Abstract
Introduction
Traumatic brachial plexus injury (BPI) is a devastating condition that primarily affects young adults after high-impact trauma. It results in substantial motor and sensory impairments of the upper limb. Epidemiological evidence suggests that BPI most commonly occurs in young males involved in motor vehicle accidents. The incidence is estimated at approximately 1–2 per 100,000 individuals annually (Kaiser et al., 2020). These injuries often lead to varying degrees of paralysis, pain, and functional loss. Complex surgical interventions, such as neurolysis, nerve grafting, and nerve transfer, are frequently required to promote recovery. Despite surgical intervention, restoration of full function is uncommon, and outcomes depend on injury severity, timing of surgery, and patient factors. The profound physical and functional consequences of BPI underscore the importance of improved management strategies for affected individuals (Aras et al., 2013; Kaiser et al., 2020).
Despite advances in surgical techniques, the likelihood of full functional recovery remains limited, with outcomes strongly influenced by injury severity, timing of intervention, and the specific surgical approach used (Armas-Salazar et al., 2022; Haldane et al., 2022).
Beyond physical impairment, traumatic BPI has profound and long-lasting consequences for psychological well-being, identity, and engagement in meaningful life activities (Dy et al., 2021).
Even when motor recovery occurs, individuals frequently report persistent disruptions in self-care, employment, social participation, and leisure, contributing to loss of autonomy and occupational identity (Dy et al., 2021; Mancuso et al., 2015). Participation restrictions often persist despite improvements in motor function and are not fully captured by conventional outcome assessments (Miller et al., 2023). Many commonly used evaluation tools prioritize objective indicators of physical recovery while underestimating the nuanced and subjective experience of living with BPI, particularly with respect to daily activities, social roles, and quality of life (Dy et al., 2015; Ferreira et al., 2017; Franzblau et al., 2014; Haldane et al., 2022; Williams et al., 2016).
Patient-reported outcome (PRO) measures are increasingly used to assess recovery; however, many upper-limb-specific PROs inadequately capture the multifactorial and context-dependent challenges experienced by individuals with BPI (Dy et al., 2021; Mancuso et al., 2015). Subtle but meaningful changes in daily functioning, productivity, or leisure participation may fall below thresholds of clinical significance yet have a substantial impact on quality of life, particularly in BPI, where even small functional gains can be highly consequential (Evertsson et al., 2025). For example, individuals may regain isolated joint movement yet remain unable to dress independently, prepare meals, return to work, or participate in social and community activities due to fatigue, compensatory limitations, or environmental barriers. These limitations highlight the need for outcome evaluation approaches that extend beyond impairment-focused metrics to better reflect lived experience.
A more comprehensive understanding of health and functioning emerges when integrating frameworks that emphasize occupational engagement and participation. The Canadian Model of Occupational Performance and Engagement (CMOP-E) conceptualizes recovery as an interaction between person, occupation, and environment, emphasizing that rehabilitation outcomes extend beyond physical capability to meaningful engagement in daily life (George, 2022).
Occupational performance, reflecting an individual's ability to engage in self-care, productivity, and leisure, is shaped by satisfaction, engagement, and contextual factors (Christiansen et al., 2024; Cruz et al., 2023). This performance is shaped not only by physical function but also by satisfaction, engagement, and contextual factors and thus constitutes a holistic marker of rehabilitation progress (Demers et al., 2002). Therefore, assessing occupational performance is essential for guiding client-centered rehabilitation and enhancing independence and quality of life following traumatic injuries such as BPI.
While occupational performance focuses on an individual's ability to complete meaningful activities and is traditionally grounded in the profession of occupational therapy, participation emphasizes broader life roles, community engagement, and social identity (Christiansen et al., 2024; Cruz et al., 2023). To situate participation within a broader, internationally recognized health framework, the International Classification of Functioning, Disability and Health (ICF) provides a comprehensive model that integrates impairments, activity limitations, and participation restrictions within the context of personal and environmental factors (Chan et al., 2009). Participation reflects both the capacity to perform activities and the extent of reengagement in valued roles, and it is strongly influenced by contextual and identity-based factors emphasized in contemporary occupational therapy frameworks such as the Canadian Model of Occupational Participation (CanMOP) (Cruz et al., 2023; Egan & Restall, 2022). Although conceptual overlap exists between the ICF and CanMOP, important distinctions remain that influence outcome measurement and clinical application, particularly regarding the balance between the classification of functioning and the subjective meaning of participation.
Disruptions in participation following traumatic BPI underscore the need for rehabilitation approaches and outcome assessments that move beyond impairment-focused metrics to capture meaningful life engagement. Accordingly, this mixed-methods study aimed to examine how individuals with traumatic BPI experience and report disability, occupational performance challenges, and participation restrictions. By integrating standardized outcome measures with ICF-guided individualized interviews, the study sought to identify which aspects of health and functioning are most affected and to evaluate the extent to which commonly used assessments reflect the complexity of lived experience. Specifically, the study aimed to describe insights derived from outcome measures representing distinct conceptual domains of health and to examine the relationships among these measures.
Methods
We employed a convergent mixed-methods design (Demir & Pismek, 2018) to examine health, functioning, and participation following traumatic BPI at least one year after surgical intervention. Quantitative and qualitative data were collected concurrently using a single, cross-sectional assessment to provide complementary insights into disability, occupational performance, and participation.
The quantitative and qualitative strands were analyzed independently, using methods appropriate to each paradigm, and integrated during the interpretation phase. Integration focused on comparing quantitative outcomes with qualitative themes and ICF-linked findings to identify areas of convergence and divergence across constructs of disability, occupational performance, and participation. This study was conducted and reported in accordance with established guidance for convergent mixed-methods research (Venkatesh et al., 2016). The ICF Core Set for Hand Conditions was selected because it includes key activity and participation domains relevant to upper-limb function; although BPI often involves proximal impairments, participation restrictions are frequently expressed through hand use and daily activities. To avoid missing broader domains, all meaning units were linked using the full ICF framework, allowing Environmental and Personal Factors (PFs) and codes beyond the Core Set to be identified.
Phase 1: Interpretive Qualitative Analysis
All interviews were audio-recorded and transcribed verbatim. Transcripts were de-identified prior to analysis by removing all personal identifiers and assigning participant codes. Audio files and transcripts were stored on secure, password-protected institutional servers, accessible only to members of the research team. All data were handled in accordance with institutional ethical guidelines. During analysis and reporting, care was taken to ensure that participant identities could not be inferred from quotations or contextual details. The transcripts were analyzed using a systematic, multistep qualitative approach. First, meaning units were extracted from the transcripts. A meaning unit was defined as a distinct statement or expression reflecting participants perceived occupational challenges, goals, or contextual barriers following traumatic BPI.
Thematic coding followed a hybrid deductive–inductive framework (Proudfoot, 2023). Meaning units were initially organized deductively using the Canadian Occupational Performance Measure (COPM) domains of self-care, productivity, and leisure. Inductive thematic analysis was then conducted in line with interpretive descriptive methodology, allowing patterns and concepts to emerge beyond the predefined domains (Fereday & Muir-Cochrane, 2006). Inductive codes were iteratively compared and grouped into higher-order categories and interpretive themes through team-based discussion, following principles of constant comparison to ensure themes were grounded in the data and aligned with the study aim.
Two occupational therapists that are coauthors of the study independently extracted and coded meaning units. To address reflexivity and reduce potential bias, the occupational therapists involved in coding were not the therapists who conducted the interviews. Initial coding was completed independently, with discrepancies resolved through structured consensus discussions. Coding decisions, code refinements, and consensus resolutions were documented throughout the analytic process.
Qualitative rigor was supported through multiple strategies consistent with interpretive descriptive methodology (Thomas & Magilvy, 2011). Credibility was enhanced through team-based coding, iterative discussion during theme development, and prolonged engagement with the data. Dependability and confirmability were supported by maintaining an audit trail that documented analytic decisions and consensus discussions. Integration of qualitative findings with quantitative outcomes provided methodological triangulation (Baralt, 2011). Given the study design and clinical population, formal member checking and saturation assessment were not undertaken.
Phase 2: Linking to the ICF
Following thematic coding, each meaning unit was linked to the ICF Core Set for Hand Conditions using the updated ICF linking rules (Cieza et al., 2019). These rules emphasize identifying the most specific ICF category for each meaningful concept based on both linguistic content and conceptual intent. When a single response contained multiple concepts, each was linked independently. Content that could not be linked was labeled Not Covered or PF (Bernardelli et al., 2021; Cieza et al., 2019).
Meaning units were additionally classified as reflecting capacity or performance based on ICF definitions (Almansa et al., 2011). Capacity was defined as the participant's intrinsic ability to execute a task under optimal conditions, independent of environmental context, whereas performance referred to task execution in the participant's everyday environment, influenced by real-world barriers or supports. For example, a participant who stated “I can lift my arm during therapy, but not while dressing at home” demonstrated preserved capacity without corresponding performance, whereas “I cannot use my hand even in therapy” reflected limitations in both domains.
The ICF linkage indicators were calculated to evaluate alignment between identified codes and the ICF framework, including Core Set Representation and Core Set Unique Disability Representation, using recommended formulas (MacDermid, 2021). Based on the recommended formulas, we calculated Core Set Representation (Number of unique ICF codes from the measure that appear in the Core Set/total number of the codes in coreset) × 100%, and Core Set Unique Disability Representation (Number of unique ICF codes from the measure that appear in the Core Set/total number of the disability codes in core set) × 100% (MacDermid, 2021).
Phase 3: Quantitative Analysis
Quantitative data were analyzed using descriptive statistics, including means and proportions, to characterize the sample. Data completeness was screened prior to analysis. Canadian Occupational Performance Measure performance and satisfaction scores were calculated by averaging participant ratings across up to five prioritized occupational performance problems, consistent with standard COPM administration guidelines. When fewer than five problems were identified, averages were calculated based on the number reported.
Missing data were present across outcome measures due to incomplete questionnaire responses. The number of participants completing each instrument varied (COPM n = 28, Disabilities of the Arm, Shoulder, and Hand Questionnaire [QuickDASH] n = 30, Participation Behaviour Questionnaire [PBQ] n = 29, Visual Analog Scale [VAS] n = 31). Analyses were conducted using pairwise deletion for correlation analyses. Assumptions underlying Pearson correlations, including linearity and approximate normality, were examined through visual inspection of scatterplots and distributions and were deemed acceptable. Bivariate Pearson correlation coefficients were used to explore relationships among COPM, PBQ, and QuickDASH scores. Correlation strength was interpreted as low (r < 0.40), moderate (r = 0.40–0.75), or high (r > 0.75) (Mukaka, 2012). Exploratory subgroup analyses based on demographic or clinical characteristics (e.g., injury type, sex, dominant vs. nondominant side) were considered; however, given the limited sample size, uneven subgroup distributions, and risk of inflated type I error due to multiple comparisons, these analyses were not undertaken.
Participants and Data Collection
Participants were consecutively recruited from a tertiary care hand surgery center. Inclusion criteria were: (1) adults aged 18 years or older; (2) a history of traumatic BPI; and (3) completion of surgical nerve repair, reconstruction, or transfer at least one year prior to enrollment. In practice, participants were recruited within a narrow postoperative window, ranging from 12 to 15 months since their most recent surgery. Time since surgery was calculated from the date of the most recent surgical intervention. All surgeries were performed by the same hand surgeon, ensuring procedural consistency. Patients with congenital brachial plexus palsy were excluded due to their distinct etiology, prognosis, and rehabilitation trajectory, as were individuals unable to provide informed consent.
Demographic and clinical variables collected included age, sex, dominant hand, affected upper limb, type of BPI (pan-plexus, upper plexus, or lower plexus), and surgical procedure type. Age, sex, and dominant hand were obtained by patient self-report at enrollment. Injury characteristics and surgical details were extracted from medical records. All variables were recorded at the time of study enrollment, concurrent with completion of PRO measures and the COPM interview.
Ethical Approval
This study was approved by our Local Research Ethics Committee. Written informed consent was obtained from all participants prior to data collection, in accordance with the principles outlined in the Declaration of Helsinki.
Sample Size and Recruitment
All eligible adult patients (≥18 years) who had undergone traumatic brachial plexus surgery with any nerve repair at least one year prior were consecutively invited to participate in the study. Using a consecutive sampling method, we contacted a total of 100 eligible patients, of whom 41 consented to participate, forming a convenience sample based on willingness and availability. Following data collection, a post hoc power analysis was conducted to assess whether the final sample size was sufficient to detect statistically meaningful associations among study variables. Following data collection, a post hoc power analysis was conducted to assess whether the final sample size was sufficient to detect a statistically meaningful association between COPM performance and QuickDASH scores. Assuming a moderate correlation (r = 0.50), the achieved post hoc power with 41 participants was approximately 80% at an alpha level of 0.05. This indicates that the study was adequately powered to detect a moderate association between occupational performance and upper-extremity disability.
Quantitative Outcome Measures
Canadian Occupational Performance Measure
The COPM (Law et al., 1990, 1998) was developed in alignment with the CMOP-E to assess patients’ self-perceived competency in occupational performance and their satisfaction with self-care, productivity, and leisure at the time of the interview, without a fixed retrospective window. As a semistructured, patient-specific tool, the COPM is administered through interviews in which patients identify and discuss occupations they find challenging due to their conditions, specifically focusing on self-care (essential daily activities like personal care), productivity (contributions to social and economic life), and leisure (activities for personal enjoyment).
During the COPM interviews, patients were prompted to articulate any occupational challenges they face and to prioritize these in terms of importance on a scale from 1 to 10, where 1 signifies “not important at all” and 10 denotes “extremely important.” They were then asked to rate their performance and satisfaction for the five most critical activities, using a scale from 1 (unable to perform or completely dissatisfied) to 10 (fully able to perform or completely satisfied). Total performance and satisfaction scores were computed by averaging the scores across identified problems, providing a quantitative measure of occupational performance and satisfaction ranging from 1 to 10, with higher scores indicating better performance and greater satisfaction. The qualitative portion of the interview allowed participants to describe and interpret the impact of traumatic BPI on their lived experiences. The Persian version of COPM was used for this study (Dehghan et al., 2015).
The Participation Behaviour Questionnaire
The PBQ was developed in Persian to evaluate participation among patients with hand and upper-extremity injuries. The PBQ contains 30 self-reported items that ask patients about the effects of the injury on their participation in important aspects of their lives over the past weeks. Each item is rated numerically from totally disagree (score = 0, lowest) to strongly agree (score = 3, highest). The total PBQ score is calculated by summing the item scores, which range from 0 to 90; higher scores indicate greater limitations in participation (Farzad et al., 2017). An item separation index of 0.91, a person separation index of 0.96, and an intraclass correlation of 0.97 indicated good reliability of the PBQ. Consistent with the Rasch model, unidimensionality and the absence of misfit items support its validity (Farzad et al., 2017).
Disabilities of the Arm, Shoulder, and Hand Questionnaire
The QuickDASH is a validated 11-item shortened version of the original 30-item DASH questionnaire, designed to efficiently assess hand- and arm-specific functional limitations and symptoms over the past week. Studies have indicated high congruence between the QuickDASH and the full version. Each item is rated on a 5-point Likert scale, with scores transformed to a 0–100 scale, where higher scores indicate greater disability. The QuickDASH has shown equivalence to the Full DASH and other cross-validated versions (Kennedy et al., 2013). We used the Persian version of the short form of the QuickDASH to evaluate upper extremity disability (Gummesson et al., 2006; MacDermid et al., 2015). The Persian version of QuickDASH used in this study has shown equivalence to the English version (Ebrahimzadeh et al., 2015).
Although condition-specific interpretive thresholds have not been firmly established for brachial plexus injuries, guidelines suggest that a change of approximately 15.9 points represents the minimal clinically important difference (MCID) in mixed upper extremity conditions. In comparison, the minimal detectable change ranges from 12 to 20 points. In the absence of brachial plexus–specific values, these thresholds can provide a reasonable framework for interpreting clinically meaningful change in QuickDASH scores in this population.
These measures were selected to capture complementary constructs aligned with the study's conceptual framework and mixed-methods design. The QuickDASH measures impairment-related disability of the upper limb (arm, shoulder, and hand), providing a standardized indicator that can be compared with person-centered outcomes from the COPM and qualitative findings. The COPM assesses individualized occupational performance. The PBQ, developed for individuals with hand and upper-extremity conditions, measures participation restrictions in daily, social, and community contexts. This combination allows direct comparison of impairment, performance, and participation across standardized and person-centered measures. The QuickDASH was selected due to its widespread use and strong psychometric properties in upper-extremity populations (Kennedy et al., 2013). However, it is recognized that its scoring structure may limit sensitivity to small, yet clinically meaningful, changes at the individual level. Its inclusion in this study was intentional, as it allowed for comparisons between standardized outcome measures and patient-reported experiences and for exploring the extent to which commonly used PROMs capture subtle yet meaningful aspects of recovery following BPI.
Visual Analog Scale
Pain intensity was assessed using a VAS (Hawker et al., 2011), a widely used self-report measure consisting of a 10-cm horizontal line anchored by “no pain” (0) and “worst imaginable pain” (10). Participants were asked to rate their current level of pain; therefore, no fixed recall period was imposed. The VAS has demonstrated strong reliability, validity, and responsiveness across a range of clinical populations, including musculoskeletal conditions, and is recommended as a standard measure of pain intensity.
Procedures
Data collection began with participants completing standardized PRO measures, including the QuickDASH, which assesses upper extremity disability, and the PBQ, which evaluates participation limitations. These measures were self-administered, with researcher support available as needed.
Interviews were conducted by an occupational therapist that is a coauthor of the study and has clinical expertise in hand therapy. During the interview, participants identified occupational performance problems, defined as activities they want, need, or are expected to perform but are unable to do, across the domains of self-care, productivity, and leisure. Participants rated the importance of each problem on a 10-point scale (1 = not important; 10 = extremely important). After prioritizing up to five problems, they rated both performance and satisfaction for each using 10-point Likert-type scales (1 = not able at all / not satisfied at all; 10 = able to do very well / extremely satisfied) (Larsen & Law, 2025). Interviews were audio-recorded and transcribed verbatim for subsequent analysis.
Results
A total of 41 patients completed the questionnaires and participated in interviews. The mean age of the cohort was 30 years (SD 12.15). Most participants were male (35/41, 85%), and 19 (46%) had injuries affecting their dominant hand. The cohort predominantly comprised patients with pan-plexus injuries, involving the entire brachial plexus and often resulting in paralysis of the whole upper limb, as well as upper-plexus injuries (19/41, 46%). The most common surgical procedure was nerve grafting (20/41, 48%). Time since surgery ranged from 12 to 15 months (mean 13.0 months, SD 1.0), indicating limited variability among participants (Table 1).
Descriptive Characteristics of Participants and Outcome Measures (N = 41).
Values are presented as n (%) for categorical variables and mean (SD) with 95% confidence intervals for continuous variables. Some categorical variables do not sum to the total sample (N = 41) due to missing or unreported data; missing categories are explicitly presented in the table. Sample sizes vary across outcome measures due to incomplete questionnaire responses. COPM = Canadian Occupational Performance Measure; QuickDASH = Quick Disabilities of the Arm, Shoulder and Hand; PBQ = Participation Behaviour Questionnaire; VAS = Visual Analog Scale. Higher scores on the QuickDASH and PBQ indicate greater disability or participation restriction, whereas higher scores on the COPM indicate better performance and satisfaction.
Interpretive
Percentages reported in this section refer either to the proportion of total meaning units identified across interviews or to the proportion of participants endorsing a given issue, as explicitly stated. A total of 85 distinct occupational performance problems were identified across the COPM interviews and categorized into the standard COPM domains of self-care, productivity, and leisure (Table 2). Self-care accounted for the largest share of reported issues, comprising 43 meaning units (50.6%) and endorsed by 36 participants (87.8%). Productivity-related challenges included 33 meaning units (38.8%) and were reported by 28 participants (68.3%). Leisure-related concerns were least common, with nine meaning units (10.6%) reported by eight participants (19.5%) (Figure 1).
Proportion of participants reporting challenges in each Canadian Occupational Performance Measure (COPM) domain.
Distribution of linked meaning units across the four International Classification of Functioning, Disability and Health (ICF) components.
Challenges in activities and participation reported by individuals with traumatic Brachial Plexus Injury. The figure illustrates the percentage of participants experiencing difficulties across key domains.
Distribution of Extracted Meaning Units from COPM and Participants by Thematic Domain.
Besides the COPM areas, 21 responses described issues beyond daily tasks, including trouble managing emotions, changes in self-identity, uncertainty about the future, and feeling judged by others. These issues show how BPI can broadly affect people's emotional and social lives and reveal that traditional ways of classifying problems may not fully reflect real experiences.
These nontask areas were grouped into three broader themes. We reported how often each theme appeared as a share of all responses and how many participants mentioned each theme.
The first theme, Emotional Regulation and Psychological Distress, was the most frequently endorsed, comprising 10 meaning units (11.8%) and reported by 13 participants (31.7%). Participants described fluctuating emotional states, psychological fatigue, disrupted body image, and persistent difficulty managing the emotional toll of their condition.
The second theme, Social Reintegration and Role Identity, was represented by seven meaning units (8.2%) and discussed by nine participants (22.0%). This theme reflected the loss or redefinition of meaningful roles, perceived marginalization in social relationships, and a diminished sense of self following injury.
The third theme, Spiritual and Existential Reflections, was present in four meaning units (4.7%) and expressed by five participants (12.2%). This theme highlighted reflections on purpose, uncertainty about the future, and efforts to reestablish existential coherence amid permanent bodily change. Unless otherwise specified, percentages reported in this section represent the proportion of total linked meaning units.
A total of 85 extracted meaning units were successfully linked to the ICF Hand Core set. Most of the linked meaning units (62.4%, n = 53) were linked to the Activities and Participation component. The most frequently represented categories included d430 (lifting and carrying objects) and d4400–d4408 (fine hand use). Self-care categories such as d510 (washing oneself), d540 (dressing), and d630 (preparing meals) were also common. These findings indicate substantial restrictions in basic and instrumental activities of daily living. Additional categories, including d640 (doing housework), d920 (recreation and leisure), and d840–d859 (work and employment), further reflected limitations in domestic life, community participation, and occupational roles.
The Body Functions component accounted for 25.9% (n = 22) of the total linked meaning units. The most frequently linked second-level categories included b7100 (mobility of a single joint) and b7101 (mobility of several joints). Other frequent categories were b715 (stability of joint functions), b7300 (muscle power functions), and b740 (muscle endurance functions). Psychological consequences of impairment were also prominent. Both b152 (emotional functions) and b1801 (body image) captured the affective and perceptual dimensions of participants’ lived experience.
Only 8.2% (n = 7) of the total linked meaning units were associated with the Body Structures component. These units primarily reflected the anatomical regions affected by injury, including s720 (shoulder region) and s7302 (hand). These codes represent the structural substrates underlying functional impairment following traumatic BPI.
Environmental Factors were linked in 3.5% (n = 3) of the total linked meaning units. This indicates a relatively lower—but meaningful—representation within the dataset. Frequently linked categories included e115 (products and technology for personal use in daily living), e135 (products and technology for employment), and e460 (social attitudes). These contextual elements were described as either barriers or facilitators influencing individual functioning.
Although PFs are not formally classified within the ICF framework, they emerged as a salient dimension across the qualitative data. Participants commonly referenced coping styles, resilience, motivation, and individual adaptation strategies, underscoring the critical role of personal characteristics in participation and performance. While not linkable to specific ICF codes, these factors were considered critical in shaping how impairments and contextual influences affected outcomes (Table 3).
International Classification of Functioning, Disability and Health (ICF) Codes.
Alignment Between Patient-Reported Challenges and ICF Core Set Domains
The Core Set Representation was calculated at 62.3%, meaning that over 60% of the categories included in the Comprehensive ICF Core Set for upper-limb conditions were reflected in the participants’ narratives. In addition, the Unique Disability Representation core set reached 83.3%, indicating that a large majority of the codes specific to the unique experiences of disability in this population were captured. In other words, participants described functional issues that mapped to more than 80% of the distinct disability-related categories in the ICF Core Set. Together, these findings confirm that the occupational and functional difficulties reported by individuals with traumatic BPI are well represented within the ICF framework, demonstrating alignment between patient-reported challenges and relevant ICF categories, supporting its clinical relevance in this context.
Capacity and Performance
Percentages in this subsection are calculated based on the total number of meaning units linked to capacity or performance constructs, respectively. Forty-six meaning units (54.1%) indicated significant capacity limitations, where participants showed intrinsic difficulty executing tasks even under standardized or ideal conditions. In contrast, 61 meaning units (71.7%) reflected performance restrictions, where participants experienced difficulties executing tasks in their actual daily environment. The greatest discrepancies between capacity and performance were observed in fine hand use activities (d4400–d4408), lifting and carrying objects (d430), and self-care activities such as dressing (d540) and preparing meals (d630). These findings highlight that although some participants retained basic task capacities in controlled settings, real-world participation was substantially restricted due to environmental, social, or personal barriers.
The type of BPI significantly influenced the pattern and severity of functional challenges experienced by participants. Individuals with pan-plexus (PAN) injuries demonstrated the most extensive limitations, with a high proportion of difficulties linked to fine hand use (d4400–d4408), lifting and carrying objects (d430), and self-care tasks (d540), along with notable emotional distress related to body image and emotional functions (b152, b1801). Major capacity limitations and even greater performance restrictions were evident, particularly in daily living and mobility activities.
Participants with upper plexus injuries primarily reported challenges associated with shoulder stability, endurance, and fine hand coordination, reflecting gross motor and fine motor control impairments. Meanwhile, individuals with lower plexus injuries exhibited more localized deficits in hand dexterity tasks, such as picking up small objects (d4402) and writing (d170), impacting productivity and social participation. Despite relatively preserved capacity in some cases, performance restrictions in real-world contexts remained significant across all injury groups. Environmental barriers and psychological factors further contributed to these participation restrictions, emphasizing the multifaceted nature of functional recovery. Figure 4 illustrates the differences in the distribution of impairments across ICF domains for each injury type.
Distribution of linked International Classification of Functioning, Disability and Health (ICF) domains across different Brachial Plexus Injury (BPI) conditions, normalized to participant group size.
Analytic
Descriptive Findings and Clinical Meaning
Participants demonstrated clinically meaningful impairment across disability, participation, and pain domains, although substantial heterogeneity was observed.
The mean QuickDASH total score was 38.36 (SD = 22.69; n = 30), a score range generally interpreted as indicating moderate upper-limb disability. Notably, the majority of participants scored above the MCID, indicating persistent functional limitations, which is consistent with traumatic BPI during the chronic phase.
Mean COPM performance and satisfaction scores were 4.59 (SD = 1.58; n = 28) and 3.99 (SD = 1.84; n = 28), respectively. Because scores below 5 on the COPM indicate participants perceive notable problems performing or being satisfied with their occupations, these results show that most participants continued to experience meaningful challenges in performing and feeling satisfied with personally important occupations.
The mean PBQ Participation Total Score was 35.00 (SD = 16.21; n = 29), and a large proportion of participants reported moderate to high participation restriction. Specifically, scores were clustered in the mid-to-upper range of the scale, reflecting significant limitations across social, independence, mental satisfaction, and leisure domains; higher scores indicated greater restriction of participation.
Pain intensity, measured using the VAS, had a mean score of 3.26 (SD = 3.07; n = 31). While this mean value falls below commonly cited thresholds for severe pain, frequency analysis demonstrated clinically relevant pain in a substantial subset of participants. Specifically, approximately 39% of participants reported VAS scores ≥4, and approximately 26% reported scores ≥6, indicating moderate-to-severe pain. Given the MCID for VAS pain is commonly estimated at approximately 1.5–2 points, these values suggest that pain was not only present but clinically meaningful for a considerable proportion of the sample, despite wide interindividual variability.
Correlation Analyses
Pearson correlation analyses examined relationships among occupational performance (COPM), upper-limb disability (QuickDASH total), participation restriction (PBQ total), and pain intensity (VAS). Only correlations between distinct instruments are reported.
Canadian Occupational Performance Measure performance showed a moderate negative correlation with QuickDASH total score (r = −.32, P = 0.093, 95% CI [−.62, .06]). This suggests that participants with greater perceived ability to perform meaningful occupations tended to report lower overall disability, although the relationship was not statistically significant. A similar pattern was observed between COPM satisfaction and QuickDASH total score (r = −.33, P = 0.091, 95% CI [−.62, .05]). Canadian Occupational Performance Measure performance and satisfaction were strongly correlated (r = .90, P < 0.001, 95% CI [.79, .95]), reflecting internal coherence of perceived occupational performance and satisfaction.
The QuickDASH total score showed a strong positive association with PBQ Participation Total Score (r = .84, P < 0.001, 95% CI [.68, .92]). Participants reporting greater upper-limb disability also tended to report greater participation restriction. Similar strong associations were observed between QuickDASH total score and PBQ social (r = .80), independent (r = .78), mental satisfaction (r = .83), and leisure/exercise (r = .68) subdomains (all P < 0.001), indicating that disability was associated with limitations across multiple participation contexts.
Pain intensity (VAS) showed a strong positive correlation with QuickDASH total score (r = .74, P < 0.001, 95% CI [.51, .87]). This indicates that higher pain levels co-occurred with higher perceived disability. Pain was also moderately to strongly correlated with PBQ Participation Total Score (r = .68, P < 0.001, 95% CI [.41, .84]), as well as with participation subdomains. This suggests pain was associated with participation restriction across social, independent, and leisure activities.
These correlations indicate co-occurrence among pain, disability, and participation restriction; however, given shared variance and the cross-sectional design, the findings should be interpreted as associative rather than causal (Table 4).
Correlations among Occupational Performance, Disability, Participation, and Pain.
Note: Values are Pearson's r with 95% confidence intervals in brackets. **P < 0.001.
COPM = Canadian Occupational Performance Measure; QuickDASH = Quick Disabilities of the Arm, Shoulder and Hand; PBQ = Participation Behaviour Questionnaire; VAS = Visual Analog Scale.
Discussion
This mixed-methods study provides an integrated snapshot of health status among adults living with traumatic BPI at least one year after surgery. Participants continued to experience moderate upper-limb disability, clinically meaningful occupational performance limitations, and substantial participation restriction. Self-care and productivity were the most frequently reported areas of difficulty, reflecting ongoing threats to independence and role functioning. When linked to the ICF, these challenges clustered around hand use, lifting and carrying, and personal care, consistent with the moderate disability levels captured by the QuickDASH. Quantitative measures of disability, participation, and pain showed clear conceptual alignment with patient-reported occupational challenges, indicating that these instruments capture clinically relevant aspects of functioning. However, qualitative interviews also revealed psychosocial dimensions, including emotional regulation difficulties, altered role identity, and existential concerns, that were not fully represented by standardized measures or ICF codes. Together, these findings highlight that recovery after traumatic BPI extends beyond physical impairment to encompass persistent occupational, participation, and psychosocial challenges, underscoring the need for rehabilitation approaches that integrate physical restoration with participation-focused and psychosocial support.
A key factor in interpreting these findings is that recovery from traumatic BPI is often prolonged and nonlinear (Cole et al., 2020). Functional improvement may take several years, with delayed reinnervation, gradual strength gains, and evolving compensatory strategies shaping occupational performance over time. Accordingly, participation restrictions and psychosocial adjustment observed one year after surgery are more likely to reflect a transitional phase rather than a final outcome (Kinlaw, 2005).
Previous studies indicate that individuals with BPI often experience prolonged uncertainty, shifting expectations, and emotional vulnerability during recovery, particularly when progress is slow or unpredictable (Bailey et al., 2009; Cole et al., 2020). Although functional improvements may be evident in therapeutic or controlled settings, participation in daily life frequently lags behind (McDonald & Pettigrew, 2014). This gap between capacity and real-world performance may contribute to frustration, altered self-concept, and difficulty sustaining engagement in meaningful roles.
Participants in the present study were enrolled at least 1 year postsurgery to capture early neurological recovery; however, substantial participation restrictions and psychosocial challenges persisted at this stage. These findings underscore that recovery following BPI is dynamic and ongoing, with occupational performance, participation, and emotional well-being continuing to evolve beyond the first postoperative year.
From an occupational therapy perspective, recognizing the prolonged nature of recovery is essential for supporting realistic goal setting, managing expectations, and delivering interventions that adapt over time. Rehabilitation should therefore address physical recovery alongside evolving participation goals and psychosocial needs, rather than assuming linear improvement or early resolution of participation restrictions.
The predominance of self-care and productivity challenges underscores how BPI disrupts occupations central to autonomy, dignity, and identity. Consistent with previous research, loss of independence in personal care tasks such as bathing, dressing, and toileting has been described as among the most distressing consequences of BPI, given their close link to personal dignity (Brito et al., 2021).
Within the CMOP-E framework (Krupa, 2024; Larsen & Law, 2025), these limitations signify reduced occupational competence and personal agency, affecting both self-concept and social participation. Similarly, the substantial productivity limitations—particularly in lifting, carrying, and fine motor control—reflect the long-term vocational and economic impact of BPI described in prior studies (Neulicht & Berens, 2004). The convergence between COPM-identified priorities and ICF activity codes demonstrates alignment between patient-reported challenges and established disability classifications. Although leisure was less frequently prioritized, its established connection to life satisfaction and well-being (Huang, 2003) suggests that reduced leisure engagement may contribute to social withdrawal and emotional fatigue. From a CMOP-E perspective, self-care, productivity, and leisure are interconnected; disruptions in one domain can compound losses in the others, collectively eroding occupational identity, satisfaction, and competence (Cruz et al., 2023; Demers et al., 2002; Krupa, 2024; Larsen & Law, 2025). However, even when functional gains are made in these domains, our findings show that they do not always translate into improved performance in daily contexts, underscoring the importance of examining the gap between capacity and performance.
An important finding was the gap between capacity and performance. Even when participants demonstrated the ability to perform certain tasks in therapeutic or optimal conditions, these capacities often did not translate into successful performance in everyday contexts. This was observed across all injury types but was most pronounced for activities requiring sustained fine motor control, lifting, and multistep self-care routines. Within the CMOP-E framework, this reflects a mismatch between the person and environment components of occupational performance: gains in physical capacity may not yield improved participation unless environmental barriers are addressed. Our ICF-linked data revealed that environmental factors such as access to assistive technology (e115, e135) and supportive social attitudes (e460) were frequently reported as either barriers or facilitators. These findings align with prior rehabilitation research, which shows that environmental and PFs can be as influential as intrinsic ability in shaping real-world outcomes (Baum et al., 2024; Bostan et al., 2014; Rebeiro, 2001). This highlights the need for rehabilitation to incorporate environmental modifications, adaptive strategy training, and psychosocial supports to ensure that restored capacities translate into meaningful occupational engagement. The following findings further illuminate how contextual and PFs shape long-term participation after BPI.
Participants’ ability to reengage in daily activities was also shaped by access to rehabilitation services, the presence of positive social environments, and individual coping mechanisms. As reported by Sarac et al. (2023), people with BPI often prioritize these supports as equally important to physical recovery. Furthermore, a conceptual model (Dorich et al., 2024) positions BPI as a lifelong condition in which quality-of-life domains evolve, even as injury-specific resources diminish. This perspective reinforces the importance of rehabilitation strategies that extend beyond physical restoration to address identity development, social participation, and emotional resilience. Occupational therapists, guided by the CMOP-E, are uniquely positioned to deliver these integrated, client-centered interventions. In addition to these environmental and personal supports, recovery is also shaped by the psychosocial and emotional adjustments that patients must navigate, which our data identified as a distinct and critical dimension of post-BPI rehabilitation.
The qualitative findings in this study also highlight psychosocial challenges that warrant targeted intervention. Participants described altered body image, persistent emotional distress, and the need to renegotiate life roles. These factors directly influence motivation, self-efficacy, and engagement in daily occupations. Our quantitative results support this connection: higher occupational performance was associated with greater satisfaction, while higher disability and participation restriction scores often coincided with narratives of frustration, isolation, and diminished self-worth. This is consistent with literature describing elevated risks of depression, post-traumatic stress, and identity disruption after BPI (Landers et al., 2018; Wellington, 2009).
Rehabilitation, therefore, needs to address not only the restoration of function but also the psychological and emotional adaptation and role renegotiation necessary for long-term recovery. Structured psychological support, peer-based interventions, and emotionally responsive goal setting should be integrated into occupational therapy to rebuild confidence and self-concept.
When considered together, the qualitative and quantitative findings reinforce the interconnected nature of function, participation, and satisfaction. The outcome measures were complementary in describing BPI outcomes, with the QuickDASH capturing the degree of physical limitation, the PBQ reflecting participation restriction, and the COPM providing insight into performance and satisfaction in meaningful occupations. These associations between the outcome measures are consistent with the CMOP-E model, which positions occupational performance as the product of interactions among person, occupation, and environment and recognizes that sustainable improvements require coordinated change across all three components. However, we also found that these measures provided different information, which may be valuable in a comprehensive assessment, and that all three together did not capture all of the concerns raised by patients in interviews. Our mixed-methods data provide a fuller picture of life beyond the first postoperative year, including partial functional recovery, persistent participation barriers, and psychosocial challenges, and highlight the need for holistic, context-sensitive rehabilitation that targets all aspects of occupational performance.
Conclusion
This mixed methods study provides a comprehensive description of recovery one year after traumatic BPI surgery, a complex set of emotions, impairments, disability, and contextual factors contribute to meaningful occupational reengagement. Guided by the CMOP-E framework, our findings demonstrate that occupational performance is shaped by the dynamic interplay between the person, occupation, and environment, suggesting that sustainable recovery requires coordinated interventions across all three components. Rehabilitation strategies should therefore combine targeted physical rehabilitation with environmental modification, adaptive strategy training, and psychosocial and emotional support to restore occupational competence, enhance participation, and rebuild identity. By addressing these interdependent elements, occupational therapists can play a central role in promoting long-term engagement in meaningful activities and improving quality of life after BPI.
Strengths and Limitations
This study enrolled patients treated by a single surgeon. This approach reduced variability in surgical technique and study site. However, it may limit generalizability. Several additional limitations should be considered when interpreting these findings. First, the modest sample size of 41 participants is appropriate for an exploratory mixed-methods design but may limit the generalizability of these quantitative results to the broader population with traumatic BPI. We achieved data saturation for the qualitative component. The demographic composition, which was predominantly young male participants, may further restrict applicability to other groups such as older adults or women. These groups may have different rehabilitation needs, life roles, and recovery trajectories.
Additionally, the cross-sectional design does not allow for examination of changes over time. This design limits our ability to see how occupational performance, participation, or functional recovery evolves. Although the ICF framework encompasses impairments, activity, and participation, we could not fully examine specific symptoms or physical impairments in depth. This was due to sample size constraints. Furthermore, some have suggested that the QuickDASH may be less sensitive to symptoms than the full DASH (Angst et al., 2009).
Another limitation relates to differences in recall periods across outcome measures. The PBQ captures experiences over the past weeks. The QuickDASH reflects symptoms over the past week. The COPM does not set a fixed retrospective time frame, and the VAS assesses current pain intensity. These variations in reference windows may influence participant responses and reduce direct comparability, especially in correlation analyses.
A notable proportion of missing data was present across outcome measures. Up to 32% of participants did not complete certain questionnaires. Although pairwise deletion allowed us to include available data, it may have introduced bias and reduced statistical power. Missingness appeared to be mainly related to incomplete questionnaire completion. Its potential influence on the findings should be considered when interpreting the results.
Despite these limitations, we were able to capture the importance of impairments. This was done through detailed descriptions of impairment-related concerns across BPI levels. Future research should include larger, more diverse samples and use longitudinal designs. This would examine recovery trajectories and the long-term effects of rehabilitation strategies across different populations.
Implications for Occupational Therapy Practice
Occupational therapists should address self-care, productivity, and leisure as interconnected domains, targeting not only physical function but also occupational competence, identity, and satisfaction.
Rehabilitation programs should bridge the gap between capacity and real-world performance through environmental modification, adaptive strategy training, and integration of psychosocial supports.
Client-centered interventions that incorporate psychological adaptation, role renegotiation, and participation-focused goal setting can enhance long-term occupational engagement and quality of life after traumatic BPI.
Key Messages
At least one year after traumatic BPI, most individuals continue to experience notable occupational performance challenges, particularly in self-care and productivity, despite surgical reconstruction.
Quantitative measures captured disability and participation restriction; however, qualitative interviews revealed additional psychosocial concerns (e.g., emotional regulation, role identity) not identified through standardized assessments alone.
Rehabilitation for BPI should integrate physical restoration with psychosocial support and environmental adaptation to meaningfully enhance participation and quality of life.
Footnotes
Acknowledgements
Joy MacDermid was supported by a Canada Research Chair in Musculoskeletal Health Outcomes and Knowledge Translation and the Dr James Roth Chair in Musculoskeletal Measurement and Knowledge Translation. Her work is supported by a foundation grant from the Canadian Institutes of Health Research (#167284).
Ethical Review Committee Statement
This study was conducted in strict accordance with ethical guidelines. Data collection occurred in Iran, and data synthesis and analysis took place in Canada. The University of Tehran (IR.TUMS.SINAHOSPITAL.REC.1403.132) Ethical Review Committee approved the study protocol.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.