Introducing purposeful activity kits in a hand rehabilitation practice: Effects on clinical practice patterns and job satisfaction among occupational therapy practitioners

Abstract

Introduction

Facilitating function through occupation and purposeful activity is the basic tenet of occupational therapy. However, the majority of research in hand rehabilitation clinics continues to focus on biomechanical interventions. The purpose of this research was to study practice patterns and personal opinions of occupational therapy practitioners before and after providing purposeful activity kits to an outpatient occupational therapy hand clinic.

Methods

Mixed-method design to evaluate an 8-week intervention of providing purposeful activity kits to a busy, military outpatient hand clinic. A paper survey was administered to nine occupational therapy practitioners before and after the intervention. Qualitative data were gathered through semi-structured interviews.

Results

A descriptive analysis indicated an increase in the use of activities, crafts, and occupation after the introduction of the purposeful activity kits. Practitioners consistently reported time as the top factor in their inability to incorporate more purposeful activities. Qualitative results support use of the new activities during both intervention and evaluation due to the focus on function and ease of use of the kits.

Conclusion

Purposeful activities can enhance any rehabilitation clinic in an organized, cost-effective manner. Practitioners responded positively toward the added equipment; however, it will take time and effort to adjust the theoretical decision making of practitioners. Additional participants and length of intervention is needed.

Keywords

Purposeful activity occupation job satisfaction practice patterns

Introduction

Regardless of whether a hand therapist is an occupational or physical therapist, there is a focused effort to assist hand-injured patients to return to functional independence.¹ For occupational therapists, the focus on function is a basic professional tenet. Since its inception as a profession in 1917, occupational therapy (OT) has facilitated ability through occupation and purposeful activity.² Nonetheless, there is often a disconnect between the theoretical underpinnings of OT and typical clinical practices.³ Some OTs lean toward a biomedical approach which is more germane to a standard medical model, while other OTs lean toward an activity-based model which is based on founding principles.^4,5 In all treatment settings, the challenge for OTs is to blend biomechanical knowledge with purposeful activities to offer holistic care.⁴

The Occupational Therapy Practice Framework was created in response to this challenge. The initial version of the Practice Framework, originally a federal requirement to create a uniform system for documentation,⁶ became the first step in generating a common language to mend the division between practice models among OTs.⁴ Each subsequent edition of the Practice Framework further defined the language and domains of OT, which focuses on body structures and functions simultaneously with habits, roles, routines, and the occupational interests of the patient for best therapeutic outcomes.⁶ The ability to utilize purposeful activity and occupational engagement as both the means and the ends of therapy is what differentiates OT from other allied health professions.⁷ Despite the development of the Practice Framework to unify the profession, there continues to be an ongoing discourse among practitioners. This discourse prompted research across a variety of OT practice areas for the use of purposeful activity and occupation-based interventions versus rote exercise, passive activity, and preparatory methods.⁸ Studies with conclusive results indicate the use of purposeful activity facilitates increased intrinsic motivation, increased tolerance and endurance, increased total active movement, and decreased pain and anxiety.^9–14 In contrast, O’Brien and Sandmire¹⁵ present inconclusive results about the benefits of purposeful activity.

Although research has been conducted on purposeful activity in a wide variety of settings, there has been little research on the use of purposeful activity as an intervention within the hand therapy setting.^16,17 Hand therapy clinics continue to be centered on interventions addressing the Practice Framework areas of body structures and body functions.¹⁸ Yet, some researchers indicate that improving strength and range of motion (ROM) are not adequate for coordinated hand function or a return to participation in activities of daily living.^18,19 Two systematic reviews of OT hand therapy literature gathered a total of 58 articles on UE injuries. Only one study included purposeful activity while the 57 remaining articles focused on interventions involving preparatory methods and physical agent modalities.^16,17 Literature showing the benefits of physical agent modalities as therapeutic interventions is inconsistent.^20–23 The American Occupational Therapy Association (AOTA) and the American Physical Therapy Association (APTA) have released position statements, which state physical agent modalities are not to be used independent of additional treatment interventions.^24,25 AOTA’s recommendation on the use of physical agent modalities has been consistent since its first position statement release in 1991: physical agent modalities are to be used in preparation for engagement in or as an adjunct to purposeful activity.²⁶ According to the most current AOTA position paper on physical agent modalities: “the exclusive use of PAMs [physical agent modalities] as a therapeutic intervention without direct application to occupational performance is not considered occupational therapy.”²⁵ Nevertheless, hand therapy remains firmly framed by a biomechanical approach. Recent research on purposeful activity in hand therapy has focused on survey research focusing on practitioners’ opinions and practice patterns.^18,27,28 In a survey of 105 hand therapy clinicians across the United States, 97% of respondents stated that occupation-based interventions are valuable to hand therapy clients, while engaging only 41–50% of clients in these types of activities.²⁸ The majority of clients, 61–90%, received active ROM, progressive resistive exercises, joint mobilization, and theraputty.²⁸

Survey studies point to three primary explanations of a reductionist approach to rehabilitation: (a) decreased time, (b) availability of equipment, and (c) the managed care environment with increased productivity and reimbursement demands.^3,18,27–29 Additionally, therapists report concerns about perceived credibility alongside other professionals and patients regarding the use of purposeful activity.^5,28,29

Despite therapists’ concerns about credibility among patients, levels of patient happiness and satisfaction have shown to increase with the inclusion of purposeful activity interventions versus rote exercise.^10,30 While there is some research on the satisfaction of OTs in various settings,^31–33 none pertain to the use of purposeful activity.

Therefore, the primary purpose of this study was to create a variety of purposeful activity kits to be added as intervention choices in a hand therapy practice for Army OT practitioners. Additionally, this study investigated job satisfaction of OT practitioners before and after the introduction of the purposeful activity kits. There was no attempt to control for choice of kit, frequency of usage, or “dosage” of the kits as interventions.

Methods

This was a mixed-method, within-subjects research study that received approval from the local institutional review board. The research included (a) a pretest/post-test survey, (b) an 8-week intervention phase, and (c) individual semi-structured interviews. All participants provided written informed consent.

Procedures

The second author met with OT staff at a large, outpatient military hand therapy clinic. All staff members were invited to participate. An informal in-service was given to the staff on the study’s intervention: 16 purposeful activity kits (explained below).

Participants

Nine out of 11 eligible staff members agreed to participate. Participants included four registered occupational therapists (OTR), three occupational therapy assistants (OTA), and two rehab aides. The allowances afforded to OT practitioners within a military OT clinic differ from a civilian clinic in that OTAs can perform their duties without certification. Of the nine participants, 77.8% (n = 7) were women and 22.2% (n = 2) men with a range of 1 to >21 years of OT experience. One OT was a certified hand therapist. An incoming military service member joined the staff at week 5 and subsequently entered the study at that point; however, a week later, one participant dropped out of the study due to his resignation. Nevertheless, all nine participants completed all quantitative and qualitative assessments and therefore remained in the study.

Intervention

Sixteen purposeful activity kits were supplied to the clinic for the 8-week intervention phase. Kits were constructed from a variety of everyday items to provide purposeful activities to address dexterity, strengthening, and neuromotor recovery. Participants were instructed to select activity kits as interventions based on clinical reasoning. Each participant was given a code at the onset of the study to maintain anonymity. Each kit contained a tracking sheet affixed inside the lid with the participants’ code. Participants checked a small box next to their assigned code every time they used that kit. In addition to the coded tracking sheet, each kit contained a brief explanation of the contents along with suggestions for upgrading or downgrading the task (Table 1).

Table 1.

Description of purposeful activity kits in descending order of frequency.

Task	Directions	Approx. cost	# of times used	Upgrade^a	Downgrade^b
Container/jar	Find lid to corresponding jar/container. Screw/unscrew lids	$0	17	Weight bearing as appropriate Perform task in standing	Perform task seated Limit number of containers required for task completion Provide correct matching lid for patient
Beads/buttons	Sorting, pinching, in-hand manipulation (translation: palm to fingertip; fingertip to palm)	$7	14	Pick up multiple (5) at a time, hold in palm Use tweezers to manipulate, sort Thread through cord	Pick up one at a time Use pincer grasp
Pouring/spraying	Fill empty gallon jug with water to specified weight. Pour into ice cube tray or other container. Fill spray bottle. Spray into ice cube tray or on table to wipe up	$2	9	Fill to heavier weight Use sprayer with specified digit (i.e. using only IF)	No weight or filled with less amount Use sprayer with all available digits
Rope and ladder	Create a ladder with cord and tongue depressors. Tie/untie knots, threading	$3	6	Tie bracelet out of cord. Create other designs	Start with loose knots only; no ladder
Key and lock	Find correct key. Lock/unlock	$12	5	Place locks around the clinic to simulate realistic scenarios	Provide correct key for each lock, complete seated
Marbles/game chips	Use tongs (two types) to sort and pick up items	$8	3	Spin chips on table Rotate in hand: clockwise/counterclockwise	Pick up one at a time No specification for number or type to pick up
Flower pen	Wrap artificial flower to pen with floral tape	$6	2	Increase target number of pens to be completed	Pre-cut floral tape for patients Hold pen and flower together for patient
Fabric and scissors	Cut strips of fabric with scissors	$15	2	Cut heavier fabric Tie/untie fabric into knots	Use lighter fabric (i.e. t-shirt material)
Paper clips	Link/unlink paper clips together, sort, pick up (pincer grasp or tweezers)	$2	2	Rotate in hand: clockwise/counterclockwise Complete unilaterally	Pick up one at a time No specification for number of type to pick up
Wrapping boxes	Cut paper bags to wrap empty boxes	$0	1		Precut paper for patient
Playing cards	Sorting, stacking, shuffling, dealing, flipping cards	$3	1	Complete unilaterally
Greeting card gift box	Follow directions to create box out of greeting card	$0	0	Work unilaterally	Precut paper for patient
Paper bead jewelry	Roll slips of paper into jewelry beads	$1	0	Patient will cut all slips of paper	Precut paper for patient
Wooden block painting	Paint/draw design on wooden block	$10	0	Work unilaterally	No design, paint full block
Newspaper gift bag/envelope	Follow directions to create gift bag or envelope out of newspaper	$4	0	Work unilaterally	Precut paper for patient
Coins/coin rolling	Counting, stacking coins. Placing coins into paper tubes	$5	0	Complete unilaterally Collect multiple coins in hand at one time	Collect coins one at a time Complete bilaterally

All activities can be upgraded by adding a time constraint or wrist weight.

All activities can be downgraded by reducing time spent or OT practitioner setting up task.

Data collection

The survey was borrowed, with permission, from a study on practice patterns and opinions about the use of occupation and purposeful activity in a hand rehabilitation setting by Colaianni and Provident.²⁸ It was adapted to include military specific demographics, as well as questions regarding job satisfaction. The survey was pilot tested by four local military colleagues (three Army OTs and one Army dietician with a PhD) to obtain face and content validity. At the end of the 8-week intervention, the first author conducted semi-structured interviews with each participant. The interviews followed a descriptive qualitative approach³⁴ to describe (a) the practitioners’ experience using the purposeful activity kits, (b) thoughts on trends and frequency of use among the kits, (c) use of the kits in a military OT setting, and (d) effects on job satisfaction. Seven interviews took place in person at the hand clinic and two were conducted via telephone. Interviews were audiotaped and transcribed verbatim by a transcription service.

Data analysis

Survey data were analyzed for descriptive statistics using SPSS (version 20.0, Armonk, NY) to illustrate demographic background as well as any change in practice patterns. A Wilcoxon signed-rank, non-parametric test was used to compare practice patterns and/or job satisfaction among the OT practitioners from the pre- to the post-survey. A p value of <0.05 was considered significant.

Responses to the open-ended survey questions and interviews were analyzed qualitatively by the primary investigator through descriptive coding³⁵ with subsequent creation of themes.

Results

Practice patterns

Participants responded to opinions on both barriers and benefits to purposeful activity as a treatment modality. According to initial survey results, limited time and limited resources were the top barriers to incorporating purposeful activity in the clinic (Figure 1). Despite 100% participant support in utilizing purposeful activity, initial practice patterns illustrate active ROM, progressive resistive exercise, theraputty, and passive stretch as the therapy techniques most utilized, while activities of daily living, crafts, and occupations were utilized less than 30% of the time (Figure 2). Active ROM, progressive resistive exercises, and physical agent modalities account for the majority of time spent in a typical treatment session (Figure 3). The post-test survey remained largely unchanged in both overall treatment modality usage and percentage of treatments used within a typical session. The use of activities, crafts, and occupations rose slightly in overall use with crafts having the largest spike; however, the changes were not statistically significant (p = 0.731, p = 0.076, p = 0.394, respectively). The purposeful activity kits used most frequently were: (a) jars/containers, (b) bead/buttons, and (c) pouring/spraying in descending order of frequency (Table 1).

Figure 1.

Participant opinion on barriers and benefits to use of purposeful activity in the clinic.

Figure 2.

Difference of overall intervention choice between pre/posttest surveys.

Figure 3.

Difference of a typical session intervention choice between pre/posttest surveys.

Satisfaction

Each of the nine participants answered five questions on aspects of job satisfaction. The majority (75%) of total responses to questions regarding satisfaction remained unchanged at “Strongly Agree” or “Agree” before and after the 8-week intervention. There was a slight increase in overall satisfaction with the alignment of practice patterns with the Practice Framework. There was a small decrease in satisfaction regarding the amount and variety of equipment available, efforts to provide quality OT, and with overall satisfaction. None of the changes on satisfaction were statistically significant.

Themes

Three main themes emerged while coding the interviews: (a) short treatment sessions constrain time, (b) kits with clear functional component were utilized more frequently, and (c) kits were simple and easy to incorporate. Seven out of nine participants mentioned time as a barrier to increased use of the purposeful activity kits. Some responses included difficulty adjusting the time from their typical routines to include the activities. Within the theme regarding the increased use of kits with a functional component, participants explained that the kits were not only used for function-based training and strengthening, but as assessment tools to determine difficulties in common everyday tasks. This delineation was dependent on the type of practitioner, with OTRs concentrating on assessments. The final theme of simplicity became clear within a majority of participants’ interviews. Comments indicated that the kits most utilized were quick and easy to incorporate into daily treatment sessions. Over the 8-week intervention, practitioners became more comfortable in using clinical judgment to easily adapt kits to fit patients’ needs (Table 2).

Table 2.

Qualitative themes from open-ended questions and interviews.

Theme	Percentage of responses and participant comments
Time	78% ”I felt like I didn’t have enough time because I have 30 minutes and I want to do a lot more than what I have.” ”It’s time constraints too, we have a patient every 30 minutes and people are running behind.” ”Some [barriers] were time…you have your regular routine because you see a patient and you just automatically do certain things.” ”We just have 30 minutes. We have just enough time to do ultrasound and strengthening.”
Functional kits most useful	67% ”I did get to use the kits for evals. I had a lady come in telling me she couldn’t open jars… I took some Dycem™ and showed her how to use her palm… she was thrilled because she had another technique for opening her jars.” ”I felt like we were doing more of what we should do as an OT and that I think it benefited the patients… I think it encouraged them to see if they can do things here in the clinic that they can translate those same things at home, that they wouldn’t be so fearful of trying.” ”We have to reproduce everything on a BTE (Baltimore Therapeutic Equipment™) or with theraputty so actually, having people open different sized jars and bottles… I think that was very helpful.” ”I had a patient with a tendon transfer who felt like it was very helpful to work on the jars. She needed a little more… that could reproduce the motion that she needed to work on at home… showing her that these are the activities, that this is what she has to think about when firing these muscles… that was helpful for her.”
Simple and easy to use	56% ”It was real easy to use…I changed up the one I used the most often.” ”Technique was not very hard. So it was very simple and easy task to do.” ”It was easy once you knew what patient it would be good for and how to do the task that was in the box.”

While in the clinic, the purposeful activity kits improved the participants’ efforts to align their practice with the Practice Framework. One participant reported, “It was nice to feel like we were doing activities that really got back to the roots of OT, of doing things that were client centered, purposeful for the specific patient.” Working in an environment that upholds a profession’s core values is a leading intrinsic factor of job satisfaction among rehabilitation professionals.³⁶ The subsequent removal of access to the activity kits at the end of 8 weeks could account for the post intervention survey decrease in satisfaction specifically related to the amount and variety of equipment. This realization is evident in excerpts of the interviews with participants asking for the activity kits to be returned to the clinic.

… as soon as the kits were gone, it was like every patient after that, oh, they would be great for purposeful activity. Where did they go?… Then when they’re gone, we suddenly realized how much we were using them or how much the patients like them.

When they were gone, I felt like, “Why? Maybe we should bring some bottles back into the clinic,” just because they were so helpful.

We miss them; are they coming back?

Discussion

This study examined practice patterns of OT practitioners before and after providing purposeful activity kits for use in a hand clinic. Participants’ favorable responses toward purposeful activity correspond with previous research.^18,27,28 However, participants’ intervention choices demonstrate a higher prevalence in use of biomechanical approaches rather than occupation-based approaches as consistent with previous research.²⁸ This narrow change in practice patterns noted by the slight rise in use of activities, crafts, and occupations is likely related to the identified barrier of limited time as well as established habits and experience of participants.

The kits allowed the participants to use clinical judgment and time management skills as each activity could be graded to fit the needs of each patient as well as the time constraints of the environment. However, consistent with discussions on best practices in healthcare,^18,28,29 limited time with each patient was reported as a barrier to use of the kits among 78% of the participants. The 8-week intervention period was also mentioned as a barrier as some practitioners stated that they needed more time to become accustomed to the kits. Decreased familiarity has been mentioned in other studies as a barrier in making efficient use of time when incorporating new interventions or assessment tools.^37,38

Similarly, some participants viewed the kits as an addition to the treatment plan, not an alternative intervention. A few participants made it clear that their primary treatment remained physical agent modalities and preparatory methods rather than using the purposeful activities as the means themselves. There is a propensity to continue using physical agent modalities despite the inconsistent data to support their use.^20–23 This highlights the fact that additional equipment will not automatically change habits within the clinic. Changes in practice patterns take time and commitment from practitioners themselves. It requires a dedication to adapt oneself along with the environment, as well as continuously assessing and developing professional skills that align with the fundamentals of OT.²⁹ OT education programs have embraced this paradigm shift back to the core tenets where students focus on occupation, purposeful activity, and the conceptual models that support these fundamental ideas.³⁹ This return to use of occupation-based theory and practice must be reintroduced to clinical practice to promote congruency throughout the profession.

The clinic in this study had a high demand for evaluations and re-evaluations, making it difficult for OTRs to participate in treatment sessions. Documented use of the kits in this study was primarily by aides and OTAs. The aides working in the clinic have some basic medical training but no formal OT education, which may explain the decreased use of some kits. Without a full understanding of the underlying theory of occupation and activity as the means, there is a limit to the use of purposeful activity kits. Consequently, there may be a limit to the rationalization and education of the patient to try different therapy interventions. Additionally, the OTAs and aides work directly from the care plan written by the OTR. With the addition of new equipment, there was likely an adjustment period to including the kits in the care plan, decreasing their frequency of use at the onset of the study.

A lack of appropriate equipment has been discussed as a barrier to occupation-based interventions.²⁷ The purposeful activity kits created for this study were inexpensive and are easily reproducible. This is beneficial due to the current cost-contained health care environment. The majority of the items cost less than $5 with two of the most frequently chosen activities costing between $0 and $2 through the use of recycled material. This study was completed in a military hand clinic and therefore ease and practicality of military-wide kit reproduction, as well as use in a deployed setting, was taken into account. Seven of the nine (78%) participants agreed that all Army OT clinics would benefit from including the purposeful activity kits. Most participants had not experienced a deployed setting and could not comment on the practicality of the kits in that setting. However, one participant who had experienced deployment as an OT remarked, “Absolutely! In a deployed setting, we’re looking for everything. We’re making stuff out of nothing and we are looking for creativity… the more stuff we have in our toolkit, the better we are as providers.”

Satisfaction

Satisfaction is an elusive construct comprised of both cognitive and emotional factors.⁴⁰ Research suggests that personality and psychological well-being play a role in predicting job satisfaction.^40,41 Moreover, fluctuation in behavior, cognition, and emotion can exaggerate responses with repeated survey data collection.⁴² Several unexpected and disrupting events took place during the 8-week intervention that may have influenced the psychological well-being of the staff and, in turn, had an effect on job satisfaction. Likewise, the Hawthorne effect has been established as inherent in research studies with human subjects.⁴² This theory describes the effects of observation on research participation, which can potentially skew responses and create bias among participant responses, although, the mix of quantitative and qualitative designs attempts to limit the Hawthorne effect.⁴² The Hawthorne effect can explain high satisfaction responses on the initial survey, which created a ceiling effect for improvement on the follow-up.

Limitations

The format of the survey borrowed for this study was initially created for one administration and may not have captured best results through use of a pre-/post-test. The survey is also considered a self-report measure, which can include imprecise personal accounts and recall bias. This was a small, convenience sample based on the clinical practice location of the authors. The representativeness of this sample is limited and results should be cautiously interpreted. Nevertheless, the study does provide insight into practice patterns and offers practical examples of purposeful activities that can be immediately incorporated into military and civilian clinics. This study was conducted in an Army OT clinic where there is a persistent awareness of streamlining practice patterns and improving exportability of interventions for military deployments. While this clearly limits generalizability, there may be value to practitioners who volunteer to serve on civilian medical missions or practice on constrained budgets with a mind toward ease of replication of intervention.

Future research

Further research on this topic is a necessity to continue moving clinical practice toward the roots of OT. Some ideas to further this topic might include (a) a control group to explore standardized, measureable outcomes using activity kits versus rote exercise; (b) gathering qualitative data of the patients’ experiences with the activity kits versus rote exercise; and (c) refining the purposeful activity kits to make them more practical, smaller in size, and easier to transport and store.

Conclusion

Incorporating purposeful activity into treatment sessions remains a challenge due to the increased reliance on biomechanical interventions in hand therapy. Research findings indicate that a shift in hand therapy practice patterns toward increasing purposeful activities will require time and effort, not simply introducing additional equipment; it will require a shift in the fundamental thought processes. The qualitative data illustrate the enthusiasm and support for the inclusion of purposeful activities in the clinic. Furthermore, this study showed that adding purposeful activities to a hand therapy clinic can be accomplished with a reasonable budget. This study serves as a beginning effort to provide simple, cost-effective tools that all hand therapy clinics can incorporate immediately. Hand therapy practitioners are encouraged to diligently engage in self-assessment and seek ways to develop skills and enhance practice variability.

Footnotes

Disclaimer

The view(s) expressed herein are those of the author and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense, or the U.S. Government.

Acknowledgement

None

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The Army Medical Department Center and School Human Protection Administrator determined this research met qualifications for Exempt research in accordance with 32 CFR 219.101(b).

Informed consent

Written informed consent was obtained from all participants before the study.

Trial Registration

not applicable

Guarantor

Contributorship

LD researched the literature, gained IRB approval, recruited participants and analyzed the data. Both authors conceived the study, developed the protocol, reviewed and edited the manuscript, and approved the final version.

References

Weinstock-Zlotnick

Bear-Lehman

. How therapists specializing in hand therapy evaluate the ability of patients to participate in their daily lives: An exploratory study. J Hand Ther 2015; 28: 261–267.

Meyer

. The philosophy of occupation therapy. Am J Occup Ther 1977; 31: 639–642.

Aiken

Fourt

Cheng

IKS

. The meaning gap in occupational therapy: Finding meaning in our own occupation. Can J Occup Ther 2011; 78: 294–302.

Pendleton

Schultz-Krohn

. Pedretti’s occupational therapy - Practice skills for physical dysfunction, St. Louis, MO: Elsevier Science Health Science Division, 2006.

Kelly

O’Connell

. Occupation why they are and aren’t using it. Adv Occup Ther Pract 1998; 14: 29–29.

American Occupational Therapy Association. Occupational therapy practice framework: Domain and process (3rd edition). Am J Occup Ther 2014; 68: S1–S48.

Trombly

. Occupation: Purposefulness and meaningfulness as therapeutic mechanisms. Am J Occup Ther 1995; 49: 960–972.

West

. Ten milestone issues in AOTA history. Am J Occup Ther 1992; 46: 1066–1074.

Harris

. The meanings of craft to an occupational therapist. Aust Occup Ther J 2008; 55: 133–142.

10.

Hoppe

Miller

Rice

. Occupationally embedded exercise versus rote exercise and psychosocial response in college-aged females. Occup Ther Ment Health 2008; 24: 176–191.

11.

King

. Hand strengthening with a computer for purposeful activity. Am J Occup Ther 1993; 47: 635–637.

12.

Omar

Hegazy

Mokashi

. Influences of purposeful activity versus rote exercise on improving pain and hand function in pediatric burn. Burns (03054179) 2012; 38: 261–268.

13.

Steinbeck

. Purposeful activity and performance. Am J Occup Ther 1986; 40: 529–534.

14.

Yoder

Nelson

Smith

. Added-purpose versus rote exercise in female nursing home residents. Am J Occup Ther 1989; 43: 581–586.

15.

O’Brien

Sandmire

. Cardiovascular and electroencephalographic response to purposeful vs. nonpurposeful activity in adults. Occup Ther Health Care 2008; 22: 19–35.

16.

Amini

. Occupational therapy interventions for work-related injuries and conditions of the forearm, wrist, and hand: A systematic review. Am J Occup Ther 2011; 65: 29–36.

17.

von der Heyde

. Occupational therapy interventions for shoulder conditions: a systematic review. Am J Occup Ther 2011; 65: 16–23.

18.

Powell

von der Heyde

. The inclusion of activities of daily living in flexor tendon rehabilitation: A survey. J Hand Ther 2014; 27: 23–29.

19.

Guzelkucuk

Duman

Taskaynatan

. Comparison of therapeutic activities with therapeutic exercises in the rehabilitation of young adult patients with hand injuries. J Hand Surg Am 2007; 32: 1429–1435.

20.

Hainan

Cote

Shearer

. Effectiveness of passive physical modalities for shoulder pain: Systematic review by the ontario protocol for traffic injury management collaboration. Phys Ther 2015; 95: 306–318.

21.

Alexander

Gilman

DRD

Brown

. Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Phys Ther 2010; 90: 14–25.

22.

Fuentes

Olivo

Magee

. Effectiveness of interferential current therapy in the management of musculoskeletal pain: a systematic review and meta-analysis. Phys Ther 2010; 90: 1219–1238.

23.

Morris

Jones

Ryan

. The clinical effects of Kinesio® Tex taping: A systematic review. Physiother: Theory Pract 2013; 29: 259–270.

24.

American Physical Therapy Association. Exclusive use or use of multiple physical agents/modalities. Policies & Bylaws: Practice. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/ExclusiveUse.pdf (August 2012, accessed July 2015).

25.

American Occupational Therapy Association. Physical agent modalities. Am J Occup Ther 2012; 66: S78–S80.

26.

American Occupational Therapy Association. Official: AOTA statement on physical agent modalities. Am J Occup Ther 1991; 45: 1075–1075.

27.

Grice

. The use of occupation-based assessments and intervention in the hand therapy setting – A survey. J Hand Ther 2015; 28: 300–305.

28.

Colaianni

Provident

. The benefits of and challenges to the use of occupation in hand therapy. Occup Ther Health Care 2010; 24: 130–146.

29.

Dale

Fabrizio

Adhlakha

. Occupational therapists working in hand therapy: The practice of holism in a cost containment environment. Work 2002; 19: 35–45.

30.

Ma A. An investigation of occupation-based practice in upper extremity intervention – A pilot study [Honors Thesis]. Durham, NH: University of New Hampshire, 2012.

31.

Eklund

Hallberg

. Factors influencing job satisfaction among swedish occupational therapists in psychiatric care. Scand J Caring Sci 2000; 14: 162–171.

32.

Hayes

Bull

Hargreaves

. A survey of recruitment and retention issues for occupational therapists working clinically in mental health. Aust Occup Ther J 2008; 55: 12–22.

33.

Lloyd

McWha

King

. An investigation of occupational therapy practice in New Zealand mental health services. New Zealand J Occup Ther 2003; 50: 9–16.

34.

Thorne

Kirkham

O’Flynn-Magee

. The analytic challenge in interpretive description. Int J Qual Methods 2004; 3: 1–21.

35.

Miles MB and Huberman AM. Qualitative data analysis: An expanded sourcebook. SAGE Publications, 1994.

36.

Randolph

. Predicting the effect of extrinsic and intrinsic job satisfaction factors on recruitment and retention of rehabilitation professionals… including commentary by Johnson SP. J Healthc Manag 2005; 50: 49–60.

37.

Valdes

MacDermid

Algar

. Hand therapist use of patient report outcome (PRO) in practice: A survey study. J Hand Ther 2014; 27: 299–308.

38.

Valdes

von der Heyde

. Attitudes and opinions of evidence-based practice among hand therapists: A survey study. J Hand Ther 2012; 25: 288–296.

39.

Gillen

Greber

. Occupation-focused practice: challenges and choices. Br J Occup Ther 2014; 77: 39–41.

40.

Wright

Cropanzano

Bonett

. The moderating role of employee positive well being on the relation between job satisfaction and job performance. J Occup Health Psychol 2007; 12: 93–104.

41.

Judge

Heller

Klinder

. The dispositional sources of job satisfaction: A comparative test. Appl Psychol: Int Rev 2008; 57: 361–372.

42.

McCambridge

Kypri

Elbourne

. Research participation effects: a skeleton in the methodological cupboard. J Clin Epidemiol 2014; 67: 845–849.