centennial vision rehabilitation research vision rehabilitation research trudy mallinson, heidi...

CENTENNIAL VISION

Rehabilitation Research

Trudy Mallinson, Heidi Fischer

KEY WORDS

� occupational therapy

� outcome assessment (health care)

� rehabilitation

� research

� review

� treatment outcome

Mallinson, T., & Fischer, H. (2010). Centennial Vision—Rehabilitation research. American Journal of Occupational

Therapy, 64, 506–514. doi: 10.5014/ajot.2010.09080

Trudy Mallinson, PhD, OTR/L, NZROT, is Assistant

Professor, Department of Occupational Science and

Occupational Therapy, University of Southern California,

Los Angeles.

Heidi Fischer, MS, OTR/L, is Clinical Research

Coordinator, Center for Rehabilitation Outcomes

Research, Rehabilitation Institute of Chicago.

The Centennial Vision of the American

Occupational Therapy Association

(AOTA; 2007a) marks a significant step

forward in occupational therapy by creat-

ing a clear statement about what the prac-

tice of occupational therapy will look like

in the future. In 2007, several ad hoc work

groups were assigned the task of translating

this vision into actionable goals for key

areas of practice. The panels met to answer

key questions that would provide a road

map to guide research and practice in those

areas. Each panel produced a report for the

AOTA Board of Directors. In its report,

the Ad Hoc Work Group on Rehabil-

itation, Disability, and Participation con-

cluded that to achieve theCentennial Vision,occupational therapists in rehabilitation

need to focus on supporting lifelong

participation through implementation of

context-based assessments and interven-

tions. The work group determined that

occupational therapy’s essential skills and

knowledge must be used to address indi-

vidual and environmental issues that impede

a person’s ability to engage in occupations

and, ultimately, to fully participate in soci-

ety. To meet this goal, the profession will

need to continue to develop evidence-based

interventions and assessment tools that are

focused at the level of activity and partici-

pation and that occur in context-rich envi-

ronments (AOTA, 2007b).

The work group praised the align-

ment of the Occupational Therapy PracticeFramework: Domain and Process (AOTA,

2008) with the International Classificationof Functioning, Disability and Health

(World Health Organization, 2001) and

the importance of an expanded view of

functional performance to include “free-

dom and citizenship . . . contributing to

communities of choice” (Hammel, Jones,

Gossett, & Morgan, 2006, p. 43). It sug-

gested that in the future, occupational

therapy would need to develop an ex-

panded focus on access to the community

and barriers to participation, which will

require an increased emphasis on re-

gaining occupational skills in real-world

environments and research that focuses

on developing and testing participation-

level outcomes and interventions.

Activity- and participation-level in-

terventions that focus on developing skilled

performance in the context of everyday

activities and environmental modifications

will increasingly require that therapy ex-

plore and exploit the similarities and dif-

ferences between real-world and therapy

environments. The field of motor control

is examining the role of adaptation, that is,

calibrating the brain’s prediction of how

the body will move and how learning

transfers between therapy environments,

such as treadmills and robotic reaching

devices, and real-world environments

(Bastian, 2008).

Several measures of underlying ca-

pacity are widely used in occupational

therapy (e.g., dynamometers, pegboard

tests). Such assessments are often easily

administered in any environment and

require little equipment. Activity- and

participation-level assessments can be more

challenging to administer and interpret

because they are more influenced by the

environment and contextual factors. For

506 May/June 2010, Volume 64, Number 3

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example, even simple tub transfers can be

influenced by the height and width of the

tub, the availability of handrails and tub

chairs, and the presence or absence of water.

With respect to patient-reported measures,

if the therapist asks an individual to rate his

or her difficulty with dressing, is the person

thinking about putting on work clothes or

sweatpants? Are the clothes already laid out,

or do they need to be retrieved from the

closet? To date, most assessments of activity

and participation either ignore the role of

context or control it to such a degree that

relevance to real-life situations may be

limited.

Clinicians also frequently comment

that the rating scales associated with

activity- and participation-level assess-

ments do not always capture the changes in

performance being achieved in therapy.

Because impairment-level assessments

tightly control the performance require-

ments and elements of the environment,

they are useful for capturing small discrete

changes in capacity. In the world of slow

progress that can be rehabilitation, such

assessments can be appealing and moti-

vating for both therapists and patients. Yet

such assessments do not capture the true

goals of rehabilitation, which are to have

the person return to the least restrictive

level of functioning and to participate in

personally meaningful activities. Occupa-

tional therapy will face a growing need to

challenge current measurement para-

digms, to find ways to measure both

person ability and environmental supports

and barriers simultaneously, and to de-

scribe performance outcomes as an in-

teraction of both of these factors, not just

in terms of person capacity.

In summary, future occupational

therapy research will need to focus on the

promotion of activity and participation,

conducted in real-life contexts, and should

evaluate the impact of the environment on

occupational performance.

Method

In this article, we report on the systematic

review of 14 occupational therapy re-

habilitation research articles published in

the American Journal of Occupational

Therapy (AJOT ) between January 2008

and September 2009 in the practice areas of

work and industry and rehabilitation, dis-

ability, and participation (Table 1). A

separate review (Gillen, 2010) published

in AJOT addressed rehabilitation research

studies in the areas of stroke and traumatic

brain injury.

To evaluate how well studies pub-

lished in AJOTmeet the Centennial Visionfor rehabilitation research, we read and

reviewed the articles and classified them by

level of evidence and types of research as

previously described by Gutman (2008,

Table 2): systematic or narrative reviews,

effectiveness studies, efficacy studies, basic

research about disability, instrument de-

velopment and testing, and studies with

a link between occupational engagement

and health.

We also summarized studies by

methodology, sampling design, analytic

methods, and findings (see Table2).Levels

of evidence in Tables 1 and 2 are based on

AOTA’s levels of evidence rating system

(Lieberman & Scheer, 2002):

• Level I: Systematic reviews,meta-analyses,

randomized controlled trials

• Level II: Two groups, nonrandomized

studies (e.g., cohort, case-control)

• Level III: One group, nonrandomized

(e.g., before and after, pretest and post-

test)

• Level IV: Descriptive studies that

include analysis of outcomes (single-

subject design, case series)

• Level V: Case reports and expert opin-

ion that include narrative literature re-

views and consensus statements.

In addition, we further classified the

studies according to our interpretation of

the priority areas identified by the Ad

Hoc Work Group on Rehabilitation,

Disability, and Participation (see Table 3).

These categories included use of activity-

and participation-level measures, use of

activity- and participation-level interven-

tions, context-based interventions, and

environmental modifications.

Results

Of the three effectiveness studies, none

could be classified as Level 1 systematic

reviews or randomized controlled trials.

Two studies could be classified as Level 2

nonrandomized studies. One study could

be classified as a Level 3 nonrandomized,

one-group pretest–posttest design. No

studies were Level 4 descriptive studies (see

Table 1).

Fourteen articles included in this re-

view were classified into the following

categories: 5 instrument development and

testing studies, 3 effectiveness studies, and

5 basic research studies. None could be

classified as an efficacy study or systematic

review. One study established a link be-

tween occupational engagement and

health. One study was qualitative, and

the remaining 13 were quantitative (see

Table 2).

Only half of the studies could be

classified according to the priority areas

established by the AOTA working group

(see Table 3). Six studies used activity-

or participation-level measures, 4 incor-

porated activity- or participation-level

interventions, 4 used context-based inter-

ventions, and only 2 included environ-

mental modifications. Seven of the 14

studies did not fall into any of these

areas.

Discussion

In recent years, most studies in this area of

rehabilitation have tended to focus on

instrument development and validation. In

addition, the instrument development

studies typically used small (between 30

and 130) convenience samples from a single

setting or geographic region that are not

necessarily representative of the patient

groups they address. The three intervention

studies used quasi-experimental and cohort

designs, in part, their authors noted, be-

cause of the challenge of randomizing in

real-world community and employment

contexts (Darragh, Harrison, & Kenny,

2008;Gentry, 2008;Kielhofner, Braveman,

Fogg, & Levin, 2008). Occupational ther-

apy has a long tradition in qualitative

methods, so the limited number of studies

using this methodology is somewhat sur-

prising. By contrast, occupational therapy

has had less of a tradition of population-

level studies, so it is encouraging to see ep-

idemiologic methods such as those used in

Finlayson, Garcia, and Cho (2008) begin-

ning to be reported in the literature.

The American Journal of Occupational Therapy 507


Activity and Participation andContext-Based Interventions

Few of the studies used strong methodo-

logical designs such as randomized con-

trolled trials (RCTs). RCTs allow for

a level of explanation of causal agents that

other designs do not and often reflect the

culmination of knowledge gained from

numerous earlier, more exploratory stud-

ies. As such, RCTs can reflect a level of

maturity and organization in thinking

about a particular area of inquiry that

demonstrates that a field is systematically

building its knowledge base. Of the 14

studies, 3 were treatment effectiveness

studies (Darragh et al., 2008; Gentry,

2008; Kielhofner et al., 2008). All 3 in-

cluded activity- and participation-level

interventions, and all 3 were context based.

Although not a randomized controlled

trial, Gentry’s (2008) study embodied how

occupational therapy uses knowledge of

underlying capacity to provide context-

based, participation-level interventions

that improve occupational performance.

Participants with multiple sclerosis were

trained to use personal digital assistants to

compensate for cognitive impairments and

to enhance participation in everyday life

tasks at home and in the community. In

more rigorous research studies that in-

cluded control groups, Kielhofner et al.

(2008) and Darragh et al. (2008) provided

interventions to increase productivity in

community settings, supported living fa-

cilities, and the workplace, respectively.

These kinds of studies, although not RCTs,

exemplify the Centennial Vision for occu-

pational therapy research by promoting

participation in real-world environments.

In other studies, the use of occupa-

tion was more tangential. For example,

May-Lisowski & King (2008) had able-

bodied people pick up brownie pieces to

analyze upper-extremity movement. The

rationale for using this food was not de-

scribed. It was not clear that substituting

brownies for apples or even a foam block

would have made any meaningful or sub-

stantive difference to the interpretation of

the study.

Activity and Participation andContext-Based Assessments

Of the 14 studies, 6 included activity-

or participation-level assessments as the

primary focus or outcome measure. The

assessments included self-reported self-

care and instrumental activities of daily

living limitations (Finlayson et al., 2008);

off- and on-road driving assessments (Kay,

Bundy, & Clemson, 2008); the Labora-

tory Assessment Checklist (Occupational

Safety and Health Administration, 2001),

used in Darragh et al. (2008); upper-

extremity function during everyday activi-

ties, using the Manual Ability Measure

(Chen, Kasven, Karpatkin, & Sylvester,

2007) and the Test d’Evaluation de la Per-formance des Membres Superieurs des Per-

sonnes Agees (Desrosiers, Herbert, Dutil, &

Bravo, 1993), both used in Rallon and

Chen (2008); the Parent Disability Index

(Katz, Pasch, & Wong, 2003), used in

Poole, Willer, and Mendelson (2009); the

Canadian Occupational Performance Mea-

sure (COPM; Dedding, Cardol, Eyssen,

Dekker, & Beelen, 2004) and the Craig

Handicap Assessment and Reporting Tech-

nique (CHART; Whiteneck, Charlifue,

Gerhart, Overholser, & Richardson, 1992),

both used in Gentry (2008); and partici-

pation in work, school, training, or vol-

unteering (Kielhofner et al., 2008).

Three of the studies used a combina-

tion of both impairment-level and activity-

or participation-level measures. For example,

Gentry (2008) used the Rivermead Be-

havioral Memory Test–Extended (Wilson,

Cockburn, Baddeley, & Hiorns, 1989) to

evaluate memory and the COPM and the

CHART–Revised to capture activity and

participation levels. Kielhofner et al. (2008)

evaluated both symptoms with the Revised

Sign and Symptom Checklist for people

with HIV/AIDS (Holzemer, Hudson,

Kirksey, Hamilton, & Bakken, 2001) and

productive participation with self-reports

of employment status, school and training,

volunteer involvement, or all of these.

Poole,Willer,&Mendelson (2009) captured

impairment-level pain with a visual analog

scale and fatiguewith theMultidimensional

Assessment of Fatigue Scale (Tack, 1991),

while capturing activity or participation level

Table 1. Summary of Research in Disability, Rehabilitation, and Participation and Work and Industry

Author and Year

Systematicor NarrativeReview

EffectivenessStudy

EfficacyStudy

BasicResearch

InstrumentDevelopmentand Testing

Link BetweenOccupationalEngagementand Health

Quantitative,Qualitative,or MixedMethod

Level ofEvidence

Baker & Redfern (2009) X Quantitative

Canny, Thompson, & Wheeler (2009) X Quantitative

Darragh, Harrison, & Kenny (2008) X Quantitative II

Dunn, Carlson, Jackson, & Clark (2009) X Qualitative

Finlayson, Garcia, & Cho (2008) X Quantitative

Gentry (2008) X Quantitative III

Jang, Chern, & Lin (2009) X Quantitative

Kay, Bundy, & Clemson (2008) X Quantitative

Kielhofner, Braveman, Fogg, & Levin (2008) X Quantitative II

Lindstrom-Hazel, Kratt, & Bix (2009) X Quantitative

May-Lisowski & King (2008) X Quantitative

Poole, Willer, & Mendelson (2009) X Quantitative

Rallon & Chen (2008) X Quantitative

Warren, Moore, & Vogtle (2008) X Quantitative



Table2.Sum

maryof

Study

Designan

dMetho

dology

ofResea

rchin

Disab

ility,

Reh

abilitation,

andParticipa

tion

andWorkan

dIndu

stry

AuthorandYear

Research

Metho

dology

Used

Levelof

Evidence

Sam

pleSelection

Metho

d

Sam

pleCharacteristics

andInclusion–

ExclusionCriteria

Instruments

orInterventions

Used

StatisticsUsed

Results

Study

Limitations

Baker

&Redfern

(200

9)Descriptive,

correlational

Con

venience

sample

from

theun

iversity

Adu

ltkeyboard

users

betweenages

18and65

with

nohistoryof

upper-

extrem

ityfracture

ortraumaticinjury

that

limitedupperextrem

ityuse

K–P

eCS,videotaping

x2,S

pearman’s

rank

correlations

r

Significantdifference

inhand

posturebetweenrigh

tandlefthand

s

Externalvalidity,moderate

intrarater

reliability,hand

dominance

notidentified

Canny,

Thom

pson

,&Wheeler

(200

9)

Prospective,

test–

retest,and

interrater

reliability

Con

venience

sample

from

treatm

entcenter

N5

60Age:20–

68yr

Dx:fib

romyalgia,h

ealthy

controlparticipants

Gender:female

Box

andBlock

Test

ofManualD

exterity

ICC

Pairedttest

Test–retest,.90;interrater,

.85;fib

romyalgiapatients

scored

significantlybelow

controlgroup

andno

rmed

values.

Con

venience

samplemay

notbe

representative;both

treatm

ent

andcontrolgroup

sscored

well

belowno

rms.

Darragh,

Harrison,&

Kenny

(200

8)

Quasi-experimental,

pretest–po

sttest

IICon

venience

sample

from

facilitywhere

stud

ytook

place

Full-tim

eprod

uction

workers

who

were

microscopeoperators

Labo

ratory

Assessm

ent

Checklist,Em

ployee

Com

fortSurvey,

ergonomiceducation

andtraining

ANOVA,ANCOVA

Significantincrease

inbo

dypo

sitioning

andworkstation

design

intheeducation1

training

grou

pandlesser

increase

intheeducation-

onlygrou

pcompared

with

controlgroup

Not

blinded,

inflation,

participant

bias,externalvalidity

(limited

generalizability)

Dun

n,Carlson

,Jackson,

&Clark

(200

9)

Qualitative,

second

ary

analysis

Participants

ofprevious

stud

ywho

developed

pressure

ulcers

19men

andwom

enwith

spinalcord

injury

who

developed

pressure

ulcers

N/A

N/A

46pressure

ulcerevents

ina1-

to5-yr

period

;8main

response

categories

with

subcategoriesidentified

that

describedrespon

seto

pressure

ulcerevents

Limitedgeneralizability

(only

looked

atpeop

lewho

developed

ulcers,not

thosewho

didno

tandcompared);categorization

ofpressure

ulcerno

tconfi

rmed

inmedicalrecord.

Finlayson,

Garcia,&

Cho

(200

8)

Prospectivecoho

rtDirectmailto

consum

ergroups,advertisingin

care

centers

N5

1,282

Age:63.8±9.4yr

Dx:Multiplesclerosis

Structuredteleph

one

interview

Proportional

odds

mod

el38%

ofparticipants

used

occupationaltherapy

since

diagno

sis;occupational

therapyservices

considered

importantto

well-being;

moreactivity

limitations

and

urbanlocationassociated

with

useof

occupationaltherapy

inpastyear.

Limitedgeog

raphicregion

,participantrecallof

serviceuse

only,detailsof

occupational

therapyserviceusenotcollected

Gentry(200

8)Cohort

III

Con

venience

sample

from

localclinicand

localchapter

ofthe

Com

munity-dwelling

peop

lewith

multiple

RBMT–

E,COPM,

CHART–

R,

PDAchecklistor

Repeated-measures

ANOVA,t

test

Significantincrease

inperformance

andsatisfaction;

significant

increase

inmobility,

Sam

plenotfully

representative,

notrand

omized,sub

jective (Continued)



Table2.Sum

maryof

Study

Designan

dMetho

dology

ofResea

rchin

Disab

ility,Reh

abilitation,an

dParticipa

tion

andWorkan

dIndu

stry

(con

t.)

AuthorandYear

Research

Metho

dology

Used

Levelof

Evidence

Sam

pleSelection

Metho

d

Sam

pleCharacteristics

andInclusion–

ExclusionCriteria

Instruments

orInterventions

Used

StatisticsUsed

Results

Study

Limitations

MultipleSclerosis

Society

sclerosiswho

had

cogn

itive

impairment

occupationaltherapists

trainedparticipantsto

use

PDAsas

cogn

itive

aidat

home

cogn

itive

andsocialsubscales;

nosignificant

change

inbehavioralmem

ory

repo

rt;treatingclinicianalso

cond

uctedevaluations.

Jang

,Chern,&

Lin(200

9)Prospective,

reliability,

andvalidity

Con

venience

sample

from

twoscho

ols,three

employmentservices,

andlocalhighschools

N5

130

Age:15–

28yr

Dx:intellectualdisability

andhealthycontrol

participants

LOTC

APictorialIQ

test

•Confirmatory

factor

analysis

•Cronbach’sa

•Spearman’sr

•Kruskal–W

allis

one-way

analysis

•Mann–

Whitney

U•ANOVAwith

Tukey’sHon

estly

Significant

Difference

Confirmed

structureof

LOTC

Awith

confi

rmatory

factor

analysis,low

internal

consistencyformotor

praxisscale.LO

TCAsubscales

correlated

.26–.63with

PictorialIQ

test.

Non

eacknow

ledg

ed.

Con

venience

samplemay

not

berepresentative.

Kay,B

undy,&

Clemson

(200

8)

Retrospective,

coho

rtAllclientsreferred

tocenter

over

a10

-yr

period

.

N5

838

Age:53±20

yrDx:orthop

edic,n

eurologic,

cogn

itive

impairment,

traumaticbraininjury,

vision

impairment,other

VRST–

USyd

on-road

drivingassessment

Rasch

Analysis

(including

MnS

qfit

statistics,point–

measure

correlations,

principal-components

analysisof

residuals)

Allitemsfit

theRasch

model;testdo

esno

tcover

fullrangeofdriving

competence;principal-

compo

nentsanalysis

provided

evidence

ofun

idimension

ality;

reliability5

.95,

nosignificant

DIFfor

gend

er;predictionof

road

performance

sensitivity5

77%,specificity

592

%,

PPV5

67%,N

PV5

95%

Con

venience

samplemay

notbe

representative.On-road

assessorswerenotblindedto

off-road

performance

results.

Reliabilityinform

ationof

on-roadtestwas

limited.

Kielhofner,

Braveman,

Fogg

,&Levin(200

8)

Quasi-experimental,

pretest–po

sttest

with

standard

ofcare

control

IICon

venience

samplefrom

four

localsup

portive

livingfacilities

Adu

ltswith

HIV

orAIDS

who

areho

melessor

atrisk

forho

melessness

SSC–H

IV/ES

Dprog

ram

Produ

ctiveparticipation

x2;odd

sratio

Significantly

high

erlevelsof

productiveparticipationin

modelprog

ram

participants.

Non

random

ized;29

%attrition

rate;standard-of-carecontrol

groupmay

notbe

equivalent

totrue

standard

ofcare.

Lind

strom-Hazel,

Kratt,&

Bix

(200

9)

Prospective,

interrater

reliability

Con

venience

sample

ofstudents

N5

73Age:not

given

Dx:healthy

Jamar

hydraulic

dynamom

eter,

B&LEn

gineering

pinchgaug

e

ICC

ICCsforJamar

dynamom

eter

ranged

from

.996

to.998

;for

pinchgaug

e,from

.949

to.99

Pairs

ofraters

wereno

tscreened,sothey

might

have

seen

whatotherraterscored.

Con

venience

sampleof

raters

may

notbe

representative.

May-Lisow

ski&

King(200

8)Within-sub

jects

repeated

measures

Con

venience

sample

from

localuniversity

University

students,

righ

t‐hand

dominant,

Motionmon

itor,

videotaping,measures

ofshou

lder

flexion

,

Pairedt-tests;

Cohen’sdeffect

size

Significantincreasesin

shou

lder

flexion/abd

uction

during

wristimmobilization;

Generalizability

topopulation

with

upper-extrem

ityinjuries



nohistoryof

upper‐

extrem

ityinjury

abdu

ction,internal

rotation

nosign

ificant

difference

with

internalrotation

Poole,W

iller,

&Mendelson

(200

9)

Cross-sectional

Advertised

for

participantsfrom

nationalsclerod

erma

foundationandlocal

chapters

Mothers

with

scleroderm

awith

children(birth

to18

yr)

livingatho

me

PDI,VAS,HAQ,MAFS

Spearman

r

correlation

coefficients

between

instruments

Poo

rerhealth,high

erlevels

ofpain,fatigue,and

more

activity

limitationwere

relatedto

greaterparenting

difficulty

Sam

plewas

notrepresentative;

author

didno

tcollectages

ofchildren.

Rallon&

Chen(200

8)Prospective,

coho

rtConvenience

sample

from

localclinic

N5

30Age:56±11

.9yr

Dx:orthopedichand

MAM–3

6TE

MPA

•Rasch

Rating

Scaleanalysis

•Spearman’sr

•Unp

airedttest

Mod

erateto

strong

correlations

between

MAM–3

6andTE

MPA,

significant

differences

betweendo

minantand

nondom

inanthand

sfor

TEMPAun

ilateraltasks

Convenience

sample

may

notbe

representative.

Severity

ofhand

dysfun

ctionno

tcategorized.

Warren,

Moore,&

Vogtle

(200

8)

Cross-sectional

Convenience

sample

from

localcom

mun

ity81

healthyadults

betweenages

20and90

Brain

Injury

Visual

Assessm

entBattery

for

Adu

lts,visualsearch

strategies,and

checking

workor

time

2-factor

ANOVA,

2-factor

x2

Horizontal,left-to-right,

top-to-bottom

search

patternfoun

dto

bepredom

inantwith

nosignificant

differencesin

ageor

gend

er;o

lder

adults

(>age60

)took

long

erto

completetests;olderadults

morelikelyto

checkwork.

Externalvalidity

regarding

ethnicity

andculture

Note.ANCOVA=analysisof

covariance;A

NOVA=analysisof

variance;C

HART–R=CraigHandicapAssessm

entandReportingTechnique–Revised;C

OPM

=CanadianOccup

ationalP

erform

ance

Measure;D

IF=differentialitem

function;

Dx=diagnosis;ES

D=EnablingSelf-Determination;HAQ=Health

Assessm

entQuestionnaire;ICC=intraclass

correlationcoefficient;K

–PeCS=KeyboardPersonalC

omputerStyle;L

OTC

A=Loew

ensteinOccupational

TherapyCognitiveAssessm

ent;MAFS

=MultidimensionalAssessm

entof

Fatigue

Scale;M

AM–36=ManualA

bilityMeasure;N

/A=notapplicable;N

PV=negativepredictivevalue;PDA=personaldigitalassistant;P

DI=Parent

DisabilityIndex;PPV=po

sitivepredictivevalue;RBTM

E=RivermeadBehavioralM

emoryTest–E

xtended;

SSC–H

IV=SignandSym

ptom

ChecklistforPeopleWith

HIV/AIDS;T

EMPA=Testd’Evaluationde

laPerform

ance

des

Mem

bres

Sup

erieursdesPersonnes

Agees;V

AS=visualanalog

scale;VRST–USyd

=VisualR

ecog

nitionSlideTest–U

niversity

ofSydney.



with the Health Assessment Questionnaire

(Fries, Spitz, Kraines, & Holman, 1980)

and a parenting tool, the Parent Disability

Index.

Eight of the 14 studies used only

assessments that evaluated impairment-

level constructs such as manual dexterity

(Keyboard Personal Computer Style in-

strument, Baker & Redfern, 2005, used

in Baker and Redfern, 2009, and the

Box-and-Block Test, Cromwell, 1976, used

in Canny et al., 2009); cognition (Loe-

wenstein Occupational Therapy Cogni-

tive Assessment; Itzkovich, Elazar,

Averbuch, & Katz, 2000) and general in-

telligence (Pictorial IQ test; Hsu &

Lu, 1995), both in Jang, Chern, and

Lin (2009); grip strength (dynamometer;

Lindstrom-Hazel, Kratt, & Bix, 2009);

kinematics through motion monitoring

of upper-extremity movement (May-

Lisowski & King, 2008); and visual

function (Brain Injury Visual Assessment

Battery for Adults; Warren, 1998) used

in Warren et al. (2008). Although un-

derstanding impairment is indeed relevant

to occupational performance, this level of

assessment predominates the occupational

therapy studies reviewed here. More im-

portant, information from this level of per-

formance evaluation is not being translated

into greater understanding of activity- and

participation-level interventions. The au-

thors of these studies have generally not

made explicit how such assessments help

understand the person–task–environment

interaction that is at the heart of human

occupation.

Environmental Modifications

Only 2 of the 14 studies included envi-

ronmental modifications. Darragh et al.

(2008) and Gentry (2008) modified work

and home environments, respectively, to

improve their clients’ functional partici-

pation. To prevent work injuries, Darragh

et al. (2008) altered workstations to im-

prove body position and ergonomic design

of workstations for workers manufacturing

microscopes. Gentry (2008) modified cli-

ents’ home computers and gave them per-

sonal digital assistants to use at home to

enhance their functional memory to per-

form everyday life tasks.

One of the most telling statistics

about these articles is not reported in the

tables. Five of the 14 studies did not ac-

knowledge a funding source, 2 reported

funding internal to their organization, 2

were student or PhD research, 1 was funded

by a national society, 2 were funded by

National Institutes of Health career de-

velopment K-awards, 1 was funded by a

government science award (Taiwan), and

1 was funded by a National Institute on

Disability and Rehabilitation Research

field-initiated award. Only the last three

categories represent research proposals that

receive significant external peer review.

The career development awards are en-

couraging because these awards build the

next cadre of researchers. However, build-

ing a systematic body of rehabilitation

research requires investigation over mul-

tiple years, requiring sustained research

funding not generally reflected in this

group of articles.

Conclusions

Occupational therapy research in the areas

of rehabilitation, disability, and partici-

pation and work and industry is showing

progress toward meeting the Centennial

Vision, with several studies focusing on

context-based interventions that result in

changes in client activity and participation.

Activity- and participation-level outcome

measures were the focus of several studies,

yetmost studies continue touse impairment-

level measures as the primary outcome.

An area of concern for an intervention-

focused profession such as occupational

therapy is the paucity of rigorous effec-

tiveness studies, that is, Level 1 research.

In an era of increasing accountability

and public reporting, clear evidence-based

demonstrations of the effectiveness of oc-

cupational therapy research will be critical

to the profession’s continued credibility and

value. For example,Medicare is increasingly

requiring public reporting of quality in-

dicators (Rhoads, Konety, & Dudley,

2009). As we have noted previously, quality

Table 3. Summary of Centennial Vision Priority Areas Related to Research in Disability, Rehabilitation, and Participation andWork and Industry

Author and YearActivity or

Participation MeasuresActivity or

Participation InterventionsContext-BasedInterventions

EnvironmentalModifications

None ofThese

Baker & Redfern (2009) X

Canny, Thompson, & Wheeler (2009) X

Darragh, Harrison, & Kenny (2008) X X X X

Dunn, Carlson, Jackson, & Clark (2009) X

Finlayson, Garcia, & Cho (2008) X

Gentry (2008) X X X X

Jang, Chern, & Lin (2009) X

Kay, Bundy, & Clemson (2008) X X X

Kielhofner, Braveman, Fogg, & Levin (2008) X X X

Lindstrom-Hazel, Kratt, & Bix (2009) X

May-Lisowski & King (2008) X

Poole, Willer, & Mendelson (2009) X

Rallon & Chen (2008) X

Warren, Moore, & Vogtle (2008) X

Number of studies (N5 14) 7 4 4 2 7



indicators require that we define and dem-

onstrate the effectiveness of our inter-

ventions, deliver them consistently to all

relevant clients, and routinely document

their outcomes (Mallinson, Fischer, Rogers,

Ehrlich-Jones, & Chang, 2009). These

concerns are also reflected in the new pri-

orities of the AOTA/American Occupa-

tional Therapy Foundation Research

Advisory Panel (2010), which noted that in

the next decade it will be “imperative that

efficacy and effectiveness of occupational

therapy interventions be ascertained” (p. 1).

We found evidence that a handful

of rehabilitation studies focused on the

effectiveness of occupational therapy in

promoting occupational engagement and

well-being. These studies highlight the

importance of context in producing

therapeutic change. Yet, a major concern

remains that enough of these kinds of

studies simply do not exist to build a co-

herent system of knowledge that serves as

a foundation for advancing the Centennial

Vision. s

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