Documenting Progress: Hand Therapy Treatment Shift

From Biomechanical to Occupational Adaptation

Jada Jack, Rebecca I. Estes

KEY WORDS
arthritis
exercise therapy
hand
human activities
patient-centered care
postoperative care

The investment of time and self to develop therapeutic relationships with clients appears incongruent with todays
time-constrained health care system, yet bridging the gap of these incongruencies is the challenge therapists
face to provide high-quality, client-centered, occupation-based treatment. This case report illustrates a shift in
approach from biomechanical to occupational adaptation (OA) in an orthopedic outpatient clinic. The progress
of a client with lupus-related arthritis who was 6 days postsurgery is documented. The intervention initially
used a biomechanical frame of reference, but when little progress had been made at 10 weeks after surgery, a
shift was made to the more client-centered OA approach. The Canadian Occupational Performance Measure was
administered, and an OA approach was initiated. On reassessment, clinically important improvements were documented in all functional tasks addressed. An OA approach provides the bridge between the application of clinical
expertise, client-centered, occupation-based therapy and the time constraints placed by payer sources.
Jack, J., & Estes, R. I. (2010). Documenting progress: Hand therapy treatment shift from biomechanical to occupational
adaptation. American Journal of Occupational Therapy, 64, 8287.

Jada Jack, OTR/L, is Private Contract Occupational

Therapist, Sequim School District, 503 North Sequim
Avenue, Sequim, WA 98382; jadajack@gmail.com
Rebecca I. Estes, PhD, OTR/L, ATP, is Department
Chair and Associate Professor, Department of
Occupational Therapy, University of South Alabama,
HAHN #2027, 307 North University Boulevard, Mobile,
AL 36688.

eloquin(1990)notedthatmechanicalexpertiseandskillweretheprimaryfocus
ofoccupationaltherapycurriculaandobservedthatthroughthesixthedition
ofWillard and Spackmans Occupational Therapy,nochapterdiscussedthetherapeuticrelationshipormadereferencetothetermsrapport,relationship,empathy,or
trust.Overthepast20years,therehasbeenanawarenessoftheneedforashiftin
focusbacktoourcaringrootstoincludeamoreholistic,client-centeredapproach
thatcouldsupplementthestrongmanualskillsofmorebiomechanicalapproaches
(Chan&Spencer,2004;Daleetal.,2002;Peloquin,1993).Fortherapiststotruly
demonstratecare,therapeuticrelationshipsmustbeformed.Thisinvestmentof
timeandselfappearsincongruentwithtodayshealthcaresystem,inwhichproductivityisparamountandtreatmenttimeiscurtailed,yetaccountabilitytoboth
patientandpayersourcesisessential.Inthiseraofmanagedcare,handtherapyis
increasinglyperceivedasapracticeareainwhichmechanicalskillmustoftenovershadowclient-centeredapproachestomeethealthinsurerdemands.Bridgingthese
incongruenciestoprovideskilled,holistic,client-centeredcareisthechallengethat
everypracticingtherapistfaces.Individualized,occupation-basedtreatmentina
hand therapy setting has been linked to enhanced patient outcomes (Chan &
Spencer,2004);however,concreteexamplesdocumentinghowtherapistscanshift
fromamechanistictoaclient-centeredandoccupation-basedapproachhavenot
beenpublished.Thiscasereportprovidesanovelillustrationofhowtheshiftfrom
astrictlybiomechanicaltoaclient-centered,occupation-basedapproachinhand
therapypracticecanbemadetoenhancepatientoutcomes.
The occupational adaptation (OA) framework (Schkade & Schultz, 1992;
Schultz&Schkade,1992)providesabasisforpatientcareregardlessofsettingand
addresses the need for a more client-centered, holistic approach by fostering a

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January/February 2010, Volume 64, Number 1

c lienttherapist relationship that facilitates the patients

adaptationandownershipoftreatmentgoalsandprogress.
TheseconceptsareembeddedintheOccupational Adaptation
Guides to Practice(Schultz&Schkade,1992)fromthedatagatheringstage,whenthepatientsevaluationisviewedholistically,andincludesobtaininginformationonthepatients
performance,abilitytoadapt,environments,roles,andoccupations.Datagatheringisalsoclientcentered,seekingpatient
and significant others input on concerns, goals, level of
desiredoccupationalperformance(efficiency,effectiveness,
andsatisfaction),andapproachtoadaptation.
BycomparingtheOAmodeltothetypicalbiomechanicalrehabilitationmodelappliedtopatientsrecoveringfrom
hipfracture,JacksonandSchkade(2001)demonstratedthat
patientsbenefitwhentheOAframeworkisused.Application
oftheOAframeworkimprovedpatientoutcomeefficiency
andgeneratedhigherpatientsatisfactionratingswhencomparedwithperformanceandratingsusingthebiomechanical
model.Providingoccupationaltherapyservicesunderthe
OAframeworkcanbebothanartandaskillexecutedwith
methodandprecision,whileprovidingthecollaborativecare
demanded by this generation of consumers (Schultz &
Schkade,1992).
Thepurposeofthiscasereportwastoillustratethata
shiftinframesofreferencefromabiomechanicaltoanOA
approach in an orthopedic outpatient clinic can facilitate
adaptation,improvepatientmotivation,andprovidedocumentationofclinicallysignificantfunctionalprogress.This
casereportpresentsacomplicated,orthopedic,postsurgical
patientwhopresentedwithseverelydeformedbilateraldistal
extremitiesaftermultiplesurgicalinterventions.TheconductofthiscasereportwasapprovedbytheTexasWomans
UniversityInstitutionalReviewBoard;thepatientprovided
informedconsenttobepartofthisstudy.

Client History
Toprotectconfidentiality,thepseudonymSusanwasused.
Susan was diagnosed with lupus at age 16; lupus-related
arthritis resulted in significant joint deformities to both
hands(seeFigures1and2)andfeet.Althoughthephysical
limitationsresultingfromthesedeformitiesdidnotprevent
Susan from participating in daily activities, she reported
havingagreatdealofdifficultygrowingupwiththediagnosis.Sheidentifiedherpositiveattitudeandsheerdeterminationastwoofhergreatestassets.Susanwasa51-year-old,
divorced mother of two children. She and her children
sharedasingle-level,three-bedroomhomeinaruralnorthwesterncommunity.Sheprovidedfinanciallyforherfamily
throughdisabilitybenefitsandstatefunds,andreceived143
hrpermonthofpersonalcaregiverassistance.

Figure 1. Volar view of (B) hands.

Figure 2. Dorsal view of (B) hands.

Initial Evaluation
Oninitialevaluation,Susanpresentedwithabulkydressing
onherleftdistalforearmandhand.Only6daysprior,she
had undergone simultaneous left thumb interphalangeal
jointhardwareremovalandarthrodesisrevision,leftopen
carpaltunnelreleaseandsynovectomy,leftradiusscapholunatefusion,andaleftindexfingerflexordigitorumsuperficialistoflexordigitorumprofundus(FDP)tendontransfer.
Susan also identified a history of emphysema but denied
furthermedicalcomplicationsorotherdiagnoses.
Afterthepatientinterview,herbulkydressingwascut
away to reveal healing, blood-crusted suture lines with no
abnormalerythemaordrainagenoted.Typicalmeasurements
were taken of the incisions; all sites presented moderately
tendertopressure.Susanslefthandrestedinadependent
flexedposturewithherwristinneutral.Goniometricmeasurements were taken on her left index finger metacarpal
joint;inactiverangeofmotion(AROM),shedemonstrated
a20extensionlagand50offlexion.Astraightfistmeasured
4cmfromfingertipstoproximalpalmarcrease.Noother

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83

ROMmeasurementsweretakenatthistimebecauseshewas
lessthan1weekpostoperative.Thefigure-8edemameasurementwastakenofthelefthandandnotedas36cm;32cm
wasnotedontherightforcomparison.Susanwasinitially
placedinaforearm-basedvolarrestingsplintwithherleft
thumbanddigitspositionedforcomforttosupport,protect,
andimmobilizethejointsduringthehealingprocess.
Problemsidentifiedontheinitialoccupationaltherapy
evaluationincludedpittinghandedema,decreasedROMin
alldigits,increasedpain,anddecreasedfunction.Susanwas
scheduledforoccupationaltherapyservicestwiceperweek
for6weeks,formodalities,manualtherapies,andtherapeutic exercise to address treatment plan goals. The patients
verbalizedgoalsnotedatthetimeoftheinitialevaluation
includedthedesiretobeabletoresumeplayingFrisbeewith
improvedgripandtheabilitytoresumenormalactivitiesof
dailyliving(ADLs)thatshehadbeenabletocompletebefore
surgery. The following short-term goals were established:
Patientwill(1)beindependentinhomeexerciseprogram
within4weeks,(2)demonstrate2-cmdecreaseinedema
usingfigure-8measurementwithin4weeks,(3)demonstrate
well-healedincisionswithmaturingflatscartissuefreeof
tetheringwithin4weeks,and(5)demonstratestraightfist
1.5cmfromproximalpalmarcreasewithin4weeks.Longtermgoalswereestablishedasfollows:Patient(1)willhave
theabilitytogrippantstopullthemupindependentlyin8

weeks,(2)willhavetheabilitytomanipulateandopenpill
jarsin8weeks,(3)wouldliketohavetheabilitytoresume
playingFrisbeewithimprovedgrip,and(4)wouldlikethe
abilitytoresumenormalADLsthatshewasabletocomplete
beforesurgery.

Treatment
Occupationaltherapyserviceswereinitiallyprovidedunder
thebiomechanicalframeofreferencewithaheavyemphasis
onprotectingthesurgicalinterventions;gainingandmaintainingbothAROMandpassiveROM(PROM);andreducingpresentedema,promotingwoundhealing,andproviding
scar management (see Table 1). Treatments consistently
included modalities, retrograde massage, and manual scar
mobilizations as well as therapeutic exercises. Dressing
changesanddebridementofwoundswereperformedasnecessary.Splintmodificationswereperformedasedemasubsided,andpressureareaswerenoted.Susanwasseeninthe
clinicsevenofeightscheduledvisits;onlyoneappointment
absenceoccurredwithinthefirst5weeksofcare.
Fiveweeksaftersurgery,afollow-upoccupationaltherapyassessmentwasperformedbecauseofpoorglideofthe
transferredindexfingerFDPtendon.Susanreportedintermittentpainwithincreasedfrequencyandlengthofduration
associatedwithswellingoftheleftindexfingerafterherhome

Table 1. Schedule of Intervention Activities and Treatment Focus

Biomechanical Focus
Postoperative Week

Evaluation/reevaluation

Shift of Focus
5

Occupational Adaptation Focus

10

Canadian Occupational Performance Measure

Ultrasound in water

Functional electrical stimulation

13

14

Range of motion of digits

Passive

Active

Range of motion of wrist

Active assisted

Active assisted

15

Scar mobilization

Dressing changes
Debridement
Splint fabricationmodification

12

Modalities
Hot pack

Manual therapies
Retrograde massage

11

Buddy tape

Occupation-based tasks
Functional activity performance

Compensatory techniques

Adaptive equipment training

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January/February 2010, Volume 64, Number 1

exerciseprogram.Shewasabletodemonstrateindependence
withherhomeexerciseprogramandverbalizedprecautions
independently.Thetherapistsobjectivefindingsincluded
healingscartissuewithlimitedmobilityatthedorsaland
volarwristincisionsitesandslowhealingatthethumbinterphalangealjoint.Oftheestablishedshort-termgoals,Susan
met two by independently performing her home exercise
programandbypresentingwitha2-cmdecreaseinhand
edema. However, tethering scar tissue and an inability to
makeastraightfistpreventedherfrommeetingtheother
two goals. The therapists assessment identified minimal
FDPfiringbutnotedthattheindexfingersdistalinterphalangealjointwasfirmwithcontraction.Thisconditionwas
attributedtoheavyscarringattheincisionsites.Itwasalso
notedthatSusanwascompensatingwiththelumbricalsat
themetacarpalphalangealjoint.Hertreatmentwaschanged
to include the use of continuous ultrasound followed by
continued aggressive scar massage to reduce adhesions.
Functional electronic stimulation, which simultaneously
blockedthelumbricalsfunction,wasaddedafterscarmassagetoaidintendonpullthrough.AnAROM,active-assisted
ROM,andPROMhomeexerciseprogramandsplintingfor
protectionwerecontinuedasappropriateuntilSusanwas
dischargedfromoccupationaltherapy(seeTable1).
Susanattendedanadditionalsevenofeightscheduled
appointmentswithoneabsenceoverthenext5weeks.She
verbalizedcompliancewithallinstructedtasksbutreported
discouragementinthepoorprogressshefeltshehadmade
regardingherscarmobilityandROM.Nineweeksafterthe
operation,buddytapewasissuedtoaddressanulnardriftof
Susansleftindexfingeroverherlongfingerduringcompositeflexion.Oneweeklater,atthe10thweekpostoperative
progressreport,wefoundthatminimalimprovementscould
be documented. Objective findings identified poor tissue
mobilityatallincisionsites.Weassessedthepatientsfunctionalgraspsthroughherabilitytopickupsmallobjects,
suchasbuttons;however,shewasunabletoholdthemin
thepalmofherhand.Shewasunabletoholdaknifetocut
foodandunabletogripamugwithherlefthand.ThetherapistencouragedSusantocontinueherhomeexerciseprogram,aggressivescarmassage,andbuddytapeasastablepost
forherindexfingertopushagainstduringtaskperformance.
Thelong-termgoalinitiallyestablishedtoaddressimproved
Frisbeethrowingskillwasdiscontinuedatthistime.Other
establishedfunctionalgoalsremainedinplace.
Afterthe10thweek,Susanagainexpresseddiscouragementwiththesmallobjectivegainsdocumented.Sheshared
herthoughtsthatalthoughonlysmallgainswereseeninthe
documentation,thesamesmallgainsoftenresultedinmajor
shiftsinheroccupationalperformance.Shewasdisappointed
thatheroccupationalperformancegainswerenotreflected

inthebiomechanicalgoalsorbiomechanicalmeasures.We
decidedthatashiftinframesofreferencetoamoreclientcenteredapproachwasneeded.Researchsupportsthatwhen
theclientisengagedinmeaningfuloccupationandisinvested
inhisorherrecoveryprocess,betteroutcomesareachieved
(Dolecheck&Schkade,1999).WeselectedtheOAmodel
becauseitwouldincorporatetheneededclientengagement
andoccupation-basedapproachandfacilitategeneralization
ofskillstonovelactivitiesandself-initiatedadaptations.The
Canadian Occupational Performance Measure (COPM;
Lawetal.,1999)wasselectedto(1)identifySusansprimary
occupationalrolesandimportantoccupationalperformances
and(2)obtainclient-ratedobjectivemeasurementsofher
currentlevelsofperformance,specificallynotingperceived
levelsofefficiency,effectiveness,andsatisfaction.
Shifting to a Client-Centered Approach
TheOAframeworkstatesthatOAisanormalprocessthat
everypersonexperiences.Whenapersonisfacedwithalife
transition, such as a surgical intervention, compounding
disabilitiesthatmayalreadybepresent,theOAprocessisat
risk for dysfunction. It is through the use of the holistic
approachofOAthatclientsmaybefacilitatedtobecome
theirownagentofchange.Themodelhasbeensuccessfully
usedinavarietyofsettingsandcomparedwithothermodels
(Gibson & Schkade, 1997; Jackson & Schkade, 2001;
Johnson&Schkade,2001).
TheCOPMisasemistructuredinterviewinwhichthe
patientreportsperformancesofconcernintheareasofself-care,
productivity, and leisure. Once problems are specified, the
patientisthenaskedtoratehisorherperceivedabilityofperformanceandsatisfactionwithperformance.Thetoolmaybe
usedtoaidintreatmentplanningandreassessmentandhas
beenfoundtobeavalidandreliablemeasurementtoolina
varietyofsettings(Carswelletal.,2004;Watterson,Lowrie,
Vockins,Ewer-Smith,&Cooper,2004).
Implementing the OA Approach
TheCOPMwasadministeredtoSusantoinitiatetheshift
fromabiomechanicalapproachtothemoreholistic,clientcenteredOAapproach.BecauseSusanwasexceedinglylimitedinherabilitiestoperformanytasks,theCOPMwas
usedasabaselinetogainherinputonwhichoccupational
taskswereofmostconcerntoher.Susanidentifiedthedesire
tobeabletosupinate,specificallytoturndoorknobsorget
changefrommypurse.Shealsoidentifiedthedesirefor
functionalpinch,soIcangetmyowntoothpasteoutor
squeezeaketchuppacket.Shevoicedthedesiretoholda
bookandcupaswellassafelymanipulatehercarwindow
controls.OnaLikertscalerangingfrom1to10,shewas
askedtoratehercurrentlevelofperformanceandherown

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satisfaction with that performance (see Table 2). Susans

averaged scores were calculated by adding the number of
performanceorsatisfactionscoresanddividingby5,which
representedthenumberofproblemsidentified.Forexample,
Susansaverageperformancescorewas16(16/5=3.2).As
seenbytheseratings,all<5(midrange),Susansperceptions
ofherlevelofperformance(3.2)andsatisfactionwithher
performance(2.2)wereverylow.
Susanattendedsixofeightadditionalscheduledtreatmentsessions;eachsessionaddressedtheactivitiesthatshe
hadidentifiedasimportanttoherontheCOPM.Thetreatmentapproachfocusedonperformanceoffunctionalactivities and included compensatory techniques and adaptive
equipmentforalternativesolutions(seeTable1).Through
collaborationandproblemsolving,eachissuewasaddressed
functionallyandinthecontextofperformance.Forexample,
twoactivitiesthatSusanverbalizedthedesiretoaccomplish
weretoopendoorsindependentlyandtoreceiveherloose
changefromstoreclerksinherhand.Shewasunhappyhavingtoaskstoreclerkstotossthechangeinmypursebecause
Icantholditinmyhand.Fromabiomechanicalperspective,thiswasalackofsupinationandhandclosure.Usingthe
OAapproachanddeeperinvestigationintotheclientsoccupationalperformanceandmasteryofheractivities,thisdesire
wasfoundtostemfromtheneedtomasterherenvironment,
toexperienceefficiencyandeffectivenessinherperformances,
andtoperformsatisfactorilyforherselfandintheeyesof
others.Useofdycemandexternalrotationattheshoulder
provided successful adaptation to manipulate door knobs.
Theuseofherdebitcardeliminatedthemajorityofsituations
whereshereceivedloosechange.Shewasabletomaintain
grasponstandardpensandprovideasignaturewithoutdifficulty.Hercarwindowcontrolswereadaptedwiththermoplasticmaterialtoprovidealevershecouldmanipulatewith
increasedeaseandsafetyperdemonstration.
Althoughthesamebiomechanicalconceptswerefollowed
toaddresstheunderlyingROMdeficits,theemphasisshifted
tofacilitatingSusansexperienceofimprovementinherown
occupationalperformance.Sheverbalizedinthesetreatments
herexcitementoverthefunctionalsolutionscatalogfilledwith

theoptionsforadaptivetechniques.Althoughshestillverbalizeddisappointmentoverthemobilitylostatherwristand
poor recovery of her index finger, she stated that she was
attemptingmoreoccupationaltasksthanshehadbefore.
On reassessment, the COPM demonstrated that the
OA-facilitatedinterventionmadeperformance-basedchanges
thatresultedinimprovementsontheCOPM(seeTable2).
Susanratedhersatisfactionwithherperformanceandher
abilitytoperformfunctionalactivitiessuchasmanipulating
doorknobs,holdingabook,manipulatingcarwindowcontrols,andgraspingacup.Heroverallperceptionofthesefive
functionaltasksincreasedfroma3.2toa5of10,andher
satisfactionlevelofherownperformanceincreasedfroma
2.2toa4.8of10.Althoughthesenumbersstillappearrelatively low, Carswell et al. (2004) identified that, on the
COPM, a changed score of 2 points, when comparing
baselineandreassessment,isclinicallysignificant.
IncomplicatedsurgicalcasessuchasSusans,thebiomechanical model and intervention tools are valuable.
However, combining the biomechanical approach with
client-centered,holistictreatmentisdifficult,especiallyfor
hand therapists working within the current conditions of
managedcareandcostcontainment(Daleetal.,2002).This
sentimentcouldbeexpressedbypractitionersinmanypracticesettings.However,itiseasiertoidentifythepresenceof
this ever-pressing challenge than it is to address it.
Documentingprogressthroughbiomechanicalgoals,inthis
casereport,notedminimalgains,discouragedtheclient,and
failedtodemonstratefunctionalgainsimportanttotheclient.Ashifttoaclient-centered,occupation-basedapproach
facilitatedtheclientsadaptation,improvedhermotivation
andoutlook,andprovideddocumentationoftheclinically
significantfunctionalprogressattained.

Discussion
Thiscasereportofapatientwhoreceivedhandtherapyinan
orthopedicoutpatientclinicaftersurgerytocorrectjointdeformitiessecondarytolupus-relatedarthritisillustratesthatashift
inframesofreferencefromabiomechanicalapproachtoan

Table 2. Susans Initial and Reassessment Scores on the Canadian Occupational Performance Measure

Identified Task

Initial
Perceived
Performance

Initial
Perceived
Satisfaction

Reassessed
Perceived
Performance

Reassessed
Perceived
Satisfaction

Supination

Functional pinch

Holding a book

Manipulating window controls

10

Static grasp of cup

Total score

1
3.2/10

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1
2.2/10

5
5/10

3
4.8/10

January/February 2010, Volume 64, Number 1

OAapproachfacilitatedadaptation,improvedmotivation,and
provided documentation of clinically significant functional
progress.Initialevaluationandtreatmentwerebasedonthe
biomechanical approach. The patient became discouraged,
andhermotivationdecreasedwithcontinueddocumentation
ofonlyminimalgainsontraditionalbiomechanicalmeasures.
Shestatedthatheroccupationalperformancegainsweremuch
more significant than what the biomechanical measures
showed.Weshiftedtoamoreclient-centeredapproachthe
OAmodelandusedtheCOPMtodocumentthepatients
primaryoccupationalrolesandimportantoccupationalperformancesandobtainclient-ratedobjectivemeasurementsof
hercurrentlevelsofperformance.
Withtheshiftintreatmentapproach,thefocusturned
towardperformanceoffunctionalactivitiesthatthepatient
identifiedasimportanttoherontheCOPMandincluded
compensatorytechniquesandadaptiveequipmentforalternative solutions to increase independent performance of
occupationalactivities.Throughcollaborativeproblemsolving,eachissuewasaddressedfunctionallyandinthecontext
ofperformance.Onreassessment,theCOPMdemonstrated
that the OA-facilitated intervention made performancebasedchangesthatresultedinimprovementsontheCOPM.
IncomplicatedhandtherapysurgicalcasessuchasSusans,
thebiomechanicalmodelandinterventiontoolsarevaluable;
however,combiningthebiomechanicalapproachwithOA
allowedamoreclient-centered,holisticapproachthatfacilitatedtheclientsadaptation,improvedhermotivationand
outlook,andprovideddocumentationoftheclinicallysignificantfunctionalprogressattained.
Therapistsinotherhandtherapysettingsmayfindthat
inclusionoftheOAframework(Schkade&Schultz,1992;
Schultz&Schkade,1992)providesabasisforpatientcare
thataddressestheneedforamoreclient-centered,holistic,
occupation-basedapproach.Patientownershipoftreatment
goals and progress is increased through collaborative goal
settinganddevelopmentofapositiveclienttherapistrelationship that facilitates the patients adaptation. The
Occupational Adaptation Guides to Practice (Schultz &
Schkade,1992)provideguidancetotherapistswhowantto
incorporateOAintotheirtreatmentapproach.Theguides
describethetherapeuticapproachfromthedatagathering
(initial assessment) stage through treatment and reassessment.ProvidingoccupationaltherapyservicesundertheOA
framework can be both an art and a skill executed with
methodandprecisionwhileprovidingthecollaborativecare
demanded by this generation of consumers (Schultz &
Schkade,1992).
Themechanicalexpertiseandskillofoccupationaltherapistspracticinginahandtherapysettingisvitalforskilled
patientcare;however,improvedpatientoutcomesmaybe

facilitatedbysupplementingbiomechanicalexpertisewitha
moreholistic,client-centered,occupation-basedapproach.
Althoughtheinvestmentoftimeandselfappearsincongruentwithtodayshealthcaresystem,bridgingthisincongruenceisachallengethattherapistsmayneedtoassumetobest
meetpatientneeds.Yetexamplesofhowtoaccomplishthis
shiftintreatmentperspectiveshaveyettobepublished.This
casereportprovidesanovelexampleofhowtoincorporate
theOAframeworktoshiftfromamechanistic,strictlybiomechanical hand therapy approach to a client-centered,
occupation-based,holisticapproach. s

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