Occupation based intervention in hand injury rehabilitation: a Malaysian perspective

Occupation refers to what people do for productive living, which includes Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), work, rest and sleep, leisure, play, education and social participation. Occupational therapy views occupation as both a healing agent and a goal to be accomplished by clients. This view is based on evidence that occupation promotes mental and physical health. Maintaining occupations as a core intervention in hand rehabilitation is challenging in Malaysia. Contextual factors such as the dominance of the medical model and organisational culture within the context of practice contribute to these challenges. Furthermore, there is no conclusive definition in the literature, nor consensus on what constitutes Occupation Based Intervention (OBI). The uniqueness of the Malaysian culture, which permits the clients to take a 'sick role', also makes it difficult to transfer western concepts of occupational therapy and OBI into practice. The aim of this study was to explore OBI in hand injury rehabilitation from a Malaysian perspective. A mixed methods approach using an exploratory sequential design was employed and conducted in three phases. Mixed methods research offers a 'completeness' to the issues studied and allows the development and expansion of research and evidence for OBI. The following research questions were formulated: (1) what is the consensus definition of OBI from a Malaysian perspective; (2) how do Malaysian occupational therapists perceive and describe their experiences providing OBI for clients with hand injuries; and (3) what is the effectiveness of combining OBI and TE in comparison to TE alone in the rehabilitation of clients with hand injuries. The research process sought a consensus definition of OBI from the perspectives of Malaysian occupational therapists in Phase One. The study was expanded further in Phase Two to describe the experience of occupational therapists applying the OBI based on the definition from Phase One. Results from Phase Two were used to develop an OBI intervention protocol, and the effectiveness of this protocol was tested in Phase Three. The mixed methods research used pragmatism as its philosophical approach and allowed the issues to be investigated using both qualitative and qualitative methods dependent upon the research question and objectives. A three round Delphi study was conducted in Phase One to achieve a consensus definition of OBI from a Malaysian occupational therapist's perspective. The participants were fifteen occupational therapy practitioners and educators who had more than five years' of experience practising occupational therapy. Findings from this study confirmed the notion of OBI as a means and as an end. Occupation as a means referred to occupations and purposeful tasks as healing agents while occupation as an end referred to occupation as the goal to be attained by the clients. The client-centred approach, top-down approach, and gradable and modifiable interventions were the basic elements of OBI. Conceptual frameworks such as the Model of Human Occupation (MOHO), Canadian Model of Occupational Performance (CMOP) and the theories of occupation as a means and as an end guided the Malaysian occupational therapists in their practise with OBI. It was found that although occupation as a means and end have different purposes, the ultimate goal is the same, which is to enable the client to engage in daily occupation regardless of their limitations and disabilities. Other forms of intervention such as preparatory and purposeful methods were also suggested to be incorporated to achieve the ultimate goal. In Phase Two, an Interpretative Phenomenological Analysis (IPA) was used to describe the experiences of occupational therapists using OBI in hand injury rehabilitation. Sixteen occupational therapists who were working and had more than five years' of experience in hand rehabilitation were interviewed individually. Five superordinate themes emerged, namely: 'Occupation as a means', 'Occupation as an end', 'Benefit of OBI', 'Challenges of OBI' and 'Making OBI a reality'. Occupation as a means and as an end can be merged together in a single therapy session when occupation acts as the healing agent and the goal is to be accomplished by the clients. Occupational therapists described OBI as having double benefits in a single therapy session, it represents the identity of occupational therapy, provides enjoyable rehabilitation experience, improves client's satisfaction and is a cost effective intervention. However, practising OBI in hand injury rehabilitation is challenging for the therapists due to logistical issues, contextual factors, therapist and client factors, and the credibility of occupation as an intervention modality. Participants suggested that practising OBI in hand rehabilitation would be enhanced through education and information, training of occupation therapists and consideration of client's occupational profile before providing the intervention. An OBI intervention protocol was developed from Phase Two by extracting occupations and purposeful tasks that were most frequently used by occupational therapists in Malaysia, and were perceived to have rich therapeutic benefits to the clients. The effectiveness of the intervention protocol was examined in Phase Three using a Randomised Controlled Trial (RCT) study. The purpose of the study was to examine the efficacy of the combination of OBI and therapeutic exercise (TE) versus TE alone in the rehabilitation of adult clients with hand injuries. Forty-six clients who had experienced bone, tendon and nerve injuries to the hand, wrist and forearm consented to participate in the study. They were randomly allocated into two groups; OBI+TE and TE. Forty participants, twenty in each group completed overall procedures for the study. Following six weeks of intervention, significant differences were found for the total active motion (TAM, p=0.04), neuropathic pain (p<0.001), Canadian Occupational Performance Measure (COPM) performance (p=0.03) and COPM satisfaction (p=0.05) in favour of OBI+TE group. At the follow-up, significant differences were found for the Disability of Arm, Shoulder and Hand (DASH) score (p=0.02), TAM (p=0.01), neuropathic pain (p=0.02), COPM performance (p=<0.001) and COPM satisfaction (p=<0.001) in favour of OBI+TE group. The linear mixed model was used to examine the effect of the intervention with the presence of confounding factors such as duration of injury, gender, injured hand, age, cause of injury, number of digits affected, occupation and type of injuries. Although the duration of injury and gender were found to influence the effect of the intervention, the OBI+TE group showed better improvements in all outcome measures as compared to the TE group. In conclusion, when framed by the sequential exploratory mixed methods design, this study was insightful as it provided better understanding and increased evidence about OBI in hand injury rehabilitation in Malaysia. The definition of OBI from Phase One allowed the term to be used more consistently in practice and education. Importantly, this study suggests potential solutions to overcome the challenges in practising OBI. This study provided empirical evidence regarding the effectiveness of OBI to support occupational therapy practice in hand injury rehabilitation. Translation of the study outcomes into practice provided better treatment effects for the clients. By encouraging the occupational therapists to use OBI with their clients, this indirectly assists them to reinforce their professional identity within occupational therapy in Malaysia.