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

Danielle Ann-Marie Lesher; M. J. Mulcahey; Peter Hershey; Donna Breger Stanton; Andrea C. Tiedgen

doi:10.5014/ajot.2017.016741

Abstract

OBJECTIVE. We sought to identify outcome instruments used in rehabilitation of the hand and upper extremity; to determine their alignment with the constructs of the International Classification of Functioning, Disability and Health (ICF) and the Occupational Therapy Practice Framework: Domain and Process; and to report gaps in the constructs measured by outcome instruments as a basis for future research.

METHOD. We searched CINAHL, MEDLINE, OTseeker, and the Cochrane Central Register of Controlled Trials using scoping review methodology and evaluated outcome instruments for concordance with the ICF and the Framework.

RESULTS. We identified 18 outcome instruments for analysis. The findings pertain to occupational therapists’ focus on body functions, body structures, client factors, and activities of daily living; a gap in practice patterns in use of instruments; and overestimation of the degree to which instruments used are occupationally based.

CONCLUSION. Occupational therapy practitioners should use outcome instruments that embody conceptual frameworks for classifying function and activity.

The ability of a person to participate in meaningful activities within the context of his or her environment is indicative of the person’s level of functioning and disability. Two conceptual frameworks have been developed to classify levels of functioning: the International Classification of Functioning, Disability and Health (ICF;World Health Organization [WHO], 2001) and the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association [AOTA], 2014).

Although the ICF is understood globally and is applicable to many health care professions, it is particularly well aligned with occupational therapy. For example, the ICF defines activity as the “execution of a task or action by an individual” and participation as “involvement in a life situation” (WHO, 2002, p. 10); activity and participation are both core constructs of occupational therapy. Other occupational therapy–aligned constructs of the ICF include body functions and structures and environment (WHO, 2001).

The Framework was developed specifically to provide a clear articulation of the scope and focus of the occupational therapy profession. The Framework outlines the process of evaluation and intervention in relation to the primary focus of the profession, the use of occupation (AOTA, 2014). Like the ICF, the Framework includes the constructs of body functions and structures, activity and participation, and context and environment.

Occupational therapy practitioners use a variety of measurement tools to evaluate clients’ level of functioning and disability. The evaluation process includes obtaining an occupational profile and analyzing occupational performance as a way to identify targeted outcomes (AOTA, 2014). The use of outcome measures can help practitioners evaluate clients’ progression toward targeted outcomes and validate the benefit of services provided. Although many outcome instruments can be used both in general occupational therapy and in the specialty area of hand therapy, some are targeted specifically to evaluation of the hand and upper extremity. Selecting the appropriate outcome instrument is highly dependent on the purpose of the measurement and the type of injury (Schoneveld, Wittink, & Takken, 2009).

Several studies have examined the relationship between these frameworks’ constructs and the general field of occupational therapy. However, in the area of hand therapy, this relationship is less defined. Traditionally, assessment in hand therapy is focused primarily on body structures and body functions, with less attention paid to activity, participation, and environment (Winthrop Rose, Kasch, Aaron, & Stegink-Jansen, 2011). In regard to postoperative hand rehabilitation, one study found that body functions, activities, and environmental factors were assessed during the early phase and participation during the late phase of rehabilitation (Fitinghoff, Lindqvist, Nygård, Ekholm, & Schult, 2011).

In the past decade, assessment of health has shifted to a focus on levels of activity and participation. In addition, Valdes et al. (2014) found that the clinical use of outcome instruments increased by 25% between 2001 and 2012. Nevertheless, limited research has been undertaken to link constructs of the ICF and Framework with the use of outcome instruments in the area of hand therapy. Because both the ICF and the Framework are commonly used for classifying body functions and structures, activity, participation, and environment, further exploration is necessary of the link between outcome instruments and these frameworks. Identifying the constructs of each framework being assessed by outcome instruments can enhance communication among health care professionals, payers, and other stakeholders.

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.

Retrieval of Publications

To identify relevant research literature, a CINAHL search strategy was developed and adapted to MEDLINE, OTseeker, and the Cochrane Central Register of Controlled Trials. As documented in the scoping review protocol, the primary author (Lesher) and content expert used a series of 55 search strategy key terms to identify potentially relevant publications. Each key term was sequentially executed into each of the identified search engines. Search results were saved within the designated search engine library.

Screening of the Title and Abstract

After retrieval of publications, the primary author screened the title and abstract of each to determine its potential to fit the inclusion criteria. Titles and abstracts potentially fitting the inclusion criteria were advanced to the next phase. Titles and abstracts that did not fit the inclusion criteria were maintained in the retrieval search library within each search engine.

Review of the Abstract for Eligibility

The primary author and senior author (Mulcahey) independently screened abstracts using a predefined criterion abstract eligibility checklist that they created; the checklist was based on outlined inclusion and exclusion criteria and was masked to each other’s assessment. Publications with the following criteria were included:

Were published between 2001 and 2013
Were peer reviewed and written in English
Addressed geriatric, adult, or pediatric populations
Included participants with congenital or manifested conditions including but not limited to orthopedic injuries, tendon injuries or repairs, nerve pathologies, injuries of the joint, congenital abnormalities, amputations, cumulative trauma disorders (carpal tunnel syndrome, cubital tunnel syndrome, lateral or medial epicondylitis, osteoarthritis, Dupuytren’s contracture, De Quervain’s tenosynovitis), and upper-extremity injuries
Used an outcome instrument that had been published by at least one additional (unrelated) author or research group other than developer of the instrument
Were authored or coauthored by an occupational therapist.

Publications that included people with primary neurological diagnoses (e.g., spinal cord injury, amyotrophic lateral sclerosis, multiple sclerosis, cerebral palsy) were excluded. Publications that primarily evaluated treatment not related to the upper extremity or that used an outcome instrument that had been published only once or only by the author of the instrument were also excluded. Nonrefereed papers, dissertations, theses, systematic reviews, practice forums, and duplicated studies also were not included.

Disagreements about the eligibility of the abstract were discussed, with the final determination made by the primary author. For abstracts that did not meet the eligibility criteria, the article title, first author, journal title, and reasons for exclusion were recorded. Abstracts that met all criteria for inclusion were confirmed for eligibility. For abstracts that did not meet all the inclusion criteria, the primary author reviewed the full article to determine whether the missing inclusion criteria could be identified.

An addendum to the scoping review was integrated before the first database search that included additional exclusion criteria (systematic reviews, practice forums, and duplicated studies). Systematic reviews were excluded because they might result in duplication of articles for this scoping review. Practice forums were excluded because they describe a standardized treatment protocol and do not address the primary focus of this study. Duplicate publications were excluded when the publication was retrieved from another search key word.

A post hoc analysis was conducted to evaluate the congruence between reviewers’ understanding of what outcome instruments evaluated and the constructs measured as defined by the instruments’ authors. Modification to the scoping review protocol is acceptable with systematic documentation of the modification and its rationale (Levac, Colquhoun, & O’Brien, 2010).

Review of Articles and Charting of Data

Review Committee.

The review committee consisted of three occupational therapists. Two of the three reviewers are certified hand therapists (CHTs), each with more than 20 yr of experience. One CHT is a hand therapy practitioner (Hershey), the other CHT (Stanton) is an associate professor in a nonresearch academic center , and the third reviewer (Tiegden) is an entry-level general occupational therapist working in a research academic center.

Formal training in the protocol for data extraction and charting was provided in a workshop webinar format. Fundamental to the training was a review of the ICF and the Framework, which were used to guide the review and data extraction. The training also included a mock review and competency assessment.

Charting the Data.

Each of the three reviewers reviewed every article. Articles were sent electronically with the corresponding data extraction sheet, one at a time, with a requested turnaround of no more than 7 days. For each article, the three reviewers identified (by name) the outcome instruments used in the study and categorized the primary constructs measured, according to the ICF and Framework. Constructs of the ICF include body functions (mental, neuromuscular, and movement), activity and participation (learning and applying knowledge; general tasks and domains; self-care; domestic life; major life areas; social, community, and civic life; interpersonal interactions and relationships; communication), and environment (products and technology; natural environment and human-made changes to environment; support and relationships; attitudes; services, systems, and policies). Constructs of the Framework include body functions (mental, neuromusculoskeletal, and movement), activity (activities of daily living [ADLs], instrumental activities of daily living [IADLs], education, work, play, leisure, social participation, rest and sleep), and context and environment (cultural, physical, social, personal, temporal, virtual). Completed data extraction sheets were returned electronically. The primary author reviewed data extraction sheets for quality, accuracy, and completeness within 24 hr of receipt; data sheets were returned to reviewers with queries if there were missing data elements or questions about data.

Data Management.

Data from the data extraction sheets were entered into an Excel (Microsoft Corp., Redmond, WA) spreadsheet and coded on the basis of the ICF and Framework constructs. Each outcome instrument and the constructs the reviewers identified were entered into the spreadsheet. When multiple articles referenced the same instrument, separate rows were created for each article. To ensure anonymity, reviewers were identified using the letters A, B, and C. For example, if Reviewer A reported that the ICF construct mental function was addressed using the COPM in Article 2, the COPM was entered in the spreadsheet under outcome instrument, the citation for Article 2 was recorded, and the letter A was entered under the mental function construct of the ICF table. ICF and Framework data were entered in separate Excel spreadsheets, but all instruments were evaluated under both frameworks; thus, the COPM, article numbers, and reviewer letters were listed in both Excel documents.

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.

Figure 1.

Flow chart of the article selection process.

Full Size | Slide (.ppt)

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.

Outcome Instruments and Constructs

Reviewers differed in their reports on which ICF and Framework constructs were evaluated by the outcome instruments. With respect to the Framework (Table 1), the highest agreement among reviewers was on body functions, self-care, work, and leisure. There was less agreement on whether the instruments addressed education, play, social participation, and rest and sleep. The only construct of context and environment that all three reviewers agreed on was the physical environment. Reviewers had the highest levels of agreement on the constructs measured by the Jebsen–Taylor Hand Function Test, MHQ, SF–36 Health Survey, Work Limitations Questionnaire, Quick DASH, FIM, Self-Liking/Self-Efficacy Scale, and DASH.

Table 1.

Report by Reviewers A, B, and C of Framework Constructs Measured by Outcome Instruments Used in Hand Therapy Articles

Instrument	Article	Body Functions		Activity								Context and Environment
Instrument	Article	Mental	Neuromusculoskeletal and Movement	ADLs	IADLs	Education	Work	Play	Leisure	Social Participation	Rest and Sleep	Cultural	Physical	Social	Personal	Temporal	Virtual
Button Board (Arthritis Hand Function Test)	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	—	A, B	B, C	—	—	B	—	—	—	—	—	A, B	—	—	—	—
COPM	Landa-Gonzalez & Molnar (2012)	A, B	A	A, C	A, C	A	A, C	A	A, C	A	A	A	—	A, B	A	B	A
DASH	Engstrand, Borén, & Liedberg (2009)	A	A, B	A, B, C	A, B, C	A	A, B, C	A, B	A, B, C	A	A	A	A, B	A, B	—	—	—
DASH	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A	A, B	A, B, C	A, B, C	A	A	A	A	A	A	A, B	A	A, B	—	—	—
Employee Comfort Survey	Boynton & Darragh (2008)	—	B	—	B	—	B	—	—	—	—	—	B	—	—	—	—
FIM	Landa-Gonzalez & Molnar (2012)	B	A, B	A, B, C	A	—	B	—	B	A, B	A, B	—	A, B	B	B	A, B	—
Functional Dexterity Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B	B	B	—	—	—	—	—	—	—	B	—	—	B	—
Health Assessment Questionnaire	Stamm et al. (2002)	A	A, B	A, C	A, B	A	A	—	A	A	—	—	A, B	—	B	A	—
Jebsen–Taylor Hand Function Test	Riggs, Lyden, Chung, & Murphy (2012)	—	A, B, C	A, C	A, B	—	—	—	—	—	—	—	—	—	—	—	—
Jebsen–Taylor Hand Function Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B, C	A, B, C	A, B	—	—	A	A	—	—	—	B	—	B	—	—
MHQ	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	A	A, B	A, B, C	A, C	—	A	—	—	—	A	A	B	A, B	—	—	—
	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A, B	A, B	A, B, C	A, B	—	A, B, C	B	B	—	A	A	B	A, B	B	—	—
	Riggs, Lyden, Chung, & Murphy (2012)	A	A, B	A, B	A	—	A, B	—	—	—	A	A	A, B	—	—	—	—
	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	A, B	A, B	A	A	—	—	—	—	—	A	—	—	—	—	—	—
Moberg Pickup Test	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	—	—	—	—	—	—	—	—	—	B	—	—	—	—
Nine-Hole Peg Test	Lowell et al. (2003)	—	B, C	—	—	—	—	—	—	—	—	—	B	—	—	—	—
PROMIS–HAQ	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	—	—	—	—	—	—	—	—	—	B	—	—	—	—
Quick DASH	Budd, Larson, Chojnowski, & Shepstone (2011)	—	A, B	A, B, C	A, B, C	—	A, C	B	A, B, C	A	A	—	B	—	B	—	—
Role Checklist	Landa-Gonzalez & Molnar (2012)	B	—	—	A	A, C	A, B	B	A, B	A, B	B	—	—	B	B	A, B	—
Self-Liking/Self-Efficacy Scale	Landa-Gonzalez & Molnar (2012)	A, B, C	—	—	—	—	—	—	—	B	—	—	B	—	B	B	—
SF–36 Health Survey	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	A, B, C	A, B, C	—	A, C	B	A, B	A, C	A	—	A, B, C	C	B, C	—	—
Task Questionnaire	Boynton & Darragh (2008)	—	B	—	—	—	B	—	—	—	—	—	B	—	—	—	—
Work Limitations Questionnaire	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, B, C	A, B, C	B	B	—	A, B, C	B	B	B	B	—	A, B, C	A, B	B, C	A	—

Note. — = no reviewer identified construct as measured by the instrument, indicating a potential gap in instruments; ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; Framework = Occupational Therapy Practice Framework: Domain and Process (3rd ed.); IADLs = instrumental activities of daily living; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire.

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Table 1.

Report by Reviewers A, B, and C of Framework Constructs Measured by Outcome Instruments Used in Hand Therapy Articles

Instrument	Article	Body Functions		Activity								Context and Environment
Instrument	Article	Mental	Neuromusculoskeletal and Movement	ADLs	IADLs	Education	Work	Play	Leisure	Social Participation	Rest and Sleep	Cultural	Physical	Social	Personal	Temporal	Virtual
Button Board (Arthritis Hand Function Test)	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	—	A, B	B, C	—	—	B	—	—	—	—	—	A, B	—	—	—	—
COPM	Landa-Gonzalez & Molnar (2012)	A, B	A	A, C	A, C	A	A, C	A	A, C	A	A	A	—	A, B	A	B	A
DASH	Engstrand, Borén, & Liedberg (2009)	A	A, B	A, B, C	A, B, C	A	A, B, C	A, B	A, B, C	A	A	A	A, B	A, B	—	—	—
DASH	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A	A, B	A, B, C	A, B, C	A	A	A	A	A	A	A, B	A	A, B	—	—	—
Employee Comfort Survey	Boynton & Darragh (2008)	—	B	—	B	—	B	—	—	—	—	—	B	—	—	—	—
FIM	Landa-Gonzalez & Molnar (2012)	B	A, B	A, B, C	A	—	B	—	B	A, B	A, B	—	A, B	B	B	A, B	—
Functional Dexterity Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B	B	B	—	—	—	—	—	—	—	B	—	—	B	—
Health Assessment Questionnaire	Stamm et al. (2002)	A	A, B	A, C	A, B	A	A	—	A	A	—	—	A, B	—	B	A	—
Jebsen–Taylor Hand Function Test	Riggs, Lyden, Chung, & Murphy (2012)	—	A, B, C	A, C	A, B	—	—	—	—	—	—	—	—	—	—	—	—
Jebsen–Taylor Hand Function Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B, C	A, B, C	A, B	—	—	A	A	—	—	—	B	—	B	—	—
MHQ	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	A	A, B	A, B, C	A, C	—	A	—	—	—	A	A	B	A, B	—	—	—
	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A, B	A, B	A, B, C	A, B	—	A, B, C	B	B	—	A	A	B	A, B	B	—	—
	Riggs, Lyden, Chung, & Murphy (2012)	A	A, B	A, B	A	—	A, B	—	—	—	A	A	A, B	—	—	—	—
	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	A, B	A, B	A	A	—	—	—	—	—	A	—	—	—	—	—	—
Moberg Pickup Test	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	—	—	—	—	—	—	—	—	—	B	—	—	—	—
Nine-Hole Peg Test	Lowell et al. (2003)	—	B, C	—	—	—	—	—	—	—	—	—	B	—	—	—	—
PROMIS–HAQ	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	—	—	—	—	—	—	—	—	—	B	—	—	—	—
Quick DASH	Budd, Larson, Chojnowski, & Shepstone (2011)	—	A, B	A, B, C	A, B, C	—	A, C	B	A, B, C	A	A	—	B	—	B	—	—
Role Checklist	Landa-Gonzalez & Molnar (2012)	B	—	—	A	A, C	A, B	B	A, B	A, B	B	—	—	B	B	A, B	—
Self-Liking/Self-Efficacy Scale	Landa-Gonzalez & Molnar (2012)	A, B, C	—	—	—	—	—	—	—	B	—	—	B	—	B	B	—
SF–36 Health Survey	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	A, B, C	A, B, C	—	A, C	B	A, B	A, C	A	—	A, B, C	C	B, C	—	—
Task Questionnaire	Boynton & Darragh (2008)	—	B	—	—	—	B	—	—	—	—	—	B	—	—	—	—
Work Limitations Questionnaire	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, B, C	A, B, C	B	B	—	A, B, C	B	B	B	B	—	A, B, C	A, B	B, C	A	—

Note. — = no reviewer identified construct as measured by the instrument, indicating a potential gap in instruments; ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; Framework = Occupational Therapy Practice Framework: Domain and Process (3rd ed.); IADLs = instrumental activities of daily living; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire.

With respect to the ICF, the highest agreement among the three reviewers was on body functions, self-care, and general tasks and domains (Table 2). Agreement was lower on whether instruments addressed learning and applying knowledge; domestic life; major life areas; social, community, and civic life; interpersonal interactions and relationships; and communication in the area of activity and participation. No environmental construct was addressed consistently by reviewers. In addition to the Jebsen–Taylor Hand Function Test, MHQ, SF–36 Health Survey, Work Limitations Questionnaire, Quick DASH, and Self-Liking/Self-Efficacy Scale (which had the highest levels of agreement regarding Framework constructs), reviewers agreed most on constructs measured by the Button Board (Arthritis Hand Function Test) and Moberg Pickup Test.

Table 2.

Report by Reviewers A, B, and C of ICF Constructs Measured by Outcome Instruments Used in Hand Therapy Articles

Instrument	Article	Body Functions		Activity and Participation								Environment
Instrument	Article	Mental	Neuromuscular and Movement	Learning and Applying Knowledge	General Tasks and Domains	Self-Care	Domestic Life	Major Life Areas	Social, Community, and Civic Life	Interpersonal Interactions and Relationships	Communication	Products and Technology	Natural Environment and Human-Made Changes to Environment	Support and Relationships	Attitudes	Services, Systems, and Policies
Button Board (Arthritis Hand Function Test)	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	—	A, B, C	—	B	—	—	—	—	—	—	—	—	—	—	—
COPM	Landa-Gonzalez & Molnar (2012)	A, B	A, B	A	A, B	A,C	A	A, B	A	—	—	A	—	B	—	—
DASH	Engstrand, Borén, & Liedberg (2009)	A	A, B	C	A, B	A, B	—	—	A	A	A	A	—	A	—	—
DASH	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A	A, B	—	A	A, C	A	—	A	—	—	—	—	A	—	—
Employee Comfort Survey	Boynton & Darragh (2008)	—	B	—	B	—	—	—	—	—	—	—	B	—	—	B
FIM	Landa-Gonzalez & Molnar (2012)	B, C	A, B	—	A, B	A, C	B	B	A	A	—	—	—	A, B	B	—
Functional Dexterity Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B	—	A, B	B	—	—	—	—	—	—	—	—	—	—
Health Assessment Questionnaire	Stamm et al. (2002)	A	A, B	—	A, B	A, C	A	A	—	—	—	A	—	—	—	—
Jebsen–Taylor Hand Function Test	Riggs, Lyden, Chung, & Murphy (2012)	B	A	A	A, B, C	A, B	A	—	—	—	—	—	—	—	—	—
Jebsen–Taylor Hand Function Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B, C	A	A, B	A, B	—	—	—	A	—	—	—	—	—	—
MHQ	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	A	A, B	—	B	C	A	A	A	A	—	—	—	—	—	—
	Riggs, Lyden, Chung, & Murphy (2012)	A, C	A, B, C	—	A, B	A, B, C	A,C	A	—	—	—	—	—	—	—	—
	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A, B	A, B	—	B, C	B	A	A	A	A	—	—	—	—	—	—
	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	A, B	A, B	—	A, B	A	—	A	—	—	—	—	—	—	—	—
Moberg Pickup Test	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B, C	—	A, B	—	—	—	—	—	—	—	—	—	—	—
Nine-Hole Peg Test	Lowell et al. (2003)	—	B, C	—	—	—	—	—	—	—	—	—	—	—	—	—
PROMIS–HAQ	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	C	A, B	A	—	A	—	—	A	A, B	B	—	—	—
Quick DASH	Budd, Larson, Chojnowski, & Shepstone (2011)	—	A, B	—	A, B	A, B, C	A	A	A	A	—	—	—	—	—	—
Role Checklist	Landa-Gonzalez & Molnar (2012)	B	—	A	A, B	—	A	A, C	C	B	—	—	—	B	—	—
Self-Liking/Self-Efficacy Scale	Landa-Gonzalez & Molnar (2012)	A, B, C	B	—	A, B	—	—	—	—	A	—	—	—	B	B	—
SF–36 Health Survey	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	—	A, B	A, B, C	A	A	A	B	—	A	—	C	—	—
Task Questionnaire	Boynton & Darragh (2008)	—	B	—	B	—	—	—	—	—	—	—	—	—	—	B
Work Limitations Questionnaire	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	A	A, B	—	—	A, B	B	—	—	A	—	—	B	—

Note. — = no reviewer identified construct as measured by the instrument, indicating a potential gap in instruments; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; ICF = International Classification of Functioning, Disability and Health; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire.

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Table 2.

Report by Reviewers A, B, and C of ICF Constructs Measured by Outcome Instruments Used in Hand Therapy Articles

Instrument	Article	Body Functions		Activity and Participation								Environment
Instrument	Article	Mental	Neuromuscular and Movement	Learning and Applying Knowledge	General Tasks and Domains	Self-Care	Domestic Life	Major Life Areas	Social, Community, and Civic Life	Interpersonal Interactions and Relationships	Communication	Products and Technology	Natural Environment and Human-Made Changes to Environment	Support and Relationships	Attitudes	Services, Systems, and Policies
Button Board (Arthritis Hand Function Test)	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	—	A, B, C	—	B	—	—	—	—	—	—	—	—	—	—	—
COPM	Landa-Gonzalez & Molnar (2012)	A, B	A, B	A	A, B	A,C	A	A, B	A	—	—	A	—	B	—	—
DASH	Engstrand, Borén, & Liedberg (2009)	A	A, B	C	A, B	A, B	—	—	A	A	A	A	—	A	—	—
DASH	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A	A, B	—	A	A, C	A	—	A	—	—	—	—	A	—	—
Employee Comfort Survey	Boynton & Darragh (2008)	—	B	—	B	—	—	—	—	—	—	—	B	—	—	B
FIM	Landa-Gonzalez & Molnar (2012)	B, C	A, B	—	A, B	A, C	B	B	A	A	—	—	—	A, B	B	—
Functional Dexterity Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B	—	A, B	B	—	—	—	—	—	—	—	—	—	—
Health Assessment Questionnaire	Stamm et al. (2002)	A	A, B	—	A, B	A, C	A	A	—	—	—	A	—	—	—	—
Jebsen–Taylor Hand Function Test	Riggs, Lyden, Chung, & Murphy (2012)	B	A	A	A, B, C	A, B	A	—	—	—	—	—	—	—	—	—
Jebsen–Taylor Hand Function Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B, C	A	A, B	A, B	—	—	—	A	—	—	—	—	—	—
MHQ	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	A	A, B	—	B	C	A	A	A	A	—	—	—	—	—	—
	Riggs, Lyden, Chung, & Murphy (2012)	A, C	A, B, C	—	A, B	A, B, C	A,C	A	—	—	—	—	—	—	—	—
	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A, B	A, B	—	B, C	B	A	A	A	A	—	—	—	—	—	—
	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	A, B	A, B	—	A, B	A	—	A	—	—	—	—	—	—	—	—
Moberg Pickup Test	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B, C	—	A, B	—	—	—	—	—	—	—	—	—	—	—
Nine-Hole Peg Test	Lowell et al. (2003)	—	B, C	—	—	—	—	—	—	—	—	—	—	—	—	—
PROMIS–HAQ	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	C	A, B	A	—	A	—	—	A	A, B	B	—	—	—
Quick DASH	Budd, Larson, Chojnowski, & Shepstone (2011)	—	A, B	—	A, B	A, B, C	A	A	A	A	—	—	—	—	—	—
Role Checklist	Landa-Gonzalez & Molnar (2012)	B	—	A	A, B	—	A	A, C	C	B	—	—	—	B	—	—
Self-Liking/Self-Efficacy Scale	Landa-Gonzalez & Molnar (2012)	A, B, C	B	—	A, B	—	—	—	—	A	—	—	—	B	B	—
SF–36 Health Survey	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	—	A, B	A, B, C	A	A	A	B	—	A	—	C	—	—
Task Questionnaire	Boynton & Darragh (2008)	—	B	—	B	—	—	—	—	—	—	—	—	—	—	B
Work Limitations Questionnaire	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	A	A, B	—	—	A, B	B	—	—	A	—	—	B	—

Note. — = no reviewer identified construct as measured by the instrument, indicating a potential gap in instruments; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; ICF = International Classification of Functioning, Disability and Health; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire.

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:

Ability to complete unilateral hand tasks such as turning a doorknob, picking up a coin, holding a glass of water, turning a key in a lock, and holding a frying pan
Performance on bimanual tasks, including opening a jar, buttoning a shirt or blouse, eating with a knife and fork, carrying a grocery bag, washing dishes, washing hair, and tying shoelaces
Ability to complete household or schoolwork activities
Pain level
Appearance and its effect on social, public, and community interactions
Satisfaction with the current usability of the extremity.

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).

Table 3.

Comparison of Reviewers’ Report of Framework Constructs Measured With Actual Constructs Measured

Instrument	Body Functions		Activity								Context and Environment
Instrument	Mental	Neuromusculoskeletal and Movement	ADLs	IADLs	Education	Work	Play	Leisure	Social Participation	Rest and Sleep	Cultural	Physical	Social	Personal	Temporal	Virtual
Button Board (Arthritis Function Test)		R, A	R, A				R					R
COPM	R, A	R	R, A	R, A	R, A	R, A	R, A	R, A	R, A	R, A	R		R, A	R	R	R
DASH	R	R	R, A	R, A	R	R, A	R	R	R, A	R, A	R	R	R, A
Employee Comfort Survey		R		R		R, A		A				R
FIM	R	R	R, A	R		R		R	R	R		R	R	R	R
Functional Dexterity Test		R, A	R	R								R			R
Health Assessment Questionnaire	R	R	R, A	R	R	R		R	R			R		R	R
Jebsen–Taylor Hand Function Test		R, A	R, A	R			R, A	R, A				R		R
MHQ	R, A	R, A	R, A	R, A		R, A	R	R	A	R, A	R	R	R	R, A
Moberg Pickup Test		R, A										R
Nine-Hole Peg Test		R, A										R
PROMIS–HAQ		R	A	A								R
Quick DASH		R	R, A	R, A		R, A	R	R	R, A	R, A		R		R
Role Checklist	R			R, A	R, A	R, A	R, A	R, A	R, A	R, A			R	R	R
Self-Liking/Self-Efficacy Scale	R, A								R, A			R	A	R	R
SF–36	R	R	R, A	R, A		R, A	R	R	R, A	R		R	R	R
Task Questionnaire		R				R, A						R
Work Limitations Questionnaire	R, A	R	R	R		R, A	R	R	R	R		R, A	R	R	R

Note. A = construct actually measured by the instrument; ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; Framework = Occupational Therapy Practice Framework: Domain and Process; IADLs = instrumental activities of daily living; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire; R = reviewer report of construct measured.

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Table 3.

Comparison of Reviewers’ Report of Framework Constructs Measured With Actual Constructs Measured

Instrument	Body Functions		Activity								Context and Environment
Instrument	Mental	Neuromusculoskeletal and Movement	ADLs	IADLs	Education	Work	Play	Leisure	Social Participation	Rest and Sleep	Cultural	Physical	Social	Personal	Temporal	Virtual
Button Board (Arthritis Function Test)		R, A	R, A				R					R
COPM	R, A	R	R, A	R, A	R, A	R, A	R, A	R, A	R, A	R, A	R		R, A	R	R	R
DASH	R	R	R, A	R, A	R	R, A	R	R	R, A	R, A	R	R	R, A
Employee Comfort Survey		R		R		R, A		A				R
FIM	R	R	R, A	R		R		R	R	R		R	R	R	R
Functional Dexterity Test		R, A	R	R								R			R
Health Assessment Questionnaire	R	R	R, A	R	R	R		R	R			R		R	R
Jebsen–Taylor Hand Function Test		R, A	R, A	R			R, A	R, A				R		R
MHQ	R, A	R, A	R, A	R, A		R, A	R	R	A	R, A	R	R	R	R, A
Moberg Pickup Test		R, A										R
Nine-Hole Peg Test		R, A										R
PROMIS–HAQ		R	A	A								R
Quick DASH		R	R, A	R, A		R, A	R	R	R, A	R, A		R		R
Role Checklist	R			R, A	R, A	R, A	R, A	R, A	R, A	R, A			R	R	R
Self-Liking/Self-Efficacy Scale	R, A								R, A			R	A	R	R
SF–36	R	R	R, A	R, A		R, A	R	R	R, A	R		R	R	R
Task Questionnaire		R				R, A						R
Work Limitations Questionnaire	R, A	R	R	R		R, A	R	R	R	R		R, A	R	R	R

Note. A = construct actually measured by the instrument; ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; Framework = Occupational Therapy Practice Framework: Domain and Process; IADLs = instrumental activities of daily living; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire; R = reviewer report of construct measured.

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:

The finding of a lack of instruments that focus on environment and participation, although not entirely unanticipated, may point to a disconnect between occupational therapy in hand therapy and the core values of the profession.
The findings and implications of this scoping review in no way minimize or discredit the contribution of occupational therapy in the rehabilitation of body functions and structures and activity participation. Constructs within these areas are important, need attention, and are tightly aligned with occupational therapy, particularly as precursors to function. Our recommendation is not that practitioners move away from assessment of body functions and structures but rather that they supplement their assessment with instruments that are occupationally based.
Occupational therapy practitioners must understand the links between the outcome instruments they use and the constructs of the ICF and Framework to select the most appropriate instrument for their clients and enhance communication among health care professionals, third-party payers, and other stakeholders.

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.

Acknowledgments

The authors thank Gary Kaplan, Thomas Jefferson University, for his expertise and assistance with this review.

*Indicates article included in the scoping review.

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Table 1.

Report by Reviewers A, B, and C of Framework Constructs Measured by Outcome Instruments Used in Hand Therapy Articles

Instrument	Article	Body Functions		Activity								Context and Environment
Instrument	Article	Mental	Neuromusculoskeletal and Movement	ADLs	IADLs	Education	Work	Play	Leisure	Social Participation	Rest and Sleep	Cultural	Physical	Social	Personal	Temporal	Virtual
Button Board (Arthritis Hand Function Test)	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	—	A, B	B, C	—	—	B	—	—	—	—	—	A, B	—	—	—	—
COPM	Landa-Gonzalez & Molnar (2012)	A, B	A	A, C	A, C	A	A, C	A	A, C	A	A	A	—	A, B	A	B	A
DASH	Engstrand, Borén, & Liedberg (2009)	A	A, B	A, B, C	A, B, C	A	A, B, C	A, B	A, B, C	A	A	A	A, B	A, B	—	—	—
DASH	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A	A, B	A, B, C	A, B, C	A	A	A	A	A	A	A, B	A	A, B	—	—	—
Employee Comfort Survey	Boynton & Darragh (2008)	—	B	—	B	—	B	—	—	—	—	—	B	—	—	—	—
FIM	Landa-Gonzalez & Molnar (2012)	B	A, B	A, B, C	A	—	B	—	B	A, B	A, B	—	A, B	B	B	A, B	—
Functional Dexterity Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B	B	B	—	—	—	—	—	—	—	B	—	—	B	—
Health Assessment Questionnaire	Stamm et al. (2002)	A	A, B	A, C	A, B	A	A	—	A	A	—	—	A, B	—	B	A	—
Jebsen–Taylor Hand Function Test	Riggs, Lyden, Chung, & Murphy (2012)	—	A, B, C	A, C	A, B	—	—	—	—	—	—	—	—	—	—	—	—
Jebsen–Taylor Hand Function Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B, C	A, B, C	A, B	—	—	A	A	—	—	—	B	—	B	—	—
MHQ	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	A	A, B	A, B, C	A, C	—	A	—	—	—	A	A	B	A, B	—	—	—
	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A, B	A, B	A, B, C	A, B	—	A, B, C	B	B	—	A	A	B	A, B	B	—	—
	Riggs, Lyden, Chung, & Murphy (2012)	A	A, B	A, B	A	—	A, B	—	—	—	A	A	A, B	—	—	—	—
	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	A, B	A, B	A	A	—	—	—	—	—	A	—	—	—	—	—	—
Moberg Pickup Test	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	—	—	—	—	—	—	—	—	—	B	—	—	—	—
Nine-Hole Peg Test	Lowell et al. (2003)	—	B, C	—	—	—	—	—	—	—	—	—	B	—	—	—	—
PROMIS–HAQ	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	—	—	—	—	—	—	—	—	—	B	—	—	—	—
Quick DASH	Budd, Larson, Chojnowski, & Shepstone (2011)	—	A, B	A, B, C	A, B, C	—	A, C	B	A, B, C	A	A	—	B	—	B	—	—
Role Checklist	Landa-Gonzalez & Molnar (2012)	B	—	—	A	A, C	A, B	B	A, B	A, B	B	—	—	B	B	A, B	—
Self-Liking/Self-Efficacy Scale	Landa-Gonzalez & Molnar (2012)	A, B, C	—	—	—	—	—	—	—	B	—	—	B	—	B	B	—
SF–36 Health Survey	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	A, B, C	A, B, C	—	A, C	B	A, B	A, C	A	—	A, B, C	C	B, C	—	—
Task Questionnaire	Boynton & Darragh (2008)	—	B	—	—	—	B	—	—	—	—	—	B	—	—	—	—
Work Limitations Questionnaire	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, B, C	A, B, C	B	B	—	A, B, C	B	B	B	B	—	A, B, C	A, B	B, C	A	—

Note. — = no reviewer identified construct as measured by the instrument, indicating a potential gap in instruments; ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; Framework = Occupational Therapy Practice Framework: Domain and Process (3rd ed.); IADLs = instrumental activities of daily living; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire.

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Table 1.

Report by Reviewers A, B, and C of Framework Constructs Measured by Outcome Instruments Used in Hand Therapy Articles

Instrument	Article	Body Functions		Activity								Context and Environment
Instrument	Article	Mental	Neuromusculoskeletal and Movement	ADLs	IADLs	Education	Work	Play	Leisure	Social Participation	Rest and Sleep	Cultural	Physical	Social	Personal	Temporal	Virtual
Button Board (Arthritis Hand Function Test)	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	—	A, B	B, C	—	—	B	—	—	—	—	—	A, B	—	—	—	—
COPM	Landa-Gonzalez & Molnar (2012)	A, B	A	A, C	A, C	A	A, C	A	A, C	A	A	A	—	A, B	A	B	A
DASH	Engstrand, Borén, & Liedberg (2009)	A	A, B	A, B, C	A, B, C	A	A, B, C	A, B	A, B, C	A	A	A	A, B	A, B	—	—	—
DASH	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A	A, B	A, B, C	A, B, C	A	A	A	A	A	A	A, B	A	A, B	—	—	—
Employee Comfort Survey	Boynton & Darragh (2008)	—	B	—	B	—	B	—	—	—	—	—	B	—	—	—	—
FIM	Landa-Gonzalez & Molnar (2012)	B	A, B	A, B, C	A	—	B	—	B	A, B	A, B	—	A, B	B	B	A, B	—
Functional Dexterity Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B	B	B	—	—	—	—	—	—	—	B	—	—	B	—
Health Assessment Questionnaire	Stamm et al. (2002)	A	A, B	A, C	A, B	A	A	—	A	A	—	—	A, B	—	B	A	—
Jebsen–Taylor Hand Function Test	Riggs, Lyden, Chung, & Murphy (2012)	—	A, B, C	A, C	A, B	—	—	—	—	—	—	—	—	—	—	—	—
Jebsen–Taylor Hand Function Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B, C	A, B, C	A, B	—	—	A	A	—	—	—	B	—	B	—	—
MHQ	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	A	A, B	A, B, C	A, C	—	A	—	—	—	A	A	B	A, B	—	—	—
	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A, B	A, B	A, B, C	A, B	—	A, B, C	B	B	—	A	A	B	A, B	B	—	—
	Riggs, Lyden, Chung, & Murphy (2012)	A	A, B	A, B	A	—	A, B	—	—	—	A	A	A, B	—	—	—	—
	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	A, B	A, B	A	A	—	—	—	—	—	A	—	—	—	—	—	—
Moberg Pickup Test	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	—	—	—	—	—	—	—	—	—	B	—	—	—	—
Nine-Hole Peg Test	Lowell et al. (2003)	—	B, C	—	—	—	—	—	—	—	—	—	B	—	—	—	—
PROMIS–HAQ	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	—	—	—	—	—	—	—	—	—	B	—	—	—	—
Quick DASH	Budd, Larson, Chojnowski, & Shepstone (2011)	—	A, B	A, B, C	A, B, C	—	A, C	B	A, B, C	A	A	—	B	—	B	—	—
Role Checklist	Landa-Gonzalez & Molnar (2012)	B	—	—	A	A, C	A, B	B	A, B	A, B	B	—	—	B	B	A, B	—
Self-Liking/Self-Efficacy Scale	Landa-Gonzalez & Molnar (2012)	A, B, C	—	—	—	—	—	—	—	B	—	—	B	—	B	B	—
SF–36 Health Survey	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	A, B, C	A, B, C	—	A, C	B	A, B	A, C	A	—	A, B, C	C	B, C	—	—
Task Questionnaire	Boynton & Darragh (2008)	—	B	—	—	—	B	—	—	—	—	—	B	—	—	—	—
Work Limitations Questionnaire	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, B, C	A, B, C	B	B	—	A, B, C	B	B	B	B	—	A, B, C	A, B	B, C	A	—

Note. — = no reviewer identified construct as measured by the instrument, indicating a potential gap in instruments; ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; Framework = Occupational Therapy Practice Framework: Domain and Process (3rd ed.); IADLs = instrumental activities of daily living; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire.

Table 2.

Report by Reviewers A, B, and C of ICF Constructs Measured by Outcome Instruments Used in Hand Therapy Articles

Instrument	Article	Body Functions		Activity and Participation								Environment
Instrument	Article	Mental	Neuromuscular and Movement	Learning and Applying Knowledge	General Tasks and Domains	Self-Care	Domestic Life	Major Life Areas	Social, Community, and Civic Life	Interpersonal Interactions and Relationships	Communication	Products and Technology	Natural Environment and Human-Made Changes to Environment	Support and Relationships	Attitudes	Services, Systems, and Policies
Button Board (Arthritis Hand Function Test)	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	—	A, B, C	—	B	—	—	—	—	—	—	—	—	—	—	—
COPM	Landa-Gonzalez & Molnar (2012)	A, B	A, B	A	A, B	A,C	A	A, B	A	—	—	A	—	B	—	—
DASH	Engstrand, Borén, & Liedberg (2009)	A	A, B	C	A, B	A, B	—	—	A	A	A	A	—	A	—	—
DASH	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A	A, B	—	A	A, C	A	—	A	—	—	—	—	A	—	—
Employee Comfort Survey	Boynton & Darragh (2008)	—	B	—	B	—	—	—	—	—	—	—	B	—	—	B
FIM	Landa-Gonzalez & Molnar (2012)	B, C	A, B	—	A, B	A, C	B	B	A	A	—	—	—	A, B	B	—
Functional Dexterity Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B	—	A, B	B	—	—	—	—	—	—	—	—	—	—
Health Assessment Questionnaire	Stamm et al. (2002)	A	A, B	—	A, B	A, C	A	A	—	—	—	A	—	—	—	—
Jebsen–Taylor Hand Function Test	Riggs, Lyden, Chung, & Murphy (2012)	B	A	A	A, B, C	A, B	A	—	—	—	—	—	—	—	—	—
Jebsen–Taylor Hand Function Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B, C	A	A, B	A, B	—	—	—	A	—	—	—	—	—	—
MHQ	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	A	A, B	—	B	C	A	A	A	A	—	—	—	—	—	—
	Riggs, Lyden, Chung, & Murphy (2012)	A, C	A, B, C	—	A, B	A, B, C	A,C	A	—	—	—	—	—	—	—	—
	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A, B	A, B	—	B, C	B	A	A	A	A	—	—	—	—	—	—
	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	A, B	A, B	—	A, B	A	—	A	—	—	—	—	—	—	—	—
Moberg Pickup Test	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B, C	—	A, B	—	—	—	—	—	—	—	—	—	—	—
Nine-Hole Peg Test	Lowell et al. (2003)	—	B, C	—	—	—	—	—	—	—	—	—	—	—	—	—
PROMIS–HAQ	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	C	A, B	A	—	A	—	—	A	A, B	B	—	—	—
Quick DASH	Budd, Larson, Chojnowski, & Shepstone (2011)	—	A, B	—	A, B	A, B, C	A	A	A	A	—	—	—	—	—	—
Role Checklist	Landa-Gonzalez & Molnar (2012)	B	—	A	A, B	—	A	A, C	C	B	—	—	—	B	—	—
Self-Liking/Self-Efficacy Scale	Landa-Gonzalez & Molnar (2012)	A, B, C	B	—	A, B	—	—	—	—	A	—	—	—	B	B	—
SF–36 Health Survey	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	—	A, B	A, B, C	A	A	A	B	—	A	—	C	—	—
Task Questionnaire	Boynton & Darragh (2008)	—	B	—	B	—	—	—	—	—	—	—	—	—	—	B
Work Limitations Questionnaire	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	A	A, B	—	—	A, B	B	—	—	A	—	—	B	—

Note. — = no reviewer identified construct as measured by the instrument, indicating a potential gap in instruments; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; ICF = International Classification of Functioning, Disability and Health; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire.

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Table 2.

Report by Reviewers A, B, and C of ICF Constructs Measured by Outcome Instruments Used in Hand Therapy Articles

Instrument	Article	Body Functions		Activity and Participation								Environment
Instrument	Article	Mental	Neuromuscular and Movement	Learning and Applying Knowledge	General Tasks and Domains	Self-Care	Domestic Life	Major Life Areas	Social, Community, and Civic Life	Interpersonal Interactions and Relationships	Communication	Products and Technology	Natural Environment and Human-Made Changes to Environment	Support and Relationships	Attitudes	Services, Systems, and Policies
Button Board (Arthritis Hand Function Test)	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	—	A, B, C	—	B	—	—	—	—	—	—	—	—	—	—	—
COPM	Landa-Gonzalez & Molnar (2012)	A, B	A, B	A	A, B	A,C	A	A, B	A	—	—	A	—	B	—	—
DASH	Engstrand, Borén, & Liedberg (2009)	A	A, B	C	A, B	A, B	—	—	A	A	A	A	—	A	—	—
DASH	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A	A, B	—	A	A, C	A	—	A	—	—	—	—	A	—	—
Employee Comfort Survey	Boynton & Darragh (2008)	—	B	—	B	—	—	—	—	—	—	—	B	—	—	B
FIM	Landa-Gonzalez & Molnar (2012)	B, C	A, B	—	A, B	A, C	B	B	A	A	—	—	—	A, B	B	—
Functional Dexterity Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B	—	A, B	B	—	—	—	—	—	—	—	—	—	—
Health Assessment Questionnaire	Stamm et al. (2002)	A	A, B	—	A, B	A, C	A	A	—	—	—	A	—	—	—	—
Jebsen–Taylor Hand Function Test	Riggs, Lyden, Chung, & Murphy (2012)	B	A	A	A, B, C	A, B	A	—	—	—	—	—	—	—	—	—
Jebsen–Taylor Hand Function Test	Staines, Majzoub, Thornby, & Netscher (2005)	—	A, B, C	A	A, B	A, B	—	—	—	A	—	—	—	—	—	—
MHQ	Adams, Burridge, Mullee, Hammond, & Cooper (2008)	A	A, B	—	B	C	A	A	A	A	—	—	—	—	—	—
	Riggs, Lyden, Chung, & Murphy (2012)	A, C	A, B, C	—	A, B	A, B, C	A,C	A	—	—	—	—	—	—	—	—
	Herweijer, Dijkstra, Nicolai, & Van der Sluis (2007)	A, B	A, B	—	B, C	B	A	A	A	A	—	—	—	—	—	—
	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	A, B	A, B	—	A, B	A	—	A	—	—	—	—	—	—	—	—
Moberg Pickup Test	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B, C	—	A, B	—	—	—	—	—	—	—	—	—	—	—
Nine-Hole Peg Test	Lowell et al. (2003)	—	B, C	—	—	—	—	—	—	—	—	—	—	—	—	—
PROMIS–HAQ	Yen, Flinn, Sommerich, Lavender, & Sanders (2013)	—	A, B	C	A, B	A	—	A	—	—	A	A, B	B	—	—	—
Quick DASH	Budd, Larson, Chojnowski, & Shepstone (2011)	—	A, B	—	A, B	A, B, C	A	A	A	A	—	—	—	—	—	—
Role Checklist	Landa-Gonzalez & Molnar (2012)	B	—	A	A, B	—	A	A, C	C	B	—	—	—	B	—	—
Self-Liking/Self-Efficacy Scale	Landa-Gonzalez & Molnar (2012)	A, B, C	B	—	A, B	—	—	—	—	A	—	—	—	B	B	—
SF–36 Health Survey	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	—	A, B	A, B, C	A	A	A	B	—	A	—	C	—	—
Task Questionnaire	Boynton & Darragh (2008)	—	B	—	B	—	—	—	—	—	—	—	—	—	—	B
Work Limitations Questionnaire	Ross, Callas, Sargent, Amick, & Rooney (2006)	A, C	A, B, C	A	A, B	—	—	A, B	B	—	—	A	—	—	B	—

Note. — = no reviewer identified construct as measured by the instrument, indicating a potential gap in instruments; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; ICF = International Classification of Functioning, Disability and Health; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire.

Table 3.

Comparison of Reviewers’ Report of Framework Constructs Measured With Actual Constructs Measured

Instrument	Body Functions		Activity								Context and Environment
Instrument	Mental	Neuromusculoskeletal and Movement	ADLs	IADLs	Education	Work	Play	Leisure	Social Participation	Rest and Sleep	Cultural	Physical	Social	Personal	Temporal	Virtual
Button Board (Arthritis Function Test)		R, A	R, A				R					R
COPM	R, A	R	R, A	R, A	R, A	R, A	R, A	R, A	R, A	R, A	R		R, A	R	R	R
DASH	R	R	R, A	R, A	R	R, A	R	R	R, A	R, A	R	R	R, A
Employee Comfort Survey		R		R		R, A		A				R
FIM	R	R	R, A	R		R		R	R	R		R	R	R	R
Functional Dexterity Test		R, A	R	R								R			R
Health Assessment Questionnaire	R	R	R, A	R	R	R		R	R			R		R	R
Jebsen–Taylor Hand Function Test		R, A	R, A	R			R, A	R, A				R		R
MHQ	R, A	R, A	R, A	R, A		R, A	R	R	A	R, A	R	R	R	R, A
Moberg Pickup Test		R, A										R
Nine-Hole Peg Test		R, A										R
PROMIS–HAQ		R	A	A								R
Quick DASH		R	R, A	R, A		R, A	R	R	R, A	R, A		R		R
Role Checklist	R			R, A	R, A	R, A	R, A	R, A	R, A	R, A			R	R	R
Self-Liking/Self-Efficacy Scale	R, A								R, A			R	A	R	R
SF–36	R	R	R, A	R, A		R, A	R	R	R, A	R		R	R	R
Task Questionnaire		R				R, A						R
Work Limitations Questionnaire	R, A	R	R	R		R, A	R	R	R	R		R, A	R	R	R

Note. A = construct actually measured by the instrument; ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; Framework = Occupational Therapy Practice Framework: Domain and Process; IADLs = instrumental activities of daily living; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire; R = reviewer report of construct measured.

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Table 3.

Comparison of Reviewers’ Report of Framework Constructs Measured With Actual Constructs Measured

Instrument	Body Functions		Activity								Context and Environment
Instrument	Mental	Neuromusculoskeletal and Movement	ADLs	IADLs	Education	Work	Play	Leisure	Social Participation	Rest and Sleep	Cultural	Physical	Social	Personal	Temporal	Virtual
Button Board (Arthritis Function Test)		R, A	R, A				R					R
COPM	R, A	R	R, A	R, A	R, A	R, A	R, A	R, A	R, A	R, A	R		R, A	R	R	R
DASH	R	R	R, A	R, A	R	R, A	R	R	R, A	R, A	R	R	R, A
Employee Comfort Survey		R		R		R, A		A				R
FIM	R	R	R, A	R		R		R	R	R		R	R	R	R
Functional Dexterity Test		R, A	R	R								R			R
Health Assessment Questionnaire	R	R	R, A	R	R	R		R	R			R		R	R
Jebsen–Taylor Hand Function Test		R, A	R, A	R			R, A	R, A				R		R
MHQ	R, A	R, A	R, A	R, A		R, A	R	R	A	R, A	R	R	R	R, A
Moberg Pickup Test		R, A										R
Nine-Hole Peg Test		R, A										R
PROMIS–HAQ		R	A	A								R
Quick DASH		R	R, A	R, A		R, A	R	R	R, A	R, A		R		R
Role Checklist	R			R, A	R, A	R, A	R, A	R, A	R, A	R, A			R	R	R
Self-Liking/Self-Efficacy Scale	R, A								R, A			R	A	R	R
SF–36	R	R	R, A	R, A		R, A	R	R	R, A	R		R	R	R
Task Questionnaire		R				R, A						R
Work Limitations Questionnaire	R, A	R	R	R		R, A	R	R	R	R		R, A	R	R	R

Note. A = construct actually measured by the instrument; ADLs = activities of daily living; COPM = Canadian Occupational Performance Measure; DASH = Disabilities of the Hand, Shoulder and Arm; Framework = Occupational Therapy Practice Framework: Domain and Process; IADLs = instrumental activities of daily living; MHQ = Michigan Hand Outcomes Questionnaire; PROMIS–HAQ = Patient-Reported Outcomes Measurement Information System–Health Assessment Questionnaire; R = reviewer report of construct measured.