additional week, for a total of four
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weeks.

The membership of ASHT consists of both occupational and physical therapists.

The decision was made to include everyone in the survey, since both disciplines

practice in the hand therapy setting and by definition, hand therapy is a merging of

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the two disciplines. In addition, while “occupational performance” is a domain of

occupational therapy, “function” is used synonymously, and is certainly a goal of

physical therapists in the hand therapy setting as well. In addition, occupation-

based assessments are not limited to use only by occupational therapists.

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A total of 2, 830 members, including the U.S. and foreign countries, were sent the

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original email. Of those, 175 were returned as “undeliverable, “ leaving a total of

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2,655 whom it is assumed received the survey invitation.

Data and responses were collected by the Survey Monkey platform. Quantitative

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responses were analyzed by frequency counts and percentages. Qualitative
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responses were coded by themes.
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Results
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Demographics
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A total of 594 members of the American Society of Hand Therapy (ASHT)

completed the survey, which represents a return rate of 22%. Of those, 91% were
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occupational therapists and 9% were physical therapists. Seventy-eight percent

were certified hand therapists and 10% also had another specialty certification. The
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majority of both disciplines had been in practice for more than 20 years (62% of
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OTs and 60% of PTs). Thirty-three percent of all respondents worked in a hospital

based setting, 28% worked in a therapist owned private practice, 19% in a

physician owned practice, 12 % in a corporate owned practice, and 6% in “other”

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settings, which included non-profit, pediatric, academic/medical school, traveling,

and jointly owned therapist/physician. (Tables 1 and 2)

Occupation-based Assessment

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When respondents were asked to estimate how often they use occupation-based

assessments in their practice, 52% said daily, 25% said less than daily but typically

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at least once a week, 8% said several times per month, 3% said once per month, 3%

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said several times per year, and 4% indicated less than once a year. Two percent of

respondents selected the “other,” response. Of these, 2% reported using them only

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at initial and discharge evaluation, 0.7% said with every patient, and 2% reported
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never using them. (Table 3)
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The next question listed eight assessments recognized as occupation-based15 and

asked respondents to indicate the frequency with which they used each one. The
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most frequently used were Activities of Daily Living (ADL) assessments (52% with
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all clients; 23% with most clients), the Quick Disability of Arm, Shoulder, Hand

(Quick DASH) (27% with all clients; 27% with most clients), and the Disability of
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Arm, Shoulder, Hand (DASH) (18% with all clients; 19% with most clients). Of those
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listed, the least utilized were the Assessment of Motor and Process Skills (AMPS)
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(96% never used it), the Canadian Occupational Performance Measure (87% never

used it), and the Jebson Taylor Hand Function Test (69% never used it). For those

who indicated they used other assessments not listed, with either all or most clients,

7% indicated the Upper Extremity Functional Index (UEFI), 3.5% the Patient Rated

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Wrist Evaluation (PRWE), and 3% the Focus on Therapeutic Outcomes (FOTO).

(Table 4)

Respondents were asked to identify reasons they may not be utilizing occupation-

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based assessments as often as they would like. Time limitation was cited as the

most common reason (56%), followed by unfamiliarity with the assessments (24%),

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and availability of the assessments (19%). Other reasons given included the

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difficulty and confusion for some clients in completing these assessments due to

cognition and language; and the cost of the assessments. Several respondents

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commented that, “in all honesty, “ they are just “too narrow minded,” “stuck in the
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their ways,” and “too biomechanical to use them.” (Table 5)

Those who use occupation-based assessments were asked how they use the
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results they obtain from them. The most common uses are for development of goals
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(82%) and to measure changes pre/post intervention (75%). Over half also use
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them for justification of services and to identity a need for services (53%). Many

utilize them for determining intervention methods (43%) and in discussion with
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clients and their families (46%). Several other ways cited for use of the results

included “for research purposes,” and measurement of functional outcomes,

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especially related to Medicare G codes. (Table 6)

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The next question asked respondents to indicate the frequency with which they

use certain impairment-based assessments. The most frequently used are

goniometry/ROM (76% with all clients; 24% with most clients) followed by pain

assessments (85% with all; 11% with most). Next most utilized were pinch strength

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(34% with all, 62% with most) grip strength,(29% with all, 60% with most),

followed by manual muscle testing (18% with all; 46% with most) and

edema/circumferential (16% with all; 50% with most). In contrast, those utilized

the least were Box and Block (91% never used), Bennett Hand Tool Dexterity (89%

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never used), Crawford Small Parts (88% never used), and the Minnesota Rate of

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Manipulation (62% never used). Those most frequently used “with a few” clients

included Sensibility/2 point discrimination (64%), Sensibility/Touch Pressure

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(51%), Edema/volumetric (54%), and the Purdue Pegboard (51%). (Table 7)

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When asked which factors influence their use of impairment-based assessments,
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64% cited time limitation, 52% indicated availability of the assessments, 19% lack

of familiarity with the assessments, and 11% reimbursement issues . Other reasons
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reported included the patients’ diagnosis (3 %), applicability to the patient (5%),
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patients’ goals (3%), and validity/reliability of the assessments (1%). (Table 8)

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The last question asked respondent to agree or disagree with four statements

about their feelings regarding the value and importance of using occupation-based
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measures. Most felt that occupation-based measures are important in a hand

therapy setting (42% strongly agreed; 37% agreed) and that all hand therapy
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practice should include occupation-based measures (41% strongly agreed; 35%

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agreed). Even if not formally measured, most felt they are considering or

addressing occupation based performance in their interventions (58% strongly

agreed; 31% agree). The majority also indicated that the use of occupation-based

measures is valued in their setting (30% strongly agreed; 33% agreed). (Table 9)

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Occupation-based Intervention

The remaining questions were aimed at ascertaining the perceptions of the

respondents about occupation-based intervention. When asked if they believed

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they are utilizing occupation-based intervention in their practice of hand therapy, of

those who answered, 85% said yes, and 17% answered no. In addition, those who

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answered “yes” were asked to describe how. The most common description for the

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use of occupation-based intervention was “simulation” of ADLs, functional activities,

work activities, leisure activities, and sports. Ways in which this is accomplished

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included the use of the BTE and actual use of items that the client brings from home,
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such as musical instruments and tools. Those who answered “no,” were asked to

explain why. The most common reasons cited for not using occupation-based
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intervention included time constraints, lack of space and equipment,

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reimbursement issues, and lack of a “natural” environment.

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Discussion

This survey was conducted to ascertain current attitudes, perceptions, and

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practice of the use of occupation-based assessment and intervention, among

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therapists who work in hand therapy practices. This was done by use of an online
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survey. When searching the literature, there is no consensus on what the

“acceptable” rate of return is for online surveys, but is well documented as less than

paper surveys.17 In recent years, the average response rate for online surveys has

been 31%.18 In comparison to other online surveys of the ASHT membership, the

rate of 22% received on this survey seems to be in the expected range. These other

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studies have had rates of 32% (2009),14 10% (2012),19 21% (2014),20 and 23.5%

(2014).21

Occupation-based Assessment

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In this survey, reasons for not using either occupation-based or impairment-

based assessment, were essentially the same: time constraints, availability of, and

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familiarity with the assessments. Alotaibi, et al.22 found that most assessments used

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in occupational therapy focus on body structure and function, particularly in the

practice areas of pediatrics, geriatrics, physical disability, and hand therapy. They

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reported the most frequently used assessments in the hand therapy setting were
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dynamometry - grip, goniometry, the nine hole peg test, and pinch strength. These

findings are similar to the findings of this survey, which found the highest frequency
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of use for impairment-based assessments was for goniometry and pain assessments
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followed by pinch and grip strength.

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Alotaibi, et al.22 found that the most cited reason for using an assessment was

simply its availability in the clinic, whether it is occupationally based or not. They
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suggested that this practice based on availability versus appropriateness, could

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threaten the values and identity of the occupational therapy profession. They
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concluded that the ideal occupational therapy assessments are “clinically relevant,

functionally oriented, client centered, standardized, and occupationally focused.”

This is in agreement with The World Health Organization International

Classification of Functioning, Disability, and Health (ICF), which now has a focus on

function instead of impairment. Increasingly, the understanding being used in

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health care systems worldwide is that “the ability of the individual to engage in

activities and to participate in society determines the daily functioning of the

individual, as well as a possible disability.”16 It is important to keep in mind that

most of the skill based assessments utilized cannot predict actual functional

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performance by the client nor be used for accurately reporting functional status.

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Since they are performed in a test environment versus “real life”, they actually

measure “capacity” rather than “performance.”16 However, there are studies that

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have explored the relationship of certain occupation-based assessments to the ICF

and have found the DASH, the COPM, and the AMPS are three that are well linked

with it.16,23
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The second most common single reason that therapists gave for not utilizing
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occupation-based assessments was unfamiliarity with the assessments. Several

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studies in the United States and Canada that looked at the use of standardized

assessments5 across all areas of practice found that the lack of knowledge and
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familiarity with the assessments was a primary barrier to using them. It was found
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that therapists felt they would benefit from continuing education on assessments

they may not have learned in school. Findings from this survey may suggest that
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hand therapists could benefit as well, from continuing education in the occupation-
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based assessments most appropriate for the hand therapy setting.

While “ADL assessments” were listed with occupation-based assessments on the

survey, it is important to note that most respondents indicated they are assessing

ADLs informally. They indicated they are doing this most often by interviewing the

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client versus actually observing actual performance. In other words, this is through

conversation with the client about their ADL performance. This self-report method

is, of course, highly subjective and does not qualify as a performance measure. It is

also less consistent and valid than using a self-report tool such as the DASH. The

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occupation-based assessment tools most closely related to ADL function are the

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AMPS and the Jebson Taylor Hand Function test, which were among the least

utilized from the list of occupation-based assessments. These findings seem

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consistent with the survey done recently by Powell and von der Heyde.20 Their

results found that 91% of respondents preferred the use of self-report measures to

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assess ADL performance. They concluded that more adequate assessment of ADL

performance “would assist therapists in recognizing potential pitfalls in their

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patients’ rehabilitation program and outcomes.” Still, the clients’ perception is

valuable24 and these self-report measures coupled with more performance based
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tools may provide the more comprehensive assessment needed. 20,24

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Occupation – based Intervention

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It is encouraging to note that the perceptions of the respondents indicate that

most believe they are utilizing occupation-based intervention in their hand therapy
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practice. The use of occupation-based intervention, especially in the hand therapy

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setting, and its benefits, has been discussed in the literature for several years.1,7,26,27

In spite of the fact that its use has been shown to enhance patient outcomes, 8,10

there is evidence that it is generally not being utilized. Colaianni1 found that the

biggest challenges to using occupation-based intervention are limited time, limited

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space, reimbursement issues, and the perception about its credibility among the

therapists themselves, the clients, and other professionals. These are similar to the

reasons given in this survey as reasons for not using occupation-based assessment.

were time limitation, familiarity with, and availability of the assessments.

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Several representative comments were:

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-ABSOLUTELY. I am an occupational therapist FIRST and then I specialize in

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hand therapy. Occupation is a core tenant of our profession and we are doing

ourselves an injustice by NOT providing occupation based interventions.

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-100%. It drives my goals and encourages the patient to stay involved with

care.
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-Now that I am consulting and on my own, that is all I use.

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-This can be a challenge in hand therapy, but I always see effective results
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when I do so. Equipment and “natural” environment is the challenge. I,

unfortunately, see far too many OT/CHTs doing only PAMs and rote
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exercise—they are missing so much! When I…incorporate a functional task

(usually more demanding than a rote exercise), the client always comments
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that they find it uniquely challenging, and most beneficial.

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For those who answered “no,” they are not using occupation-based intervention, the

most frequently cited reasons were “time” and “too busy.” The next most cited

reasons were space limitations, “no natural environment,” and lack of

equipment/resources. Several representative comments were:

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-No, it is quicker to identify specific limitations and address those.

-No—hand patients respond well to objective increases in ROM and strength.

All use of hands is purposeful and meaningful.

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-No, I am not truly doing occupation based therapy. I am not sure how to

truly bring it into my hand therapy setting. Most patients find exercises

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purposeful to be able to improve their function but I do not believe they

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necessarily find meaning in these activities as much as they would with the

activities they perform at home or work.

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While lack of space and equipment were given as limitations for not utilizing

occupation-based intervention, many participants in this survey have found ways

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around these constraints. Some of the ideas provided included: cooking, cutting

food, food preparation in a microwave; sewing, laundry, folding clothes (most clinics
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have washing machines and towels); money handling; computer use; cleaning
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cabinets, wiping tables, putting dishes on shelves; writing; use of tools (shovels,

hand tools); games; crafts such as macrame, origami, knitting (having the client
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bring in their own craft). These are just some of the activities that can be done in a
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typical hand clinic with little additional space or equipment.

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In the present climate of shrinking reimbursement and competition for

healthcare dollars, therapists have to justify and provide documentation that what

they are providing is valuable. “Providing cost-effective, evidence-based care is the

goal of every professional. One of the most important underpinnings of an

evidence-based occupational therapy practice is the consistent use of outcome

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measures to evaluate occupational therapy service….thus building evidence to

support occupational therapy intervention.”13, 25 This should be one motivation for

utilizing occupation-based assessments, and certainly standardized tools as well.

PT
Since it has been shown that occupation-based intervention in a hand therapy

setting has been linked to enhanced outcomes,12 we as hand therapists may want to

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attempt to incorporate it more in practice where we are able. Many respondents in

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this survey are attempting to do so, in spite of barriers such as time limitation and

reimbursement issues.

Perceptions
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Colaianni and Provident1 asked respondents if there were benefits to using
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occupation as a modality in hand therapy practice and 97% said “yes” and 3% said

“no.” Benefits identified were “facilitating meaningful therapy experiences,

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facilitating functional activities, and facilitating holism.” Similarly, the majority of

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the respondents in this survey (78%) felt that occupation-based measures are

important and that all hand therapy practice should include them (75%). Several
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comments from participants were:

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-Occupation-based assessment and intervention lead to functional outcomes

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and better understanding on patients’ part as to why they are performing

these activities.

-People are more driven if they have a goal to obtain and you can figure out

what their goals are by these assessments.

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-It’s the heart of what we do; even if I am doing impairment-based

treatments, we are talking about the impact of impairment on function; it’s

all that matters in the end.

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- I admit that much of the treatment approach is based solely on the

biomechanical frame of reference. That being said, I feel that these

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approaches have a definitive and necessary place in UE rehabilitation. The

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importance is tying “impairment” into improving “function.”

Limitations

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One limitation of this survey study was that respondents were all members of

ASHT. The survey was open to all members who had an email address, including
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physical therapists. It is unknown exactly how many members actually received the

emailed survey. In addition, most were certified hand therapists. Not all therapists
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who practice hand therapy are members of ASHT or certified, so the results may not
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be representative of all occupational therapists who are providing hand therapy.

Interestingly, the majority of those who did respond had been in practice more than
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20 years. It is possible that they may have different ideas about occupation as a
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“means” and an “outcome” than younger and less experienced therapists. While
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definitions were given in the survey for occupation-based assessments, it seemed

that some respondents at times were not making a distinction between these and

other assessments, in that when asked to list “others”, there was no distinction

made. This could have been due to lack of clarity in the questions as well. Lastly,

another limitation may be that a formal piloting of the survey was not done.

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While the response rate was similar to other online surveys of the membership, it

was less than the average for paper/face to face formats. In the future, it might be

better to distribute a paper survey at an annual meeting, face to face, to increase the

number of participants, or even use a mailed survey, although much more

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expensive.

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Significance of this Study

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In the present climate of shrinking reimbursement and competition for

healthcare dollars, therapists have to justify and provide documentation that what

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they are providing is valuable. “Providing cost-effective, evidence-based care is the
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goal of every professional. One of the most important underpinnings of an

evidence-based occupational therapy practice is the consistent use of outcome

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measures to evaluate occupational therapy service….thus building evidence to

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support occupational therapy intervention.”13, 25 This should be one motivation for

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utilizing occupation-based assessments, and certainly standardized tools as well.

Since it has been shown that occupation-based intervention in a hand therapy

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setting has been linked to enhanced outcomes,12 we as hand therapists may want to
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attempt to incorporate it more in practice where we are able. Many respondents in

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this survey are attempting to do so, in spite of barriers such as time limitation and

reimbursement issues.

Conclusion

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There has been criticism of occupational therapists practicing in the hand therapy

setting for moving away from using occupation as a “means” or modality. It seems

that in spite of the fact that hand therapy utilizes a more reductionist approach,

hand therapists do recognize occupation as having value as a means to the same end

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– function and participation in occupations. However, as found in the results of this

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survey, there are numerous reasons that many are not using occupation-based

assessments and intervention, or are not using them as much as they would like, the

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primary reason being time limitation. Most report they are utilizing occupation-

based assessments in relation to ADL function and for the development of goals.

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Possibly, providing training in these assessments in continuing education courses

may help to increase awareness and familiarity with them among hand therapists.
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Future studies might look more specifically at assessment tools related to just ADL

function, since this seems to be the most common reason hand therapists assess
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function.
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Since function is the ultimate goal and outcome for our clients who receive
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rehabilitation, occupation-based assessments and intervention should be advocated

and utilized, especially in the hand therapy setting, where we are treating the
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primary tool of function—the hand.

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References

1. Colaianni D, Provident I. The benefits of and challenges to the use of

occupation in hand therapy. Occup Ther Health Care. 2010; 24(2): 130-146.

2. Colaianni D. Man, through the use of his hands. Advance for Occ Ther
Practitioners. 2010; 26(15): 12-14.

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3. Dale LM, Fabrizio AJ, Adhlakha P, et al. Occupational therapists working in
hand therapy: The practice of holism in a cost containment environment.

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Work. 2002; 19:135-145.

4. Wood W. It is jump time for occupational therapy. Am J Occup Ther. 1998; 52:

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403-411.

5. Piernik-Yoder B, Beck A. The use of standardized assessments in

occupational therapy in the United States. Occup Ther Health Care. 2013; 26:

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97-108.
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6. HTCC. Definition of hand therapy. Hand Therapy Certification Commission.
2014. Available at htcc.org.
M

7. Fitzpatrick N, Presnell S. Can occupational therapists be hand therapists? Br J

Occup Ther. 2004; 67:508-510.
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8. Royeen CB. Occupation reconsidered. Occup Ther International. 2002; 9:

111-120.
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9. Trombly CA. Occupation. In Trombly CA, Radomski MV, eds. Occupational

Therapy f or Physical Dysfunction. 5th ed. Philadelphia: Lippincott, Williams,
EP

and Wilkins, 2002: 255-297.

10. Christiansen CH, Baum CM. The complexity of human occupation. In

Christiansen CH, Baum CM, eds. Occupational Therapy: Performance,
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Participation, and Well-Being. 3rd ed. Thorofare, NJ: Slack Incorporated;

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2005:339-370.

11. Fisher AG. Uniting practice and theory in an occupational framework. Am J

Occup Ther. 1998; 52: 509-521.

12. Jack J, Estes R. Documenting progress: Hand therapy treatment shift from
biomechanical to occupational adaptation. Am J Occup Ther. 2010; 64: 82-87.

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13. Law M, Baum CM, Dunn W. Occupational performance assessment. In

Christiansen CH, Baum CM, eds. Occupational Therapy: Performance,
Participation, and Well-Being. 3rd ed. Thorofare, NJ: Slack Incorporated;
2005: 3-17.

14. Dimick MP, Caro CM, Kasch MC, et al. 2008 practice analysis study of hand
therapy. J Hand Ther. 2009; 22: 361-376.

PT
15. Asher IE (ed). Occuaptional therapy assessment tools: An Annotated Index. 3rd
ed. Bethesda, MD: AOTA Press, 2007.

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16. Stamm TA, Cieza A, Machold KP, Smolen JS, Stucki G. Content comparsion of
occupation-based instruments in adult rheumatology and musculoskeletal

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rehabilitation based on the international classification of functioning,
disability, and health. Arthritis and Rheumatism (Arthritis Care and
Research). 2004; 51: 917-924.

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17. Sax JL, Gilmartin SK, Bryant AN. Assessing response rates and nonresponse
AN
bias in web and paper surveys. Research in Higher Education. 2003; 44(4):
409-32.

18. Sheehan KB. E-mail survey response rates: A Review. Journal of Computer-
M

mediated Communication. 2001; 1-15. Doi: 10.1111/j.1083-

6101.2001.tb00117.x
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19. Valdes K, von der Heyde R. Attitudes and opinions of evidence-based practice
among hand therapists: A survey study. J Hand Ther. 2012;25:288-96.
TE

20. Powell RK, von der Heyde RL. The inclusion of activities of daily living in
flexor tendon rehabilitation: A survey. J Hand Ther. 2014; 27:23-28.
EP

21. O’Brien VH, McGaha JL. Current practice patterns in conservative thumb
CMC joint care: Survey results. J Hand Ther. 2014; 27: 14-21.
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22. Alotaibi NM, Reed K, Nadar MS. Assessments used in occupational therapy
practice: An exploratory study. Occup Ther Health Care. 2009; 32(4): 302-18.
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23. Drummond AS, Sampaio RF, Mancini MC, Kirkwood RN, Stamm TA. Linking
the disabilities of the arm, shoulder, and hand to the International
classification of functioning, diability, and health. J Hand Ther. 2007; 20:336-
44.

24. Kaskutas V, Powell R. The impact of flexor tendon rehabilitation restrictions

on individuals’ independence with daily activities: Implications for hand
therapists. J Hand Ther. 2013; 26: 22-28.

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25. Velozo CA, Woodbury ML. Translating measurement findings into

rehabilitation practice: An example using Fugl-Meyer Assessment-Upper
Extremity with patients following stroke. J Rehabil Res Dev. 2011; 48:1211-
1222.

26. Colaianni D. The case for holism in hand treatment. Advance for Occ Ther
Practitioners. 2011; 27(22): 8.

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27. Colaianni D. Standardized evals for occupation-based hand therapy. Advance
for Occ Ther Practitioners. 2011; 27(26): 8.

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Table 1. Demographics of Participants n=594

<5 years 5-10 years 11-15 years 16-20 years >20 years
Occupational 22 (4%) 31 (6%) 71 (13%) 81 (15%) 330 (62%)
therapist
n=535 (91%)
Physical 3 (6%) 4 (7.5%) 4 (7.5%) 10 (19%) 32 (60%)

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therapist
n=53 (9%)
Certified hand 62 (13%) 60 (13%) 92 (20%) 79 (17%) 174 (37%)

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therapist
N=467 (78%)
Other 9 (14%) 19 (29%) 20 (31%) 3 (5%) 14 (21%)

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specialty
certification
N=65 (11%)

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Table 2. Employment settings n=594

% n
Hospital based 33 198
Private practice-therapist owned 28 170
Private practice – physician owned 19 114
Corporate owned 12 74

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Other 6 38

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Table 3. Frequency of use of occupation-based assessments n=556

% n
Daily 52 292
Less often than daily, but typically at least once a week 25 142
Several times per month 8 48
Once per month 3 17

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Several times per year 3 18
Less than once a year 4 24
Other 2 13

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Table 4. Frequency of use of specific occupation-based assessments n=556

With all clients With most clients With a few clients Never
ADL assessments 52% 23% 14% 11%
Quick DASH 27% 27% 23% 20%
DASH 18% 19% 35% 28%
AMPS 1% 1% 2% 96%

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COPM 1% 1% 11% 87%
Jebson Taylor 1% 1% 29% 69%
OPH 7% 6% 4% 83%

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FIM 4% 3% 13% 80%
Other:
UEFI 7%

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PRWE 3.5%
FOTO 3%

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Table 5. Reasons for not utilizing occupation-based assessments n=556

% n
Time limitation 56 313
Not familiar with assessments 24 133
Availability of assessments 19 105
Reimbursement issues 8 43

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Other: 30 166
Cost; cognition of client; therapist preference

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Table 6. How results obtained from occupation-based assessments are used n=556

% n
Development of goals 83 459
Measure change pre/post intervention 75 419
Justification for approval of services 65 364
Identify need for services 53 294

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Discuss with client/family 46 253
Determine intervention methods 43 240
Other: 5 29

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Medicare G coding 13
Functional outcomes 8
Reimbursement 6

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Research 1

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Table 7. Frequency of use of specific impairment-based assessments n=554

With all clients With most clients With a few clients Never
Goniometry 76% 24% 0.1% 0%
Pain assessments 85% 11% 4% 0.4%
Grip strength 29% 60% 1% 0%
Pinch strength 34% 62% 4% 0.2%

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Edema /Circumferential 16% 50% 31% 2%
Manual muscle testing 18% 46% 35% 1%
Sensibility – 2 point 3% 17% 64% 15%

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Sensibility – Touch pressure 7% 38% 52% 3%
Edema/Volumetric 2% 8% 54% 35%
Purdue pegboard 0.7% 5% 51% 43%

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Nine hole peg test 4% 15% 48% 33%
Moberg Pick-up test 0.6% 2% 37% 60%
Minnesota Rate of Manip 0.2% 1% 36% 62%
O’Connor Tweezer Dexterity 0.6% 1% 23% 75%

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Crawford Small Parts 0% 0.8% 11% 88%
Bennett Hand Tool 0% .7% 10% 89%
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Box and Block 0.5% .7% 7% 91%
Other: 4% 6% 14%
Valpar; BTE; FCE; Grooved
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Table 8. Factors that influence use of Impairment-based assessments n=554

% n
Time limitation 64 356
Availability of assessments 52 289
Not familiar with assessments 19 105
Reimbursement issues 11 63

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Other: 19 110
cost; applicability, patients’ goals; patients’
diagnosis; validity/reliability

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Table 9. Perceptions about occupation-based measures in hand setting n=540

Strongly agree Agree Neutral Disagree Strongly disagree

Using occupation based 42% 37% 12% 4% 5%
measures is important for
the services provided in
hand therapy setting

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Even if not formally 58% 31% 4% 1% 6%
measured, occupational
performance is

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considered in
interventions with each
client
Use of occupation-based 36% 33% 21% 5% 5%

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measures is valued in my
practice setting
All hand therapy practice 41% 35% 15% 3% 6%

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should include
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• Occupation-based assessments and intervention are not utilized as much as therapists would
like in the hand therapy setting
• Over half of respondents indicate they do use occupation-based assessments daily
• Time constraints are the primary reason cited for not using occupation-based assessments
• Most utilized occupation-based assessments address Activities of Daily Living and are done
informally

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• The majority of those who responded indicated that even if not formally assessed, they feel they
do address occupation in their assessments and interventions

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