Quantitative survey results
Approximately one-quarter of the participants reported utilizing the biomechanical approach in their practice with 90%-99% of their hand therapy clients. Nearly 90% of the participants (n
= 105) used the biomechanical approach with 50% or more of their clients, and all participants reported using the biomechanical approach at least 10% of the time. Approximately one-quarter of the participants reported using an occupation-based approach with at least half of their clients (n =
30). Twenty-five participants reported using a combination approach with over half of their clients (n
= 25). See Table 2
for more details.
Table 2Intervention approaches (n = 117).
Approximately half of the participants routinely screened for psychosocial factors in their clients (n =
56, 48%). Thirty-nine percent of the participants (n =
45) reported that the frequency their clients present with psychosocial factors is at least weekly. Of the assessments grounded in a biomechanical approach, The Quick-Disabilities of the Arm, Shoulder, and Hand (Quick-DASH; n
= 45, 40.9%) and the Disabilities of the Arm, Shoulder, and Hand (DASH; n
= 17, 15.2%) were the 2 most frequented reported assessments used with hand therapy clients. The participants reported that they administer the following assessments at least 75% of the time; the Quick-DASH (n
= 23, 20.9%), followed by the DASH (n
= 9, 8%), Patient-Specific Functional Scale (PSFS; n
= 7, 6.8%), Patient-Rated Wrist and Hand Evaluation (PRWHE; n
= 3, 2.9%), and the Patient Evaluation Measure (PEM; n
= 1, 1.0). See Table 3
for more details.
Table 3Common assessments used in hand therapy.
Note. Totals may not add up to 117 due to non-responses or use of multiple assessments.
BDI = beck depression inventory; DASH = disabilities of the arm shoulder and hand; HADS = hospital anxiety and depression scale; IES = impact of events scale; IES-R = impact of events scale-revised; MHQ = Michigan hand outcomes questionnaire; PC-PTSD = primary care PTSD screen; PEM = patient evaluation measure tool; PRWHE = patient-rated wrist and hand evaluation; PSFS = patient specific functional scale; Quick-Dash = quick-disabilities of the arm shoulder and hand.
Additionally, participants rated the frequency of their use of psychosocial assessments in hand therapy. Eighty participants (68%) responded that they never administer psychosocial assessments. Approximately 4% (n
= 5) of the participants administered the Beck Depression Inventory (BDI) 25% of the time to their hand therapy clients. The participants responded that they administer the Hospital Anxiety and Depression Scale (HADS), Impact of Events Scale-Revised (IES-R), and the Primary Care PTSD Screen (PC-PTSD) less than 10% of the time (n
= 2; 1.8% each respectively). See Table 3
Significant differences were found between the mean frequency of combined biomechanical and occupation-based approaches and participants who worked in an inpatient hospital setting and those who did not (P
< .01). Significant differences were also demonstrated between the participants who worked in a physician's office and those who did not (P
= .01) and between participants in a single setting and those in multiple settings (P
= .01) throughout their occupational therapy career. A significant mean frequency difference (P
= .03) indicated that participants who worked in private practice used an occupation-based approach more often than those who worked in other settings. See Table 4
for further details.
Table 4Mean ratings of percentage of use of intervention approaches by practice setting.
Note. Independent samples t-test. Percentage of Interventional Approach was rated on a 10-point scale: 1 = less than 10%, 2 = within 10%-19%, 3 = within 20%-29%, 4 = within 30%-39%, 5 = within 40%-49%, 6 = within 50%-59%, 7 = within 60%-69%, 8 = within 70%-79%, , 9 = within 80%-89%, 10 = within 90%-99%, 11 = within 100%.
No significant differences were found between the years of experience as an occupational therapist or years of experience as a CHT and the frequency of use of the biomechanical, occupation-based, or combined intervention approaches. Furthermore, no statistically significant relationships were found between gender, age, years of experience as an occupational therapist, or years of experience as a CHT and routine psychosocial screening. However, there was a significant relationship between the participants working in a hospital-owned outpatient setting and routinely screening clients for psychosocial factors (P = .014).
Open-ended survey questions
Participants identified the following 8 categories as indicators of needing to complete a psychosocial screen as part of the care plan: past medical history (n = 84, 77.1%), limited engagement in ADLs (n = 69, 63.3%), failure to progress (n = 27, 24.8%), poor coping skills (n = 19, 17.4%), pain issues (n = 15, 13.8%), limited social support (n = 8, 7.3%), and communication with the client (n = 7, 6.4%). The participants reported screening or addressing these psychosocial factors through the following means: discussing psychosocial factors that influence recovery and participation (n = 100, 91.7%), using a non-standardized observation (n = 32, 29.4%), performing a standardized screen (n = 23, 21.1%), and completing a standardized assessment (n = 12, 11%).
Participants reported that unfamiliarity with standardized assessments (n = 54, 51.9%), time restraints (n = 51, 49.0%), and unavailable preferred assessments (n = 13, 12.5%) were reasons why they limited the administration of assessments or screens that identify psychosocial factors that impact participation in everyday activities. Additional reasons were fear of a client negative response (n = 7, 6.7%), the need to focus on other client factors (n = 4, 3.8%), perceiving that addressing psychosocial factors are outside the occupational therapy scope of practice (n = 4, 3.8%), not covered for reimbursement with worker's compensation clients (n = 4, 3.8%), wanting to build therapeutic rapport (n = 3, 2.9%), and lack of reimbursement for assessment administration (n = 3, 2.9%).
Participants were asked what interventions they use when clients present with psychosocial factors that negatively impact their functional outcomes. Participants reported that referring for mental health support (n = 68, 62.4%) is an intervention they use followed by educating the client on effective coping strategies and pain management (n = 66, 60.6%). The remaining responses were using cognitive behavioral therapy (CBT) techniques (n = 26, 23.9%), building rapport (n = 21, 19.3%), communicating with the client and the health care team (n = 17, 15.6%) identifying support network and community resources (n = 12, 11%), using graded motor imagery (n = 6, 5.5%), and referring the client to alternative therapies (n = 3, 2.8%).
Five themes emerged from the focus group including hand dysfunction impacts roles and routines, client rapport building takes time, certified hand therapists are hesitant to address psychosocial factors, standardized assessments need to evaluate psychosocial factors that impact client function, and education and communication are critical intervention approaches.
Hand dysfunction impacts roles and routines
Participants identified that clients may experience role changes following a hand injury due to psychosocial factors. One participant stated that their client could no longer provide caregiving to their aging parents, and another client was unable to fulfill his role working in a manufacturing plant due to anxiety symptoms when returning to the site of where his injury occurred. Participants further identified stress, fear, shame, and embarrassment as responses observed in some clients with hand injuries. Further, participants stated that symptoms associated with PTSD, anxiety, and depression are also occasionally noticed. The psychosocial sequelae were viewed as contributors to avoidance of participation in everyday activities including intermittent therapy attendance. One participant shared how their client was unable to perform her normal ADLs, such as playing with her grandchildren and hiking due to psychosocial factors. Another participant shared the story of a client who was not able to wear the clothing she wore the day of her injury because it elicited a post-traumatic stress reaction. Another participant shared the story of one of their clients whose participation in therapy decreased due to symptoms of depression.
Client rapport building takes time
Focus group participants discussed their evaluation process and assessment of their clients’ psychosocial factors that negatively impact roles, routines, and occupations. Participants indicated the need for therapists to build a rapport with clients before addressing psychosocial factors. One participant stated that she uses the therapeutic use-of-self to help clients relax. Another participant stated that they first establish a rapport with their clients before asking sensitive questions regarding psychosocial factors. When clients avoid answering questions regarding psychosocial factors on intake forms, participants stated that therapists should take note of the questions left blank so that they can become alert to signs related to psychosocial factors throughout the therapeutic process. If, on subsequent visits, the therapists observe client behaviors that indicate psychosocial factors that impact function, the therapists can then address the psychosocial factors that they have observed. One participant, however, responded that she immediately addresses psychosocial factors as they are presented by the client.
CHT hesitation to address psychosocial factors
Consensus showed among the focus group participants that acknowledging clients’ psychosocial factors is pertinent for holistic care. However, participants stated that they are hesitant to address psychosocial factors during the therapeutic process. One participant explained that physicians are opposed to therapists addressing psychosocial factors because clients are referred to therapy to address their neuromusculoskeletal limitations, not psychosocial factors. Likewise, another participant indicated that payers of worker's compensation cases are reluctant to pay for services focused on psychosocial factors.
Standardized assessments need to evaluate psychosocial factors that impact client function
Participants identified common assessments they administer in practice which included: Quick-DASH, PSFS, Orebro Musculoskeletal Pain Questionnaire (OMPQ), Pain Catastrophizing Scale (PCS), and the Tampa Scale of Kinesiophobia (TSK). They choose assessments based on their clients’ needs. However, consensus among the participants indicated that there is a lack of standardized assessments that solely identify psychosocial factors related to participation in everyday activities.
Education and communication are critical intervention approaches
Participants discussed interventions they implement when clients present with psychosocial factors. They educate clients on effective coping strategies and pain management. One participant indicated that it is important for therapists to empathize, encourage, and calm clients’ fears. Further, participants stated that it is imperative to educate clients on how psychosocial factors and pain can negatively influence participation in everyday activities. The participants discussed providing clients with community resources for mental health counselors or referring clients to mental health counseling as being important interventions. Participants also valued communicating with the physician regarding observations. Like in the open-ended survey results, one participant responded that she finds it effective to engage her clients in graded activities or graded motor imagery.
Mixed method results
For this study, a mixed-methods design was used to collect and analyze the data. Integration of the quantitative and qualitative results allowed for the identification of a connection between the phases.
- Creswell JW
- Plano Clark VL
Designing and Conducting Mixed Methods Research.
Having a qualitative component, such as the focus group, was beneficial for expanding upon the survey's data. Responses from this study's focus group supported the survey results and answered all research questions.
In the identification of assessments that the participants administered in their practice, there was a contraindication between the quantitative and the qualitative data in that the results of the survey's qualitative questions only identified 2 of the 5 assessments typically administered by therapists in hand therapy: Quick-DASH, PSFS. Additionally, 2 routinely administered assessments, the OREBRO and the TSK were not asked about in the survey but were both identified by one focus group participant. None of the participants in the focus group identified that they administer any of the commonly administered psychosocial assessments presented in the survey. Two participants responded as using the PCS when appropriate. A key finding from the focus group is that there is a need for a standardized assessment tool that focuses on psychosocial factors related to participation in everyday activities.
Regarding the assessment of psychosocial client factors, the survey participants indicated that, during the evaluation process, psychosocial factors are identified by clinical observation, screening, formal and informal assessments, and communication with the clients. The participants in the focus group expanded upon this by describing how hand injuries can negatively affect their clients’ participation in everyday activities and roles, such as a worker, family member, or caregiver. However, before psychosocial factors can be addressed, both survey and focus group participants emphasized the importance of utilizing therapeutic use-of-self to build rapport with their clients.
Results from both the focus group and the survey indicated that education and communication were the interventions most used with clients who had psychosocial factors related to their condition. Additionally, participants in both the survey and focus group stated that they use CBT techniques, refer clients to a mental health counselor, educate clients on effective coping strategies and pain management, and communicate with physicians regarding psychosocial factors observed.