Alignment of Outcome Instruments Used in Hand Therapy With the Occupational Therapy Practice Framework: Domain and Process and the International Classification of Functioning,Disability and Health: A Scoping Review

Literature Review

Although occupational therapy practitioners who specialize in hand therapy have advanced competencies and expertise relevant to the upper extremity, the focus of their intervention and outcomes remains aligned with the core concerns of occupational therapy: occupational competence and purposeful engagement in life activities. Occupational therapy practitioners are trained in evaluating the occupational strengths and needs of clients, the contexts and environments in which occupations occur, and clients’ personal and social factors, enabling them to provide therapeutic interventions that prevent decline and restore occupational competence.

Outcome instruments in hand therapy practice often include measures of physical impairment such as range of motion (ROM), strength, edema, pain, and sensation; other instruments measure patient-reported outcomes (PROs) and performance-based outcomes. The practitioner selects the most appropriate instrument, whether a physical impairment measure, PRO measure, performance-based instrument, or combination, on the basis of clients’ needs and goals, congruent with the practitioner’s theoretical model of practice and knowledge of the instrument’s psychometric properties and protocols.

Although some PRO instruments are body region specific (e.g., Patient-Rated Wrist Evaluation; MacDermid, Turgeon, Richards, Beadle, & Roth, 1998), other PRO instruments focus on satisfaction with and prioritization of specific occupational domains such as self-care, productivity, and leisure (e.g., Canadian Occupational Performance Measure [COPM]; Law et al., 2005). Still other PRO instruments focus on specific daily tasks such as driving, fastening buttons, and opening a jar (e.g., Upper Extremity Functional Index; Stratford, Binkley, & Stratford, 2001). PRO instruments gather valuable subjective information about a client’s perceptions of success and goal attainment, such as confidence, self-efficacy, sustainability in valued occupations, and overall health and well-being (AOTA, 2014).

Performance-based outcome instruments differ from PRO instruments in that they include direct observation of a client’s performance. For example, the Jebsen–Taylor Hand Function Test (Jebsen, Taylor, Trieschmann, Trotter, & Howard, 1969) measures unilateral hand function by having the client perform the activities of writing, card turning, picking up small objects, stacking checkers, simulating feeding, and moving light and heavy objects; scores reflect speed but not quality of performance.

Several studies have examined the link between outcome instruments and predictability of function. Spieler, Barth, Burton, Himmelstein, and Rudolph (2000) examined the evaluation process for people with permanent impairment and found that the degree of impairment identified by physical impairment measures did not accurately portray the severity of disability or how limited people were functionally. Michener and colleagues (2001) examined people with hand trauma and determined that more than one variable predicts hand function. Thus, multiple methods of collecting information should be used in measuring aspects of the domain influencing engagement and performance (AOTA, 2014; Majnemer, 2009). Although some potential barriers to integrating outcome assessments into clinical practice include high burden for clients (e.g., time consuming, difficult to complete independently) and for clinicians (e.g., difficult to score), the benefits of using outcome instruments include enhanced communication with clients and payers, improved documentation of patient outcomes, and guidance in directing patient care (Shanahan, 1992; Valdes et al., 2014).

Very little of the published literature on hand and upper-extremity rehabilitation reflects current views on measuring disability, and clinicians often fail to measure outcomes with tools designed to measure the complex question of human performance. The purposes of this scoping review were threefold. The first purpose was to identify which outcome instruments are frequently used by occupational therapists in the area of hand therapy. Second, we explored the link between the constructs of the ICF (body functions, activity and participation, and environment) and the Framework (body functions, activity and participation, and context and environment) and the constructs addressed in each identified outcome instrument. Finally, we examined gaps in the constructs measured by the outcome instruments as a basis for making recommendations for clinical practice and future research.

Method

This scoping review was conducted between July 2013 and January 2014. No repeat searches were conducted. The methodological framework included four distinct steps: (1) retrieval of each publication identified from the search, (2) screening of the title and abstract, (3) review of the abstract for eligibility, and (4) review of the article.

Results

As shown in Figure 1, the search identified 7,267 potentially relevant publications, of which the majority were excluded on the basis of title and abstract alone. A total of 65 titles and abstracts were identified as potentially fitting the inclusion criteria and underwent the abstract eligibility process. The abstract review resulted in 16 articles that fit the inclusion criteria. The excluded publications and reasons for exclusion were recorded.

OPEN IN VIEWER

Figure 1.

Flow chart of the article selection process.

In the 16 reviewed articles, 18 outcome instruments were identified. The Michigan Hand Outcomes Questionnaire (MHQ; University of Michigan, 1998) was identified in 4 of the 16 (25.0%) articles. The Jebsen–Taylor Hand Function Test (Jebsen et al., 1969) and the Disabilities of the Arm, Shoulder and Hand (DASH; Institute for Work and Health, 2006a) were each identified in 2 (12.5%) articles. The SF–36 Health Survey (Ware, Kosinski, & Gandek, 2005), Nine-Hole Peg Test (Mathiowetz, Volland, Kashman, & Weber, 1985), Work Limitations Questionnaire (Lerner, Amick, & Glaxo Wellcome, 1998), Employee Comfort Survey, Button Board (from the Arthritis Hand Function Test; Backman, Mackie, & Harris, 1991), Quick DASH (Institute for Work and Health, 2006b), COPM (Law et al., 2005), FIM™ (Uniform Data System for Medical Rehabilitation, 1997), Self-Liking/Self-Efficacy Scale, Role Checklist (Oakley, 2006), Health Assessment Questionnaire (Fries, Spitz, Kraines, & Holman, 1980; Tafarodi & Swann, 1995), Moberg Pickup Test (Ng, Ho, & Chow, 1999), Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire (PROMIS–HAQ; Choi et al., 2012), Functional Dexterity Test (Aaron & Stegink Jansen, 2003), and Task Questionnaire (Boynton & Darragh, 2008) each were identified in 1 of the 16 (6.3%) articles.

Physical impairment measures such as edema, pain, ROM, sensation, and strength were also evaluated and reported. ROM was reported in 11 of the 16 (68.8%) articles; the majority (9 of 11, or 81.8%) of articles reported ROM in conjunction with another outcome instrument. Strength was reported in 5 of the 16 (31.3%) studies and pain in 3 (18.8%) studies, all in conjunction with another outcome instrument. Edema and sensation were each reported in 1 (6.3%) study. Edema measurements were not reported in conjunction with another outcome instrument; sensation was reported in conjunction with two outcome instruments (DASH and MHQ).

Overall, 3 of the 16 (18.8%) studies included a physical impairment measure (ROM, strength, pain, edema, sensation) without the use of another outcome measure. One study used neither an outcome instrument nor a physical impairment measure.

Discussion

This scoping review identified outcome instruments used by occupational therapy practitioners in the field of hand therapy and examined the degree to which the instruments are aligned with core concerns of occupational therapy. The degree of alignment was determined by asking reviewers who were occupational therapists to identify the ICF and Framework constructs the instruments measured on the basis of the description of the instrument, presentation of results, and discussion in 16 published articles. The results indicate that assessment of clients in hand therapy focuses primarily on body structures and functions and activity performance, including ADLs, work, and leisure, with less attention paid to assessment of the personal, social, and virtual dimensions of participation and to assessment of the environment.

Selection and use of appropriate outcome instruments are important because the constructs measured allow clients, third-party payers, and other stakeholders to accurately ascertain the impact of occupational therapy intervention on occupation-based activities and participation. The use of psychometrically sound outcome instruments fabricated using constructs from the ICF and Framework reflects a view of health and wellness as complex and multidirectional and enables practitioners to evaluate and report outcomes in relationship to occupation. In this way, practitioners can communicate to third-party payers and other stakeholders an accurate understanding of occupational therapy and its outcomes in terms of function and participation, resulting in continued reimbursement for these skilled services.

The MHQ was the most commonly used instrument. The MHQ is a PRO measure of a client’s perception of strength, sensation, joint mobility, and hand and wrist usability; specifically, clients rate their perception of the following:

Finally, the MHQ includes several questions about race and ethnicity, past and current employment, level of education, and family income.

Although the MHQ is well aligned with the construct of occupation, including clients’ perceptions of both unilateral and bilateral functional activities, reviewers agreed on only two of the four articles as addressing the Framework construct of ADLs and one of the four articles as addressing the ICF construct of self-care. Appearance and its effect on social, public, and community interactions are addressed in four questions of the MHQ (e.g., “the appearance [look] of my left hand sometimes made me uncomfortable in public,” “the appearance [look] of my left hand interfered with my normal social activities”). Surprisingly, there was no agreement among reviewers that the ICF domains of social, community, and civic life and interpersonal interactions and relationships were addressed in these articles. In fact, reviewers identified these areas as constituting a potential gap in constructs examined by existing instruments.

The five performance-based measures identified in the articles were designed to assess hand function, arm function, or both. The Jebsen–Taylor Hand Function Test is a norm-referenced, timed measure of unilateral hand function. The items are designed to simulate everyday activities and include writing (copying) a 24-letter sentence, turning over 3-in. × 5-in. cards (simulated page turning), picking up small common objects, simulating feeding using a teaspoon and five kidney beans, stacking checkers, picking up a large light object (empty tin can), and picking up a large heavy object (full tin can weighing 1 lb). All three reviewers agreed that the instrument assesses the ICF constructs of neuromuscular and movement functions and general tasks and domains; two reviewers also reported that it assessed the Framework construct of ADLs. Although items were designed to simulate ADLs, no study has correlated scores with actual performance of ADLs; thus, caution must be used when making assumptions about activity performance on the basis of results using this measure.

The DASH is a commonly used PRO instrument that addresses both unilateral and bilateral hand and upper-extremity function. Items include questions related to ADLs such as washing one’s back and donning a pullover sweater; IADLs such as opening a tight or new jar, turning a key, making a bed, and preparing a meal; and social participation, including “to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbors or groups?” (Institute for Work and Health, 2006a). In this study, all three reviewers agreed that the DASH evaluated the Framework construct of ADLs and IADLs; only one reviewer reported that the DASH evaluated the ICF construct of social, community, and civic life.

In a format similar to the DASH, the Work Limitations Questionnaire assesses how health problems interfere with clients’ ability to perform roles within their job. Items include time management, physical demands (strength, endurance, coordination), mental functions, cognition, and socialization (e.g., being able to interact with people on the job). All three reviewers agreed that this instrument addresses ADLs, IADLs, and physical environment; however, only one reviewer stated that social participation is addressed by this instrument.

The COPM and the Role Checklist are two measures designed by occupational therapists. The COPM is a semistructured interview with items related to the three main constructs of (1) self-care (personal care, functional mobility, community management), (2) productivity (paid and unpaid work, household management, play, education), and (3) leisure (quiet recreation, active recreation, socialization). None of these constructs was identified consistently by reviewers. In fact, with respect to the Framework, the education, play, and social participation constructs were reported by only one of the three reviewers. Although the COPM does not address neuromusculoskeletal and movement body functions, one reviewer reported these constructs as included in the Framework data and two reviewers reported them as included in the ICF data.

Using the Role Checklist, clients identify major roles in their life as completed in the past, engaged in at present, or predicted for the future. They then document how important each role is in their life, from not at all valuable to very valuable. Reviewers identified this instrument as including the social, personal, and temporal constructs of context and environment and the activity construct of rest and sleep when the instrument does not address these constructs. Reviewers were, however, accurate in identifying the remaining activity constructs measured by the Role Checklist.

The PROMIS–HAQ is a self-report instrument that assesses ADL and IADL difficulty; reviewers, however, were unable to identify these constructs in the single article that used this measure. Reviewers reported only neuromusculoskeletal and movement functions and the physical environment as being addressed by this instrument.

Given the intense focus on neuromusculoskeletal function in hand therapy, it is not surprising that the studies included in this scoping review focused primarily on body functions and activity. With the exception of one article (Landa-Gonzalez & Molnar, 2012), each study had a focused question specific to the hand and its use in ADLs. Landa-Gonzalez and Molnar (2012) reported on the only study that evaluated the effectiveness of occupational therapy across the spectrum of constructs.

Several unexpected findings require further attention. First, we did not anticipate that reviewers’ interpretations of what the instruments measured would vary so widely. As an example, the FIM, which is one of the most widely used instruments in rehabilitation in the United States, is a measure of “burden of care.” FIM items that address mobility, self-care, communication, and cognition are scored on a scale from 1 (dependent) to 7 (independent). Reviewers indicated that the FIM evaluates not only ADLs but also IADLs, work, leisure, social participation, and rest and sleep, as well as context and environmental constructs including the personal, temporal, physical, and social domains (Table 3).

The finding that reviewers differed in their interpretation of what an instrument measures and, at times, were inaccurate in their assessment was not anticipated. The results might have differed if we had provided the original instruments or had educated the reviewers about each of the instruments identified. Nonetheless, the findings suggest that occupational therapists who use instruments may not fully understand the design and intent of the instruments, which may lead to over- or underinterpretation and misuse. A post hoc analysis was added as a third phase of data management and synthesis to compare reviewers’ responses with the constructs actual measured by each identified instrument. Table 3 summarizes reviewers’ report of Framework constructs measured compared with constructs actually measured. Further work, in particular with respect to education, is needed to make sure occupational therapy practitioners have an accurate and full understanding of outcome instruments.

Limitations

Several limitations of this study must be considered in the interpretation of the results. First, the guidelines for scoping review methodology are inexact. Therefore, although we applied a standardized scoping review protocol, the results of the search strategy may not be reproducible. Second, this study was limited by the number of databases searched (four). Searching additional databases might have resulted in more articles to review, yielding additional outcome instruments. Third, reviewers varied in their interpretation of what constructs the instruments measured, likely because they were not provided with the actual instruments. Although the identified instruments were familiar to and used in practice by some of the reviewers, providing reviewers with the actual instrument would have increased rater clarity. Last, although we selected reviewers with various clinical backgrounds and experience, additional reviewers would have offered alternative perspectives.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:

Conclusion

This scoping review revealed that occupational therapy in the specialty area of hand therapy focuses primarily on body functions and ADLs and underevaluates areas related to participation and environment. This scoping review revealed a need for continued research related to the outcome measures used in the evaluation and treatment of injuries to the hand and upper extremity. Occupational therapists who specialize in the area of hand therapy are encouraged to reevaluate the alignment between their practice and the outcome instruments they select. Use of psychometrically sound outcome instruments to monitor client progress and participation reflects adherence to evidence-based decision making.