ORIGINAL ARTICLE

Long-term Effects of a Group Communitybased Constraint-induced Movement
Therapy on Motor Recovery and Activities
of Daily Living in Community-dwelling
Older Adults with Chronic Stroke: A
Preliminary Study with 6-month Follow-Up
Min Y. JUNG, OT, PhD1#, Jung R. KIM, OT, MS1#,
Eun Y. YOO, OT, PhD1, Hye S. JEON, PT, PhD2,
Joshua H. YOU, PT, PhD2
1Department of Occupational Therapy, Yonsei University
2Department of Physical Therapy, Yonsei University

Abstract: The standard one-on-one constraint-induced movement therapy (CIMT)
recently gained widespread acceptance as a means of effective stroke rehabilitation, butinherent issues associated with cost-effectiveness, safety, lack of dynamic groupinteraction, and compliance hampered this novel approach. This preliminary study
highlights the effect of the group community-based CIMT, which integrated the conceptsof the standard CIMT regimen. Eight participants were recruited from a local citycommunity center and trained in the usage of mittens and safety management on theaffected upper extremity for 90% of the hours when awake. The community-based CIMT
was provided for 2 hours a day over 10 days. Outcome measures include motor recovery,
strength, amount of use and quality of movement, self-perceived occupational
performance and satisfaction as well as other psychological factors such as motivation,compliance, and enjoyment. These results all showed significant improvement after
intervention and were maintained even after the 6-month follow up (P<0.05).
Key words: Canadian occupational performance measure, constraint-induced movement
therapy, motor recovery, stroke

Received: May 15, 2008, Accepted: February 13, 2009
Correspondending to: Joshua (Sung) H. You, PT, PhD,
Associate Professor, Department of Physical Therapy,
Graduate School of Rehabilitation Science, Yonsei
University, Director of Virtual Reality Education &Research Center/Center for Movement Impairment
Solutions, 234 Heoungup-Myon, MaeJi-Ri, Wonju City,
Kangwon-do, Republic of S. Korea 220-710
Phone: 82-33-760-2476 fax: 82-33-760-2496
e-mail: neurorehab@yonsei.ac.kr#These authors (Dr. J and Ms K) equally contributed to thiswork.

(Asian J Occup Ther 7: 1–11, 2009)

Introduction
Grasping and manipulation are an importantbasis for normal fine motor skills associated withpreparing a meal, gardening, and handwriting(Kwakkel, 1999). In stroke, however, these motor
functions are commonly affected (Carr et al.,2Group Community-based CIMT1998). As many as 70–80% of all stroke survivors
continue to suffer from this residual fine motor
dysfunction even after they regained functional
independence in ambulation (Wade et al., 1983).
Hemiparetic stroke patients tend to compensate
with the unaffected or less affected hand rather
than re-utilizing the affected hand in theiractivities of daily living (ADL) (Taub et al., 2006).
Subsequently, this leads to disuse or learned nonuse of the affected limbs and further impairs fine
motor skills in the involved limb (Taub et al.,2006). To restore lost motor skills, improve
quality of life, and reduce the long-term socioeconomic cost from stroke, annual cost for stroke
is estimated to be as much as 30–40 billion dollars(Dobkin, 1995). Hence, there is a great demandfor cost-effective stroke intervention to improve
motor recovery and skills of the affected limbs.
To improve motor recovery, different
neurorehabiliation approaches, including
neurodevelopmental treatment (NDT) (Dickstein
et al., 1986), muscle reeducation training using
functional electrical stimulation (Handa et al.,1987) biofeedback training (Wolf et al., 1983),
virtual reality, strength training (Ada et al., 2006),
and a various array of constraint-induced
movement therapy (CIMT) have been used, but
the outcome results were variable (Page et al.,
2002; Taub et al., 1999). Among them, the CIMT
evolved and accumulated sufficient evidence as aneffective intervention paradigm to address thelearned non-use of the involved hand, associatedmuscle weakness and motor skills. For example,
an intensive, one-on-one CIMT was found to
produce measurable functional motor
improvement in a child with a hemiparetic cerebral
palsy (Gordon et al., 2005) and adults with chronic
hemiparesis (Liepert et al., 1998), but its
practicality in a clinical setting warrants further
study due to cost-effectiveness, safety, andcompliance issues (Page, 2002; Underwood et al.,2006). It was suggested that a community-based
CIMT program could help reduce socio-economic
costs and also increase accessibility for a numberof community dwelling people suffering fromchronic hemiparetic stroke (Pang et al., 2006).
To overcome these potential limitations withthe conventional CIMT (Hakim et al., 2005; Yenet al., 2005), we have developed a group
community-based CIMT paradigm where eighthemipareitc stroke patients were grouped andgiven CIMT for 2 hours a day, 5 times a week over
2 weeks at a local health community center. Our
specific aim was to investigate whether thecommunity-based group CIMT was effective in
improving motor recovery of the affected upper
extremity, muscle strength, and associatedoccupational performance. Motor recovery,
muscle strength, hand dexterity, occupational
performance and satisfaction associated with ADL
were assessed by the standardized Fugl-Meyer
assessment (FMA), strength test, gross motor
dexterity, and Canadian occupational performancemeasure (COPM), respectively at pretest, posttest, and a 6-month follow-up test. Additionally, a
post-intervention survey about enjoyment,
motivation, meaningfulness, compliance,
accessibility, social interaction, and fatigue relatedwith the participation in therapy was implemented.

Methods
Participants
A convenience sample of 8 older adults withchronic hemiparetic strokes who met the inclusion
criteria for CIMT was recruited from the local
community. Initially, the total number of 120
target population who registered in the handicap
beneficiary recipient list of a local city healthcenter in the city of Wonju was screened for
eligibility via a telephone interview. Of 120, only
8 subjects who met the inclusion and exclusion
criteria provided signed consent before theparticipation. The inclusion criteria for CIMT
encompass: 1) ≥6 months post-stroke onset; 2) theability to perform 45° shoulder flexion andabduction, 90° elbow flexion and 20° wrist
extension, and 10° finger range of motion (ROM)(Taub et al., 1999). Exclusion criteria included
severe cognitive (>22 in the mini-mental state
examination, MMSE) and verbal (e.g., receptiveaphasia) dysfunctions and non-ambulatory.
Additionally, confidentiality was protected tocomply with the requirements of ethics andnational laws. For example, dummy code
procedure and security cabinet were used toAsian J Occup Ther 7: 1–11, 2009

Jung MY et al.

3

Table 1. Demographic and clinical characteristics of the participantsParticipants

Age

Genderparetic side

Dominant hand

Post-stroke onset
time (months)

1
2
3
4
5
6
7
8

63
68
68
67
71
38
65
65

F
M
M
M
M
M
F
M

R
R
R
L
R
L
L
L

R
R
R
R
R
R
R
R

6
144
48
60
24
33
24
48

Mean ± SD

63.13 ± 10.44

48.38 ± 42.23

SD: standard deviation, F: female, M: male, R: right, L: left.

protect identification of participant and safe
security. Subjects’ demographic and clinicalcharacteristics are shown in Table 1.

Intervention
Intervention was provided at a local thecommunity health clinics of Kangwon province,
South Korea. As with the conventional CIMTdeveloped by Taub (2000), the concept andprinciples of our community-based group CIMT
c o n s i s t e d o f t w o c o m p o n e nt s . F ir s t , t h eparticipants were educated in the usage ofrestraining mittens and safety management on theunaffected upper extremity for 90% of the hours
when awake. Secondly, “shaping” of the CIMT
training procedures was then initiated (Morris etal., 2006). Experienced therapists in CIMT
provided the intervention for 2 hours a day over 10
days. “Shaping” is a form of motor behavioral
technique to develop a target motor behavior bymeans of presenting motivating and functional
activities to the participants (Uswatte et al., 2006).
Specifically, this self-directed CIMT exercise
included (1) moving objects from one shelf toanother; (2) throwing little balls in a bucket; (3)delicate motor practice such as fastening nuts onbolts, putting pegs in a board, buttoning andunbuttoning, rubbing and pressing therapeutic
putty; (4) using a spoon and chopstick; (5)brushing of teeth, and so on. Before the intensive
training, the participants and the therapist met as agroup to discuss efforts how to effectively use themore affected hand, exercised the day before athome, and also to encourage their efforts tocontinue participating in the training period.
Positive feedback including visual, verbal ortactile cues was given to direct the desirable motor
skill acquisition whereas positive reinforcement
including immediate and frequent praise or
cheering, supportive gestures was provided
whenever the participants made meaningful efforts
and progressed toward a novel task with anincrease in the utilization of the affected extremity(Smania, 2006). Based on the motor learning
practice paradigm, functional reaching, grasping,and manipulation tasks along with bearing weighton the arm were broken down in ways that eachparticipant could start practicing on an individualcomponent of the whole task and systematicallywork toward the entire task (Shumway-Cook et al.,2001). Once the adult successfully acquired anovel motor skill, the therapist challenged him or
her to internalize this by gradually increasing the
motor task demands for accuracy, fluidity,
consistency, strength, coordinated automaticity,and ecological carry-over (Morris et al., 2006).
The CIMT was also integrated with daily tasks
including preparing a meal, shaving, dressing,
eating, and grooming in typical home situations.
Shaping motor skills were developed considering(1) client centered goals, motivational andmeaningful activities, age- and gender-appropriate
self-help skills and independence as determined by
the client-centered COPM assessment; and (2)4Group Community-based CIMT

therapeutic exercises that therapists recommended
for optimal functional improvement (Taub, 2000).
No additional treatment was provided because all
the participants had already completed a routine
course of stroke rehabilitation before their
participation of this intervention.

Clinical measurements
The pre-test, post-test, and follow-up-tests
were scheduled at baseline, 2 weeks after thebaseline test, and a 6-month post-intervention,
respectively. The standardized motor recovery,
muscle strength, and functional motor skill tests
were used to determine intervention-relatedchanges in motor recovery, strength, andassociated daily living activities and motor skillsof the affected upper extremity. In addition, we
performed a survey about enjoyment, motivation,
meaningfulness, and compliance. The
standardized tests included the Fugl-Meyer
assessment (FMA), hand grip and pinch strength
test, box and block test, and the Canadian
occupational performance measure (COPM). The
validity and reliability for these standardized tests
are well established (Desrosiers et al., 1994; FuglMeyer et al., 1975; Law et al., 1990; Mathiowetz etal., 1985). The mean value of three successive
trials was calculated in all tests and was used infurther statistical analysis.
Fugl-Meyer Motor Assessment (FMA):
FMA was used to assess motor recovery of theaffected upper extremity and hence only the upper
extremity subset of FMA was utilized. The upper
extremity subset of FMA includes range ofm ot io n , pa in , sen sat io n, re fl ex , sy ne rg y,coordination, and speed. The scores ranged from 0(lowest) to 66 (highest) points (Fugl-Meyer et al.,1975).
Box and Block Test (BBT): The box andblock test was used to measure unilateral manual
dexterity. The test involves a hand motor
performance task that requires moving as many
blocks as possible from one container to the otherwithin one minute. An increase in the number ofblocks moved represents better performance inmanual hand dexterity (Mathiowetz et al., 1985).
Hand strength: Grip and pinch strength were
measured with a Jamar dynamometer (Asimow

Engineering, US) and pinch gauge (B & L
Engineering, US), respectively. For both tests, thesubjects were asked to sit on a chair with shoulder
adduction, 90° elbow flexion and the wrist in aneutral position. The subjects were then instructed
to maximally grip the dynamometer handle for 5
seconds without any compensatory movement.
The pinch strength was determined by asking the
subjects to maximally press a pinch gauge for 5
seconds (Mathiowetz et al., 1985).
Activity of Daily Living: Canadian
Occupational Performance Measure (COPM) :COPM was used to determine a client-centeredoccupational performance associated withactivities of daily living. In the present study, thestandardized COPM was used to assess functional
carry-over or transfer effects of meaningful
occupational performance of each client or
individual. Compared to motor activity log(MAL), the advantage of this test is that it involves
a semi-structured interview which measures boths e l f - r a t ed o cc u p a t i o n a l p e r f o r m a n c e a n dsatisfaction in the domains of self-care,productivity, and leisure. Therefore, this test
reflects the client’s actual ADL performance andsatisfaction accurately which cannot be measured
by MAL. From this test, the top five problem
areas were identified and self-rated by eachindividual based on a scale from 1 (unable toperform ) t o 10 (a ble t o p erform) and fo r
satisfaction from 1 (not satisfied) to 10(satisfied)(Carpenter et al., 2001; Law et al.,1994).
Post-intervention survey: Upon the
successful completion of the intervention, allsubjects were instructed to complete a postintervention survey that asked about enjoyment,
motivation, meaningfulness, compliance,
accessibility, social interaction, and fatigue
associated with therapy. The scale ranges from 1(worst) to 4 (best).

Statistical analysis
The independent variable was a group
community-based CIMT and dependent variables
included motor recovery, strength, andoccupational performance and satisfaction
measures. The mean and standard deviation, andAsian J Occup Ther 7: 1–11, 2009

Jung MY et al.

5

Fig. 1. Effects of the group community-based CIMT on
FMA scores. *P<0.05.

Fig. 2. Effects of the group community-based CIMT on
pinch strength. *P<0.05.

one-way repeated analysis of variance (ANOVA)
were computed to compare intervention-relatedchanges across three tests. Post-intervention
survey data were analyzed using descriptive
statistics. Statistical analysis was performed using
SPSS (version 12). All significance level was set
at P<0.05.

Specifically, post hoc analysis demonstrated thatno significant differences between the pretest andpost-test scores (P=0.580) as well as between thepretest and follow-up test scores (P=0.605) wereobserved. Similarly, these results indicated thatthe intervention was beneficial in the effective
enhancement of manual hand dexterity inindividuals with chronic hemiparesis. This
intervention effect was maintained even at the 6month follow-up test.

Results
Motor recovery
One-way repeated ANOVA analysis revealed
a significant difference across the three points ofmeasurement (P=0.008) (Table 3). Post hoc
analysis showed that there were significant
differences between the pretest and post-testscores (P=0.012) as well as between the pretestand follow-up test scores (P=0.004). However,there were no significant differences between the
post-test and follow-up test scores (P=0.613).
These findings suggest that the group communitybased CIMT was effective in the restoration of
motor recovery of the affected upper extremity andthis effectiveness was retained in the follow-up
test (Fig. 1).

Muscle strength
Pinch strength data showed significant
differences across the three points of measurement(P=0.006) (Table 3). Post hoc analysis confirmedthat there were significant differences between thepretest and follow-up test scores (P=0.002) as well
as between the post-test and follow-up test scores(P=0.013) (Fig. 2). However, grip strength data
analysis was unaffected by this intervention(P=0.788). These results imply that only pinch
strength was enhanced as a function ofintervention and still remained after postintervention.

Hand manual dexterity

Clients’ perception of self-rated occupational
performance

ANOVA analysis showed no significant
difference across the three tests (P=0.822).

Table 4 presents significant intervention
effects on the occupational performance and6Group Community-based CIMT

Table 2. Individual Fugl-Meyer Motor Assessment data
Participants
1
2
3
4
5
6
7
8
Mean ± SD

PretestPost-test

6-month follow-up test

53
52
60
52
55
58
50
60

59
57
63
56
57
61
58
61

61
57
63
59
57
61
59
61

55.00 ± 3.89

59.00 ± 2.45

59.75 ± 2.12

P-value0.008*

SD: standard deviation, *P<0.05.

Table 3. Individual pinch strength (kg) data
Participants
1
2
3
4
5
6
7
8
Mean ± SD

PretestPost-test

6-month follow-up test

0.5
2
4
2.7
2
3.5
1.5
1.7

0.5
2
4.5
4.5
2
4
1.5
3.5

3.7
2
8.5
4.5
5
5
4
7.3

2.24 ± 1.13

2.81 ± 1.51

5.00 ± 2.05

P-value

0.006*

SD: standard deviation, *P<0.05.

satisfaction scores. A significant difference acrossthe three mean COPM performance scores wasfound (P=0.0001). Post hoc analysis showed thatsignificant differences between the pretest andpost-test scores (P=0.000) as well as between thepretest and follow-up test scores (P=0.000) wereobserved. However, there was no significant
difference between the post-test and follow-up testscores (P=0.156) (Fig. 3). A significant difference
across the three mean COPM satisfaction scores
was found (P=0.0001). Post hoc analysis showedthat significant differences between the pretest andpost-test scores (P=0.000) as well as between thepretest and follow-up test scores (P=0.000) wereobserved. There was a significant difference

between the post-test and follow-up test scores(P=0.021) (Fig. 4). These findings suggest that theperceived self-rated occupational performance
improved after the intervention and wasmaintained even in the 6-month follow-up test.

Post-intervention survey
The survey revealed that all participants
enjoyed the social interaction during the program;
were highly motivated and supportive each other.
They also reported that the therapy was extremely
meaningful, realistic, individualized, andfunctional because it was a client-centeredprogram. All participants showed perfectattendance, indicating an excellent compliance.

Asian J Occup Ther 7: 1–11, 2009

Jung MY et al.

7

Table 4. Individual Canadian Occupational Performance Measure data
Participants
Pre

Performance scores
Post

FU

Pre

Satisfaction scores
Post

FU

1
2
3
4
5
6
7
8

3.70
6.00
1.30
1.70
2.00
4.00
1.80
2.30

7.70
6.00
8.30
7.30
7.70
7.30
6.30
4.60

8.60
7.50
8.30
7.30
7.60
8.30
8.00
6.70

4.30
3.50
3.30
2.30
3.00
3.00
2.00
2.00

7.30
4.50
8.00
7.30
8.70
7.70
5.30
4.20

8.60
7.50
8.30
7.60
8.30
9.00
7.80
7.30

Mean ± SD

2.85 ± 1.60

6.90 ± 1.20

7.79 ± 0.63

2.93 ± 0.80

6.63 ± 1.71

8.05 ± 0.59

P-value

0.0001*0.0001*

SD: standard deviation, Pre: pretest, Post: post-test, FU: 6-month follow-up test, *P<0.05.

Fig. 3. Effects of the group community-based CIMT on
COPM performance. *P<0.05.
Fig. 4. Effects of the group community-based CIMT on
COPM satisfaction. *P<0.05, **P<0.001.

Discussion
Our basic assumption was that the group
community-based CIMT may improve restorationof motor function, muscle strength, and associated
ADL. As anticipated, our results demonstrated
that motor recovery and associated ADL skills of
the affected upper extremity increased after theintervention and these improvements weretransferred to home environments and retainedeven during a 6-month follow-up. Certainly, ournovel findings suggest that the group communitybased CIMT paradigm can be an alternative
approach which can appropriately address thesocio-economic and compliance issues raised in
the conventional CIMT. The target population iscommunity-dwelling chronic stroke survivors andintervention implemented in community health8Group Community-based CIMT

clinics to increase integration into the community.
Despite the fact that our community-based
CIMT protocol had much less treatment time (2hours a day for 2 weeks) and was implemented ina group session, the present study showedpromising results which could favorably becompared to previous clinical trials investigating
the effects of CIMT in stroke rehabilitation.
Several CIMT studies have produced measurable
neuroplastic changes and associated functional
outcomes in participants with hemiparetic stroke(Bonifer et al., 2005; Dettmers et al., 2005;
Sunderland et al., 2005). However, considering
the current managed health care model, the CIMT
approach which often requires a prolonged
individual client-therapist session, and associatedcost and compliance issues may not be viable, butrather demands for effective alternative
neurorehabilitation programs. For example, it was
documented that several undesirable behavioral
patterns connected with individual client-therapist
session for 5 to 6 hours a day during the standard
CIMT resulted in boredom and fatigue coupledwith stressful and depressing feelings andemotions (Boylstein et al., 2005). In fact, several
patients who participated in the CIMT became
depressed and required psychologicalconsultations. On the contrary, in our communitybased group CIMT intervention, we observed thatall participants appeared to enjoy the dynamic
group interactions which were evidenced by no
attrition rate, perfect attendance, good compliance,
supportive atmosphere, and positive body gestures(smile and appraise). Perhaps, the group session
may have facilitated motivation and encouraged
individual participant to obtain his or her goals via
pleasant dynamic group interaction (Pang et al.,2006). Additionally, the cost-effectiveness isanother advantage of our community-based group
CIMT intervention. In fact, we can reduce thecurrent therapy cost by as much as 50%.
In an attempt to offset cost while improving
effectiveness that was neither attempted nor
afforded by the standard one-on-one CIMT, recent
studies (Lum et al., 2004; Page et al., 2005; Pang etal., 2006; Taub et al., 2005) started to modify theconventional CIMT approach. For example, theparadigm shifted from a clinic to a home setting,thus from an individual basis to a small group basis(2–3 persons), which in addition, resulted in
reduced supervision time. However, to ourknowledge, this is the first attempt examining theeffectiveness of a group community-based CIMT
on motor recovery, strength and occupational
performance and satisfaction. Our FMA results
showed significant changes in motor recovery as afunction of intervention and this recovery
continued to exist even 6 months after initialintervention. This motor recovery was further
corroborated by significantly increased pinch
strength and hand dexterity function. Similarly,
clients’ perception of self-rated occupational
performance showed that all participants haveachieved their established goals and reported
higher satisfaction as evidenced by the COPM
satisfaction score.
Most importantly, our primary inquiry
addressed in this preliminary experiment, wassupported by the fact that there were significant
differences in the outcome measures of motor
behaviors and ADL performance across the threetest points. Such evidence seems to imply thenotion that both reduced supervision or treatment
time and a group-based approach used in ourpresent group community-based CIMT regimen
does not preclude a possible advantage or benefit.
Further study warrants elucidating the potential
equality or superiority in cost-effectivenessbetween the standard and group community-based
CIMTs.
Post-intervention survey data showed that theparticipants reported psychosoical benefits
including enjoyment, motivation, meaningfulness,compliance. For example, we observed no
attrition rate, greater interaction with happy
smiles, and supporting and encouraging eachother. Probably, these benefits may havefacilitated engagement on tasks and the amount of
use and quality of the movement of the more
affected limb during activities, which in turncontributed to motor recovery, strength, and selfperceived occupational performance andsatisfaction.

Asian J Occup Ther 7: 1–11, 2009

Jung MY et al.

Limitation of study and suggestions for futurestudy

maximizing therapeutic efficacy.

This preliminary study explored thefeasibility of a community-based group CIMT
program for the effective management of upper
extremity motor dysfunction and associatedgrasping and manipulation performances inindividuals with chronic stroke. Someshortcomings identified in this preliminary study
that could assist in improving the design of future
research include small sample size, and lack of acontrol group. Therefore, precaution should be
exercised when interpreting our results. This
study invites future research that should be
implemented with a robust experimental design
and a larger sample size to generalize our findings.
It would be of great interest to compare costeffectiveness between the community-based group
CIMT and the conventional therapy models in
future.

References

Conclusions
This present study represents a successful
steppingstone toward the development of a group
community-based CIMT program. Numerous
stroke survivors are financially burdened and often
discharged to home without receiving the benefitsof an essential long-term rehabilitation program tomaximize motor recovery (Lum et al., 2004).
Consequently, stroke victims who were notproperly rehabilitated may predispose them tofatal falls or other medically debilitating
conditions such as pneumonia, contracture,decubitis ulcers, and atrophy due to a lack ofphysical activity and meaningful occupational
performance (Taub et al., 2006). This may lead toa vicious cycle of physical disabilities and socioeconomic constraint to the individual, family, andsociety at large. The group community-based
CIMT program may thus be an alternative choiceof intervention that embraces both emerging
health promotion and prevention in individuals
with chronic disabilities resulting from stroke. In
addition, this program can accommodate a large
number of community dwelling older adults anddoes not require individual attention as in thestandard CIMT, thereby reducing costs and

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16–20.

ORIGINAL ARTICLE

More Appropriate, Practical Outcome
Measures in Clinical Trials for
Rehabilitation: A Survey of Medical
Literature from 1996–2005
Tomoko OHURA, OTR, MPH1, Chika NISHIYAMA, RN, MPH2,
Takeo NAKAYAMA, MD, PhD3
1Doctoral student, Department of Health Informatics, Kyoto University School of Public

Health2Doctoral student, Department of Preventive Services, Kyoto University School of Public

Health3Professor, Department of Health Informatics, Kyoto University School of Public Health

Abstract: This study aimed to characterize outcome measures used in trials of
rehabilitation for stroke patients using the “International Classification of Functioning,
Disability, and Health (ICF)”. We investigated descriptions of randomized controlled
trials (RCTs) published between 1996 and 2005. We then identified and classified
outcome measures into three ICF-based categories: “body functions and structure,”“activities and participation,” and “other.” Within rehabilitation RCTs, 21 focused oncommunity residents and 20 focused on hospitalized patients. We identified 215 mentionsof the measures in total and 103 types were used in 41 stroke rehabilitation RCTs from1996–2005. Of the 41 articles, 7 were RCTs of occupational therapy while 6 RCTs
focused on community residents. The percentage of outcome measures in the domain of“body functions and structures” has increased since ICF adoption. It is necessary todemonstrate evidence that outcome measures are useful in patient-oriented decisionmaking in occupational therapy and rehabilitation.
Key words: stroke, rehabilitation, occupational therapy, outcome measures(Asian J Occup Ther 7: 13–22, 2009)

Introduction
In order to maintain quality of life, stroke
Received: November 27, 2008, Accepted: February 22, 2009
Corresponding to: Tomoko Ohura, Department of Health
Informatics, Kyoto University School of Public Health,
Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
Phone/fax: +81-75-753-9479
e-mail: oh-ura@umin.ac.jp

survivors require support such as proper living
assistance and nursing care due to physical andmental disabilities. The Japanese society has been
rapidly aging in recent years. Stroke mortality rateis decreasing (Health and Welfare Statistics
Association, 2005), but cerebrovascular disorders
including strokes comprise 29.1% of causes which
require elderly patients to seek nursing care
(Ministry of Health, Labour and Welfare, 2004).

14

A LITERATURE SURVEY ON OUTCOMES OF REHABILITATION TRIALSThis trend is particularly pronounced among
younger seniors, for whom this is the primaryreason they require nursing care. Until they return
to home life, stroke patients are recommended tocontinue to receive care for various disabilities
from the period immediately after the stroke
through the period of rehabilitation andmaintenance (Shinohara, Yoshimoto, Fukuuchi, &Ishigami, 2004).
Evidence-based medicine (EBM) seeks tofacilitate better decision-making in clinicalmedicine, integrate “patients’ preferences andactions,” “clinical state and circumstances” and“research evidence,” and provide patients with thebest treatment possible (Haynes, Devereaux, &Guyatt, 2002). These principles are applied toboth individual clinical situations and publichealth (J.A. Muir Gray, 2004). Randomized
controlled trials (RCTs) are thought to yield thebest assessment of treatment efficacy (Shinohara,
Yoshimoto, Fukuuchi, & Ishigami, 2004; Fletcher,
Fletcher, & Wagner, 1996; Straus, Richardson,
Paul Glasziou, & Haynes, 2005). In the field ofoccupational therapy, evidence is limited in bothquantity and quality.
In May 2001, the World Health Organization(WHO) adopted the International Classification of
Functioning, Disability, and Health (ICF) as ameasure to assess human life functioning. Humanlife functioning and disability are classified by atotal of 1500 items, which consist of domains suchas “body functions and structure,” “activities andparticipation,” and “environmental factors”(World Health Organization, 2001). Furthermore,
the codes for each medical condition are now
being standardized (Geyh, Cieza, Schouten,
Dickson, Frommelt, et al., 2004).
In rehabilitation of stroke patients, indicatorsfor measuring effectiveness vary according toanatomical location and time from onset of thestroke. It is often true that different patientsrequire different rehabilitation goals.
Occupational therapists strive to help patients
improve “occupational performance” in thehospital, at home, and within their community.
Consequently, the evidence necessary to select thebest treatment method varies by setting. As aresult, gaps arise between patients and providers intreatment expectations and information-sharing,which make shared decisions regarding
rehabilitation goals difficult. Geyh, Kurt,
Brockow, Cieza, Ewert, et al. (2004) reviewed
outcome measures used in stroke trials and foundthat the most frequently used ICF categories were“walking,” “defecation functions,” and “supportand relationships, unspecified”. Duncan,
Jorgensen, and Wade (2000) reviewed RCT ofpharmacological interventions in the acute phaseof stroke and recommended that future studies
include extended/instrumental activities andadvanced mobility. It does seem, however, thatclinical purpose and treatment effects varydepending on whether patients are community
residents or hospital patients. To our knowledge,
no studies have examined the effect of thesesettings on measurement trends.
This study was conducted to better
understand RCT outcome measures in different
settings. We divided target research articles into
two groups according to the characteristics ofresearch participants as community residents or
hospital patients. We then investigated theoutcome measures used in RCTs of stroke patient
rehabilitation published between 1996 and 2005.
We reviewed relevant literature and considered thefollowing questions: (i) For the outcome measuresused, was there a difference in percentages of the
ICF domains, “activities and participation,” and“body functions and structures” in RCTs focusedon community residents versus hospital patients?
(ii) Did percentages of ICF domains of theoutcome measures differ between the period
beginning 5 years before ICF adoption and 5 years
after adoption? (iii) Did the special characteristics
of outcome measures used in multiple studies
differ between RCTs of community residents andhospital patients? (iv) For the outcome measuresused, was there a difference in percentages of the
ICF domains and analyzed outcome measuresused in multiple studies in occupational therapy?

Methods
We performed a quantitative literature
review. The method used can be divided into threemain steps:

Asian J Occup Ther 7: 13–22, 2009

Step 1: Among studies on rehabilitationintervention for stroke patients that are listed in the
medical database, MEDLINE (PubMed), we
reviewed studies involving RCTs. For the current
study, selection criteria included: (i) clinicalmedical research using human subjects, (ii) studies
including subjects at least 65 years of age, (iii)
studies noting that the distribution of intervention
was random, (iv) studies written in English or
Japanese, and (v) studies published between
January 1, 1996 and December 31, 2005. Twosearches were performed in PubMed as described
below. The following types of studies were
excluded from our review: designs which could be
judged from the title or abstract not to involve
RCT; designs involving pharmaceutical or
surgical interventions; and studies which either did
not clarify whether subjects were community
residents or hospital patients, or combined bothtypes of subjects.
[Search method 1]: Searched on May 18, 2006
Search: “Cerebrovascular Disorders” [majr]
AND “rehabilitation” [majr]
Limits: Age of 65+years, English, Japanese,
Pu blication Date fro m 1996 to 2 005,
Randomized Controlled Trial, Humans.
[Search method 2]: Searched on May 1, 2007
Search: “Cerebrovascular Disorders” [majr]
AND “occupational therapy” [majr]
Limits: Age of 65+years, English, Japanese,
Pu blication Date fro m 1996 to 2 005,
Randomized Controlled Trial, Humans.
Step 2: When reviewing research articles, we
identified (i) the journal title and year of
publication, (ii) whether research subjects werelocal residents or hospital patients, (iii) period ofintervention, (iv) evaluation period used tomeasure outcome, and (v) outcome measures used.
Step 3: Outcome measures identified weredivided into three domains in accordance with the
ICF: “body functions and structures,” “activities
and participation,” and “other,” a category that
includes factors such as environment and qualityof life (QOL).
After steps 1 and 2 were performed by the
first reviewer (TO), results were checked by asecond reviewer (TN) when necessary to resolve
any inconsistencies. In addition, steps 2 and 3

Ohura T et al.

15

were checked against the results of third reviewer(CN), who worked independently of the first andsecond reviewers. Inconsistencies were also
discussed by the first and third reviewers (TO,CN).
Next, the following analyses were performed:(i) comparison of the percentage of RCTs ofcommunity residents and hospital patients among
the types of outcome measures used over a periodof 10 years and the frequency of mentions ofoutcome measures; (ii) comparison of thepercentage of studies from 1996–2000 and from2001–2005 in terms of the types of outcome
measures used and the frequency of mentions ofoutcome measures; (iii) examination of thenumber of times that outcome measures were used
at least twice during the 10-year period anddescriptions of the domains of these measures.
Descriptive statistics were used to analyze thenumber of times the various outcome measures
were mentioned. Data were analyzed statisticallyby the Chi-square and Fisher’s exact test using
SPSS 16.0 Japanese, whereby statisticalsignificance was set at the 0.05 level. Then
Bonferroni correction was made for multiple
comparisons, after which statistical significancewas set at the 0.017 level (p=0.05/3).

Results
Among the 70 articles found on PubMed insteps 1 and 2 of our process, there were 53 studies
of rehabilitation intervention based on RCTs. Of
these studies, 41 met the selection criteria bystating whether RCT subjects were community
residents or hospital patients (21 RCTs focused oncommunity residents, 20 RCTs focused on
hospital patients), as shown in Fig. 1. Of the 41
articles that described rehabilitation intervention
RCTs on specific subject types, 26 articles were
published between 2001 and 2005. For thenumber of outcome measures used per study, themode was 4 and the median was 5 (lowest 1,
highest 10). For the number of outcome measuresin each study analyzed by test subject, the modewas 3 and 7, and the median was 6 (lowest 2,
highest 10) for RCTs of community residents,
whereas in studies of RCTs of hospital patients,

16

A LITERATURE SURVEY ON OUTCOMES OF REHABILITATION TRIALS

Fig. 1. RCT inclusion criteria for the present study

the mode was 4 and the median was 4 (lowest 1,
highest 9).
Step 3 of our process demonstrated that all 41
studies used at least one outcome measure in thedomain of “activities and participation.” In stroke
rehabilitation intervention RCT studies publishedin the 10-year period from 1996 to 2005, 103 typesof outcome measures were used, with a total of
215 mentions of measures. Of the mentions ofoutcome measures, 62 (28.8%) were in the domainof “body functions and structures,” 123 (57.2%)
were in the domain of “activities andparticipation,” and 30 (14.0%) were in the “other”
domain.
The ICF breakdown of outcome measuresused in RCTs of community residents and hospitalpatients is shown in Table 1. Of outcome
measures mentioned in RCTs of community
residents, 59.2% belonged to the domain of“activities and participation,” which was greaterthan the 54.7% of outcome measures from thesame domain in RCTs of hospital patients. On theother hand, there was a tendency for outcome
measures in the domain of “body functions andstructures” to constitute a greater percentage of
total mentions of outcome measures among RCTsof hospital patients. However, no statisticallysignificant difference was found in thecomposition of the two groups.
Table 2 compares the percentages of ICF
outcome measures mentioned in studies from1996–2000 and from 2001–2005. Mention of

Table 1. Outcome measures used in 41 RCTs in different patient settings

All
Body functions and structures
Activities and participation
Other

Community residentsn(%)

Hospital patients
n
(%)

120
31
71
18

95
31
52
12

(100)
(25.8)(59.2)(15.0)(100)(32.6)(54.7)(12.6)

p value*

0.292
0.579
0.694

* Chi-square test and Fisher’s exact test were used to determine the composition of the two groups.

Table 2. Outcome measures used in 41 RCTs
1996–2000
All
Body functions and structures
Activities and participation
Other

2001–2005

p value*

n

(%)

n

(%)

78
14
50
14

(100)
(17.9)(64.1)(17.9)

137
48
73
16

(100)
(35.0)(53.3)(11.7)* Chi-square test and Fisher’s exact test were used to determine the composition of the two groups.

0.008
0.152
0.233

Asian J Occup Ther 7: 13–22, 2009

Ohura T et al.

17

Table 3. Comparison of outcome measures from different patient settings in 1996–2000 and 2001–2005
1996–2000
Community residents
All
Body functions and structures
Activities and participation
Other
Hospital patientsAll
Body functions and structures
Activities and participation
Other

2001–2005

p value*

n

(%)

n

(%)

39
5
26
8

(100)
(12.8)(66.7)(20.5)

81
26
45
10

(100)
(32.1)(55.6)(12.3)

0.027
0.322
0.279

39
9
24
6

(100)
(23.1)(61.5)(15.4)

56
22
28
6

(100)
(39.3)(50.0)(10.7)

0.122
0.300
0.542

* Chi-square test and Fisher’s exact test were used to determine the composition of the two groups.

outcome measures in the domain of “bodyfunctions and structure” increased from 17.9% in
1996–2000 to 35.0% in 2001–2005, whereas
mentions in the domain of “activities andparticipation” decreased from 64.1% in the earlier
period to 53.3% in the later period. Thus, in recent
years, percentage of outcome measures in thedomain of “body functions and structures” hassignificantly increased (p=0.008). A comparisonof studies from 1996–2000 and 2001–2005, sorted
by type of test subject studied in RCT, is shown in
Table 3. In RCTs of community residents,
percentage of outcome measures in the domain of“body functions and structures” increased(p=0.027), however, it was not significant after the
Bonferroni correction was made.
During the 10-year period between 1996 and2005, 23 types of outcome measures (of a total of
63 types) were used in at least 2 RCTs ofcommunity residents, whereas 18 types (of a totalof 57 types) were used at least 2 times in RCTs of
hospital patients (of a total of 57) (Table 4).
“Walking speed,” “gait distance,” and “Barthel
Index” were used in studies of either group of test
subjects. Although the “activities andparticipation” outcome measures used in RCTs of
hospital patients consisted of measures related tob a s i c m ov e m e n t s a n d s e l f - c a r e , R C T s o fcommunity residents included measures related tohandicaps and leisure.
Of the 41 articles found in steps 1 and 2, 7
were RCTs of occupational therapy, while 6 ofthese focused on community residents. In RCTs ofoccupational therapy for stroke patients publishedfrom 1996 to 2005, 23 types of outcome measures
were used, with a total of 37 mentions of themeasures. Of these, 6 (16.2%) were in the domainof “body functions and structures,” 22 (59.5%)
were in the domain of “activities andparticipation,” and 9 (24.3%) were in the “other”
domain. From 1996 to 2005, 5 types of outcome
measures (out of a total of 21 types) were used in
at least 2 RCTs of community residents (Table 5).

Discussion
We found that outcome measures in thedomain of “activities and participation”
represented over half of all outcome measuresused in RCTs of either community residents or
hospital patients. There were no major differencesin the ICF composition between the two groups ofparticipants. Given the advances in medical andrehabilitation management, it has been previously
suggested that the currently used outcome
measures that focus on functional assessment arelimited (Jette, & Haley, 2005), and that there is aneed to adopt measures related to more practicallyapplicable movements within the domain of“activities and participation” (Geyh, Kurt,
Brockow, Cieza, Ewert, et al., 2004). With regard
to rehabilitation outcomes of adult stroke patients,
assessment of stroke-related impairments andfunctional status and encouragement of patient

18

A LITERATURE SURVEY ON OUTCOMES OF REHABILITATION TRIALS

Table 4. Type and frequency of outcome measures used in ≥2 of 41 RCTs
Outcome measures in RCTs ofcommunity residents
Body functions and structures
Maximum VO2
Muscular strength
Grasping power
Fugl-Meyer Assessment

RCT(times)Outcome measures in RCTs of
hospital patients

RCT(times)3524National Institutes of Health Stroke Scale score
Heart rate
Blood pressure
Ashworth Scale
Fugl-Meyer Assessment
Rivermead Motor Assessment Score
Lower extremity portion of an early version of
the Stroke Rehabilitation Assessment ofMovement (STREAM)

2
2
2
4
2
3

Action Research arm test
Berg Balance Scale
Time for standing up/ sitting down
Gait distance (e.g., in 6 minutes)
Walking speed (e.g., in a 10 m gait)
Maximal workload
Barthel Index
Functional Independence Measure (FIM)
Nottingham Extended Activities of Daily
Living Scale

2
2
2
6
8
2
7
4

Nottingham Health Profile
Length of hospital stay2
2

Activities and participation
Action Research Arm Test
2
Functional Reach Test
2
Motor Activity Log
2
Jebsen Test of Hand Function
2
Berg Balance Scale
5
Timed Up and Go test
2
Gait distance (e.g., in 6 minutes)
7
Walking speed (e.g., in a 10 m gait)
5
Stair climbing
2
Barthel Index
7
Functional Independence Measure (FIM)
3
Lawton Scale of Instrumental ADL
2
Nottingham Extended Activities of Daily Living Scale 5
Nottingham Leisure Questionnaire2London Handicap Scale
2
Other
Nottingham Health Profile
Sickness Impact Profile
Medical Outcomes Study short-form,
36-item questionnaire (SF-36)
General Health Questionnaire

2
4
2
4

Table 5. Type and frequency of outcome measures used in ≥2 of 6 RCTs
(occupational therapy intervention for community residents)
Outcome measures in RCTs

RCT (times)

Activities and participation
Barthel Index
Nottingham Extended Activities of Daily Living Scale
Nottingham Leisure Questionnaire
London Handicap Scale

4
5
2
2

Other

4

General Health Questionnaire22Asian J Occup Ther 7: 13–22, 2009

participation in community and social activities
have been recommended (Duncan, Zorowitz,
Bates, Choi, Glasberg, et al., 2005). We found,however, that these criteria have not been fully
incorporated when trials of rehabilitation forstroke patients are planned and conducted.
Since adopting the ICF, the focus has been on“activities and participation” as an outcome
measure. Nevertheless, in considering thecharacteristics of outcome measures used before(1996–2000) and after (2001–2005) ICF adoption,
it is clear that the percentage of outcome measuresin the domain of “body functions and structures”
has increased. Although not statisticallysignificant after Bonferroni correction, thist e n d e n c y w a s o bs e r v e d m or e i n R C T s o fcommunity residents than in those of hospitalpatients. There are two possible reasons for thisfinding. First, prior to ICF adoption, “bodyfunctions and structures” outcome measures wereused less frequently in RCTs of community
residents, compared with RCTs of hospitalpatients. Secondly, these outcome measures may
be less influenced by environmental factors during
the research design stage, which makes it easier toobserve changes in patient outcomes. When
conducting evidence-based clinical practice, it isperhaps necessary to understand the special
characteristics and limitations of outcome
measures used in quantitative research.
Only a few of the outcome measures used in
RCTs between 1996 and 2005 appeared in at least
two studies; rather, each study tended to use its
own unique measures of outcomes. Althoughoutcome measures in the domain of “activities andparticipation” comprised over half of the total,many of these measures assessed basic
movements. In several RCTs of community
residents, measures of Instrumental Activities of
Daily Living (IADL) and leisure were used inaddition to outcome measures of basic movement
abilities (such as balance and walking) andActivities of Daily Living (ADL). On the other
hand, RCTs of hospital patients primarily usedoutcome measures related to basic movement
ability and self-care. This difference in outcome
measures may reflect the fact that recovery of

Ohura T et al.

19function and achievement of self-care are viewed
as more important aspects of treatment in RCTs of
hospital patients.
Furthermore, the pattern of outcome
measures used in RCTs of occupational therapy
differed from those of rehabilitation in general.
Six out of 7 RCTs of occupational therapy wereconducted in community settings. Three of 5 typesof outcome measures used in at least two studies
were adopted in more than half of those RCTs.
One main limitation of our literature review
was that it was limited to RCTs of rehabilitationintervention in the field of medicine. Moreover,
the only database used was MEDLINE, anddatabases in the fields of psychology andsociology were not utilized. Our review was also
limited to studies written in English and Japanese.
Finally, because our study sought to characterize
outcome measures considering ICF domains byclinical setting (community or hospital), RCTs that
did not clearly state the type of participants were
excluded.

Conclusions
In recent years, the percentage of outcome
measures in the domain of “body functions andstructures” has increased in RCTs of stroke both incommunity residents and in hospital patients.
Outcome measures used at least 2 times in RCTs
were limited, and “activities and participation” inhospital patients were limited to only basic ADLs.
As stroke patients have long survival periods,
evidence that focuses on patient perspective is
v it al fo r se lect io n of treat m ent m eth od s.
Therefore, in order to build evidence that supports
clinical practice, it is important for researchers tomake use of practical outcome measures thatconsider patient quality of life, including “humansocial life,” rather than outcome measures that
focus solely on parameters such as basic
movements and self-care. In particular, to build
evidence in occupational therapy, it is necessary toconsider these domains when conducting RCTs,
non-randomized control trials, as well as
observational studies.

20

A LITERATURE SURVEY ON OUTCOMES OF REHABILITATION TRIALS

Acknowledgements
We would like to acknowledge Professor
Takashi Kawamura and the staff of Kyoto
University School of Public Health for theirvaluable comments. We would also like to thankmy colleagues at Shiga School of Medical
Technology. This paper was completed as part ofa Master’s project at Kyoto University School of
Public Health.

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Asian J Occup Ther 7: 13–22, 2009

life activities and quality of life: a controlled,
prospective, and randomized study of acute stroke
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N. B. (1997). A randomized controlled trial ofenhanced Social Service occupational therapy forstroke patients. Clinical Rehabilitation. 11(2),107–113.
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M. F., Dyas, J., & Groom, L. (2004). Randomised
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stroke. BMJ. 329(7479), 1372–1375.
* Lum, P. S., Burgar, C. G., Shor, P. C., Majmundar,M., & Van der Loos, M. (2002). Robot-assisted

Ohura T et al.

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T., Harris, J. E., & Gylfadottir, S. (2005). Exercise
leads to faster postural reflexes, improved balance
and mobility, and fewer falls in older persons withchronic stroke. Journal of the American Geriatrics
Society. 53(3), 416–423.
* McClellan, R., & Ada, L. (2004). A six-week,resource-efficient mobility program after
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Physiotherapy. 50(3), 163–167.
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toukei/saikin/hw/k-tyosa04/4-2.html (inJapanese).
* Moreland, J. D., Goldsmith, C. H., Huijbregts, M.
P., Anderson, R. E., Prentice, D. M., Brunton, K.
B., O’Brien, M. A., & Torresin, W. D. (2003).
Progressive resistance strengthening exercises
after stroke: a single-blind randomized controlled
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M u i r G r a y , J . A . ( 2 0 0 4 ) . E v i d e nc e - ba s e d
Healthcare: How to Make Health Policy andManagement Decisions. 2 n d e d . E l s e v i e r
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Phillips, E., Stein, J., Frontera, W. R., & Fielding,
R. A. (2004). High-intensity resistance training
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Medicine and Rehabilitation. 86(3), 399–402.
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(2004). Efficacy of modified constraint-induced
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A LITERATURE SURVEY ON OUTCOMES OF REHABILITATION TRIALS

Physical Medicine and Rehabilitation. 85(1), 14–18.
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Is dosage of physiotherapy a critical factor in
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* Teixeira-Salmela, L. F., Olney, S. J., Nadeau, S., &Brouwer, B. (1999). Muscle strengthening andphysical conditioning to reduce impairment anddisability in chronic stroke survivors. Archives ofPhysical Medicine and Rehabilitation. 80(10),1211–1218.
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floor muscle training is effective in women withurinary incontinence after stroke: a randomised,
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Health: ICF. World Health Organization.

WFOT SYMPOSIUM IN THE 42nd JAOT, BUILDING AND REBUILDINGCOMMUNITY THROUGH OCCUPATION

Minimum Standards for the Education of
Occupational Therapists: Building
Occupational Therapy Communities in
WFOT Member Countries*
Anne CARSWELL, PhD, FCAOT, OT(C), OT Reg.(NS)Vice-President, World Federation of Occupational Therapists

Abstract: The Standards for the Education of Occupational Therapists were based upon
three documents fundamental to international educational, cultural and human rights. This
presentation will describe the documents; discuss how they are embedded in the Standards
and through the use of a case study illustrate how the Standards support the building or
rebuilding occupational therapy communities among WFOT member countries.
Key words: occupational therapy, education, minimum standard(Asian J Occup Ther 7: 23–26, 2009)

Introduction
In 2002 the World Federation of
Occupational Therapists (WFOT) revised the
Minimum Standards for the Education of
Occupational Therapists (Standards), which were
initially developed in 1958 and revised many times
since then. However, this time the revision was
Received: July 8, 2008, Accepted: July 27, 2008
Corresponding to: Anne Carswell; School of Occupational
Therapy, Faculty of Health Professions, Dalhousie
University, 5869 University Ave, Forrest Building, Room
215, Halifax, NS B3H 3J5, Canada
Phone: 1-902-494-6578 fax: 1-902-494-1229
e-mail: anne.carswell@dal.ca*All the information contained in this paper is documented
in the WFOT Publication, Revised Minimum Standards for
the Education of Occupational Therapists, 2002. compiled
by Clare Hocking (former New Zealand Delegate) and Nils
Erik Ness (former Norwegian First Alternate) andpublished by the WFOT.

major and radically changed the Standards to meetthe needs and demands of the many countries andcultures that comprise the WFOT. The rationales
for revising the Standards were that member
countries wanted clearer guidance for thedevelopment and monitoring of educational
programs and that there be greater flexibility incurricular content to reflect cultural, economic,
and political realities.

Purposes
The overall purpose of the Standards is tomake occupational therapy services more evident
internationally in order to provide quality healthand welfare services. More specifically, thesestandards promote the consistency and quality ofoccupational therapy practice and educationinternationally through: (1) encouraging a sharedunderstanding of occupational therapy education,

24

WFOT Minimum Education Standards(2) fostering international research on occupation,and occupational therapy education and practice,and (3) supporting the development ofoccupational therapy in countries where it is notestablished. The Standards facilitate aninternational exchange of knowledge as well as theinternational mobility of occupational therapists.
They guide the planning of new educational
programs in institutions of higher learning andassist in monitoring the quality of establishedprograms.

Revisions
The revised Standards were founded ininternational contexts of health and welfare
perspectives as well as educational perspectives
along with the developments in occupational
therapy and occupational science. The documentsthat helped to frame the revisions included the
Declaration of Alma-Ata (1978) and the Ottawa
Charter (WHO, 1986) for their social perspective
on health requiring a reorientation of healthservices toward using occupation to build healthy
communities and to enhance individual wellness
through occupations that support well-being.
Other United Nations documents (United Nations,
1982, 1993, 2002; UNESCO, 1995, 1998) that
advance health promotion and equalization ofopportunities for those with disabilities and theInternational Classification of Functioning,
Disability and Health (ICF) (WHO, 2001) helped
to focus occupational therapy education toward
how health conditions and health related factors in
the environment impact upon health, well-being,
and participation.
From an educational point of view the revisedStandards encouraged occupational therapy
educational programs to be relevant to local
health, social and community contexts, to havemechanisms to improve the quality of the
program, and to have links to the international
occupational therapy community.

occupational therapy program is the international
and local contexts together with the areas ofessential knowledge skills and attitudes forcompetent occupational therapy practice (WFOT,2002). The components of the educational
program enable students who enter the program tobecome competent practitioners of occupational
therapy.

Contexts
Local contexts help to place the program
within the economic, cultural, political andinstitutional environment. An occupational
therapy educational program must be designed sothat its students have the appropriate, relevant
knowledge, skills and attitudes for effective
practice applicable to local health needs,
occupations and services. The refore theexperiences of students who are entering the
program, local health and welfare needs, the local
views of health giving occupations, local healthsystems, and local occupational therapy history are
all germane to the development of an occupational
therapy educational program.

Program components
Occupation is central to all occupational
therapy education programs and therefore allcomponents of the educational program; thecurriculum content and sequence, educational
methods, fieldwork, educators and resources andfacilities, are informed by an occupational
perspective. Each component is congruent witheach other component, has sufficient depth andbreadth to reinforce student learning, balances
local and international knowledge, anddemonstrates a mechanism for consistentevaluation and quality improvement. The
educational program is expected to enable
substantial knowledge, skills and attitudes
essential for competent practice framed by the
program philosophy and purpose.

Practice competencies

An Occupational Therapy Educational
Program
The starting point for the development of an

The essential knowledge, skills and attitudes
for competent practice of graduates ofoccupational therapy education programs are theperson-occupation-environment relationship, theAsian J Occup Ther 7: 23–26, 2009

relationship of occupation to health and welfare,therapeutic and professional relationships, theoccupational therapy process, professional
reasoning and the context of professional practice.
The ‘person-occupation-environment’relationship includes knowledge of theories andresearch evidence about people’s participation in
occupation, skills of assessment, analysing,
adapting and grading occupation, using occupation
therapeutically and understanding the attitudes
a b o u t d i f f e r e n t p e o p l e ’ s p a r t i ci p a t i o n i noccupation. Essential aspects of practicecompetencies enabled through the education
program include knowledge about people, skills inworking with people and attitudes towards people;
knowledge of the environment and skills inanalysing and modifying environments to promoteparticipation and attitudes about environmental
issues. Finally students must be exposed toknowledge about how occupation affects healthand participation and how health and participation
impact upon occupation.
Knowledge, skills and attitudes concerning
therapeutic and professional relationships enable
students to establish effective working
relationships with recipients of occupational
therapy services and with professional colleagues
and peers. The occupational therapy processembraces clinical reasoning, problem solving,
enabling, empowering collaboration andconsultation when working with recipients ofoccupational therapy services. Professional
reasoning and behaviour means using research
evidence or information to inform practice,practicing in an ethical manner, evaluating andimproving current knowledge skills and attitudes,
and reflecting on practice. The final component ofan occupational therapy educational program is
the context of professional practice which arethose aspects of the physical, attitudinal and social
environments that affect peoples’ health andparticipation as well as an occupational therapy
practice.
An occupational therapy education program
includes a variety of learning opportunities for the
student, such as case studies, reflective exercises,
experiential or problem-based learning, lectures
and/or small group experiences. Clinical

Carswell A

25

fieldwork of at least 1000 hours is a requiredelement of an occupational therapy program
fieldwork as it is essential that students in
occupational therapy programs be given sufficient
opportunity to develop their knowledge, skills andattitudes related to the occupational therapy
process with live clients.

Building Occupational Therapy
Communities
In recent years there have been a number of
newly approved programs in member countries,
which has enabled the establishment ofoccupational therapy communities in thosecountries. WFOT approval of existing educational
programs has facilitated the development of aprofessional occupational therapy organization insome countries (WFOT, 2004), while in othercountries WFOT approval of existing educational
programs using the Standards has given legislative
legitimacy to the educational program and to theprofession (WFOT, 2006). WFOT approval of
new educational programs has provided a strong
base for growth and development of the profession
in many countries (WFOT, 2004).

Summary
The revised WFOT Minimum Standards for
the Education of Occupational Therapists — 2002
are not prescriptive but emphasize program
outcomes within an international and local context
that focus on a person-occupation-environment
relationship and an educational process thatfacilitates graduates to achieve essential practicecompetencies. More specifically the changes
move occupational therapy education (1) fromhaving a biomedical focus to an occupational
perspective, (2) from a universal orientation to one
that is culturally sensitive, (3) from a diagnostic
label to a health and welfare perspective, (4) froma having a focus on only the individual to having a
focus on the individual, groups and populations,(5) from concentrating only on treatment toincluding prevention and health promotion, and(6) from academic content to practicecompetencies. As such these Standards foster

26

WFOT Minimum Education Standards

building occupational therapy communities bothin countries with established occupational therapy
programs, and in countries where there is little orno formal occupational therapy community.

References
Declaration of Alma-Ata. (1978).
Retrieved, June 1, 2008, from http://www.who.int/
hpr/NPH/docs/declaration/almaata.pdf
United Nations. (1982). World programme of action
concerning disabled persons. Retrieved, June 1,
2008, from http://www.un.org/documents/ga/res/37/a37r052.htm
United Nations. (1993). Resolution on standard rulesof the equalization of opportunities for persons
with disabilities. Retrieved, June 1, 2008, fromhttp://www.un.org/esa/socdev/enable/
dissre00.htm

United Nations. (2003). Convention of the rights ofthe child. Retrieved, June 1, 2008, from http://
www.unhchr.ch/html/menu3/b/k2crc.htm
UNESCO. (1995). Policy paper for change anddevelopment in higher education. Retrieved, June
1, 2008, from http://unesdoc.unesco.org/images/
0009/000989/098992e.pdf
UNESCO. (1998). World declaration on higher
education for the twenty-first century: Vision andaction. Retrieved June 1, 2008, from http://www/
unesco.org/education/wche/declaration.shtml.
World Federation of Occupational Therapy. (2002).
Revised minimum standards for the education ofoccupational therapists 2002. Adelaide, Australia:
AuthorWorld Health Organization. (2001). Internationalclassification of functioning, disability and health.
Geneva: Author.

WFOT SYMPOSIUM IN THE 42nd JAOT, BUILDING AND REBUILDINGCOMMUNITY THROUGH OCCUPATIONInternational Agreement on Occupation
Kit SINCLAIR, PhD; WFOT Past President
Department of Rehabilitation Sciences, Hong Kong Polytechnic University

Abstract: All the WFOT member countries endorsed and welcomed the resurgence ofdiscussion about occupation that has been demonstrated in pivotal WFOT documents,
such as the minimum standards (WFOT, 2003), definition of OT (WFOT, 2004a) and theCommunity Based Rehabilitation (CBR) position paper (WFOT, 2004b). These
documents confirm that occupational therapists are well placed to facilitate community
development, health promotion and participation in community through occupation.
Occupational Therapists use a people-centered process applying an enabling occupation
approach which integrates medical and social knowledge and skills in tune with theWHO’s ICF and the underlying philosophy of occupational therapy.
Key words: occupation, community based rehabilitation, human rights, ICF(Asian J Occup Ther 7: 27–29, 2009)

The World Federation of Occupational
Therapists (WFOT) produces documents andposition papers for use by occupational therapists
internationally. They include definitions ofoccupation and occupational therapy for use in the
global arena. The international views of health at
World Health Organization (WHO) level coincidewith the Occupational Therapy (OT) perspectivethat occupation is the basis of health. All the
WFOT member countries endorsed and welcomed
the resurgence of discussion about occupation thathas been demonstrated in pivotal WFOT
documents, such as the minimum standards(WFOT, 2003), definition of OT (WFOT, 2004a)
and the Community Based Rehabilitation (CBR)
position paper (WFOT, 2004b). These documents
Received: July 1, 2008, Accepted: January 31, 2009
Corresponding to: Kit Sinclair, PhD, Department of
Rehabilitation Sciences, Hong Kong Polytechnic
University
e-mail: kits@pacific.net.hk

confirm that occupational therapists are wellplaced to facilitate community development,
health promotion and participation in community
through occupation.
Occupational therapy is a profession
concerned with promoting health and well being
through occupation. The primary goal ofoccupational therapy is to assist people toparticipate in the activities of everyday life andenhance the quality of their lives. Occupational
therapists achieve this outcome by enabling
people to do things that will enhance their ability
to participate or by modifying the environment tobetter support participation (WFOT definition of
Occupational Therapy, WFOT, 2004a).
This revised definition reflects terminologyof the WHO International Classification of
Functioning, Disability, and Health (2002) and iswelcomed by member countries. It has beentranslated into the official languages of WFOT. It
is important to note the emphasis on participation

28

INTERNATIONAL AGREEMENT ON OCCUPATION

through occupation in all of these documents.
Through our documentation, WFOT plays arole in leading occupational therapists and otherinternational agencies in understanding
occupational issues faced by disadvantaged people
around the world. e.g. concepts of occupational
deprivation, occupational apartheid - andpromoting societies where people get fair access toa range of occupations that will sustain health occupational justice for all people.
Occupational therapists are committed toadvance certain core principles, one of which is
the right of all people—including people withdisabilities—to develop their capacity and power
to construct their own destiny through occupation,
which seems congruent with the basic tenets of
CBR. (WFOT position paper on CBR, WFOT,
2004b)The emphasis is on participation throughoccupation and daily life activities.
WHO developed the International
Classification of Functioning Disability and
Health (2002) in response to the changes in social
thinking over the past two decades. Where 20
years ago there was an emphasis on
institutionalization for people with impairment or
disabilities, there is now an emphasis on issues ofparticipation and equalization for all people insociety. These concepts are very much reinforcedby documents produced by the United Nations as
well. The framework for participation has, ofcourse, a foundation of the philosophy ofoccupational therapy.
Participation in meaningful occupation has animportant positive influence on health, and lack ofparticipation has been shown to lead to poor healthand well being. Many examples of disruption anddeprivation in occupation exist in the world today,
including persons who are unemployed, refugees,
belong to minorities, or those living in areas ofconflict and living with disabilities.
WHO (2001a) has focused attention on theparticipation perspective with the development of
the International Classification of Function (ICF).
The ICF provides common language to describe
how people live with a health condition. It
highlights the international concern about
healthcare outcomes and proposes a shift ofemphasis away from viewing a person in terms of
impairment and handicap and towards theperspective of a person as a human beingfunctioning in daily tasks, undertaking a variety ofroles, and being a member of society.
WHO defines participation as involvement ina life situation and uses the domains of learningand applying knowledge, general task anddemands, communication, mobility, self care,domestic life, interpersonal interactions andrelationships, major life areas such as work, orschool, community, social and civic life. (You can
see that occupational therapists had a big hand inwriting this document.) It implies being involved,
making choices and taking risks.
The im plicati ons of th is m ajor W HO
document for occupational therapy are in
reinforcing the client-centered and community
approaches that are already being implemented inmany aspects of occupational therapy practice.
From the occupational therapists’ view, now
reinforced by this document, the focus should be
on a person’s occupations within his or her naturalenvironment and on occupational routine for
quality of life. The focus should be on the client’s
opportunity to make choice, set goals and better
control circumstances to make life moremeaningful.
As noted in Rethinking Care from the
Perspective of Disabled Persons, WHO (2001b)
points out that there should be a holistic approachof access, legislation and funding. Occupational
therapists are involved in improving opportunities
and access for people with mobility related
impairments, establishing accessible information
media for people with learning difficulties, as well
as appropriate support services for those withmental health problems and multiple impairments.
Occupational therapists are involved at alllevels (national, international and local) with
consumer groups and organizations and take up
grass roots public awareness initiatives of theimportance of occupation in and with thecommunity.
As mentioned earlier, WFOT Council ratified
the WFOT position paper on community based
rehabilitation in 2004. The paper incorporates theconcepts of participation and equalization andAsian J Occup Ther 7: 27–29, 2009

notes where occupational therapists facilitate thisprocess. The development of this paper was an
excellent example of international cooperation andglobal communication. WFOT had the input ofoccupational therapists working in CBR in
virtually every part of the world. We discussed,
collaborated and agreed on the principles that we
as occupational therapists uphold as well as
strategies to empower and enable communities
and community members to go beyond strict
rehabilitation services to build on the principles ofsustainable livelihoods, service integration andsocial inclusiveness. We found some of ourtherapists are working with the addictions, sexual
abuse and family/community violence whichconstitute common occurrences in war zones. We
note that the role of occupation as a primary toolfor individual and collective recovery.
Considering the service focus of occupational
therapists—enabling people to choose, organizeand perform those daily life activities that theyfind meaningful and useful in their environments,
affording them with opportunities to gain greater
control over their health and their destinies—
occupational therapists are particularly able tofacilitate the process of establishing CBR program
development at both government and community
level. Occupational therapists provide and pass on
to community workers and disabled people
relevant knowledge and skills to enable them tomore actively participate in and take control of
their lives and the lives of others within thecommunity.
A good example comes from South Africa’s
Grandmothers Against Poverty and Aids (GAPA).
An occupational therapist worked with
grandmothers of children who had lost theirparents to AIDS. The Occupational Therapist

Sinclair K

29brought these depressed, distressed, and frustrated
women together through a patchwork quilting
group. Over their quilting activities, they
discussed their mutual problems of their orphaned
teenagers and found solutions and support fromeach other. From one small class within two years
17 quilting groups developed and are run by the
grandmothers who also offer support within theirown communities.
In conclusion, occupational therapists use apeople-centered process applying an enabling
occupation approach which integrates medical andsocial knowledge and skills in tune with theWHO’s ICF and the underlying philosophy ofoccupational therapy.

References
World Federation of Occupational Therapist. (2003).
Overview of the WFOT minimum standards foreducation of occupational therapists 2002.
Forrestfield, Western Australia: World Federationof Occupational Therapists.
World Federation of Occupational Therapist. (2004a)
Definition of OT. Retrieved January 10, 2009,
from http://www.wfot.com/office_files/
final%20definitioncm20042.pdf
World Federation of Ocupational Therapist. (2004b).
CBR Position paper. Retrieved January 10, 2009,
from http://www.wfot.org/office_files/
CBRposition%20Final%20CM2004(1).pdf
World Health Organization. (2001a). International
Classification of Functioning, Disability and
Health (ICF). Retrieved January 10, 2009, fromhttp://www.who.int/classifications/icf/en/
World Health Organization. (2001b). Rethinking
care from the perspective of disabled people.
Retrieved January 10, 2009, from http://
www.who.int/inf-pr-2001/en/note2001-16.html

WFOT SYMPOSIUM IN THE 42nd JAOT, BUILDING AND REBUILDINGCOMMUNITY THROUGH OCCUPATION

Global Community of Occupational
Therapists
Kit SINCLAIR, PhD; WFOT Past President
Department of Rehabilitation Sciences, Hong Kong Polytechnic University

Abstract: The World Federation of Occupational Therapists (WFOT), with 65 country
members, is a dynamic and proactive organization as demonstrated by the tremendous
level of activity and project work presently taking place. Reflections on international
involvements of WFOT as well as present and future global projects taking place within
the WFOT are described.
Key words: World Federation of Occupational Therapists, global occupational therapy
activities(Asian J Occup Ther 7: 31–33, 2009)

The World Federation of Occupational
Therapists (WFOT), with 65 country members, isa d yn a m ic a nd pr o a c t iv e o r ga ni z a t i on a s
demonstrated by the tremendous level of activity
and project work presently taking place.
As we look toward the future, we must also
reflect on the past few years that have been
fulfilling and exciting. We have been able toaccomplish a great deal through excellent
teamwork and commitment to importantd e ve l o p m e n t th r o u g h p r o j e c t s . A r e a s o fachievement for our team include smoothtransition in management, major projects in
Community Based Rehabilitation (CBR), humanrights, and disaster preparedness and response.
Relations with the World Health Organization(WHO) and other international and national
Received: July 1, 2008, Accepted: February 24, 2009
Corresponding to: Kit Sinclair, PhD, Department of
Rehabilitation Sciences, Hong Kong Polytechnic
University
e-mail: kits@pacific.net.hk

organizations have been extended by responding
quickly to requests and by taking the initiative toadvance WFOT and occupational therapy
perspectives.
The WFOT is the international voice andrepresentative of the profession in an evershrinking world. As the profession achieves
greater recognition for its unique perspective on
occupation and its power to make a difference inpeople’s lives, there is an increased demand forour expertise and participation in the global
community.
The Federation’s continually increasing
efficiency has resulted in a major expansion ininternational liaison activity. The WFOT is the
key international representative of the profession
and liaises regularly with WHO, United Nations(UN) agencies such as UNESCO and otherinternational non-governmental organizations(NGO’s).
In the last few years, these interactions havemultiplied and the WFOT has developed even

32

GLOBAL COMMUNITY OF OCCUPATIONAL THERAPISTS

stronger working partnerships internationally. In
2006, WHO commended WFOT for its stellar
participation in WHO initiatives in relation to
WFOT triennial report on collaborative activities.
As WFOT enters its 50th year as an NGO memberof WHO, the high profile reflects increased
awareness of the occupational therapy
contribution to world health.
WFOT coordinates, facilitates andparticipates in the development and transfer ofoccupational therapy’s knowledge and expertisefor the international scene through its projects,
through International Advisory Groups, andthrough personal contact in meetings andconferences. WFOT has embarked upon
identifying and liaising effectively with its
international experts through the International
Advisory Groups.
WFOT is able to coordinate the profession’s
response to global health and wellness needs
through participating in social and economic
development initiatives. WFOT is aware of therelationship between poverty and disability andaccepts the need for more integrated multi-sectoral
approaches for all forms of development.
An example of this is in the WFOT responses
in January 2006 and again in June that year, toMental Health Guidelines and action sheets for theInter-Agency Standing Committee (IASC) Task
Force on Mental Health (World HealthOrganization: IASC, 2007) and Psychosocial
support in Emergency Settings. Another isinvolvement in the illuminating World Bank ediscussions on ‘Disabled and other Vulnerable
People in Natural Disasters’ (World Bank, 2006).
The new management model enables more
people beyond council members to participate inproject teams. The Federation is undertaking inexcess of 175 individual projects both minor andmajor in the last five years.
The Federation’s projects are becoming moreproactive, e.g. the Tsunami Project/Disaster Relief
and Preparedness project—this initiative serves as
the basis for the development of the WFOT
Disaster Preparedness and Response Package(WFOT, 2007) which is now available to members
through the WFOT on-line shop. WFOT is
assuming the leadership role here in consolidating,promoting and employing the profession’s vast
knowledge and expertise. This is to assist theinternational community in dealing with theramifications and the aftermath of devastating
events that impact on the fundamentals of humanoccupation. Major donations have substantiallycontributed to the ability of WFOT to make asignificant response.
Strengthening engagement with government
coordination and programming systems at
national, district and local levels will be crucial toprogressing successful Occupational Therapy
involvement in Disaster Preparedness & Response
initiatives. National workshops took place in thefirst half of 2006 in Indonesia, Thailand, and Sri
Lanka, with members of the Executive acting as
facilitators.
Occupational Therapy national action plansto address disaster preparedness and response havebeen drawn up and national task forces establishedin these countries. The regional and national
workshops which resulted from this initiative will
inform international actions.
The capacity building which took place atthese workshops will support local therapists tocontribute to disaster response e.g. the tragic
Indonesian earthquake where Occupational
Therapists and Occupational Therapy students are
involved in recovery efforts. A culturally sensitive
manual on disaster preparedness and response foroccupational therapists has been produced.
This project which started in response to amajor world emergency has developed into an
initiative for future action to raise awareness todisaster and to prepare occupational therapists to
be involved at all stages to re-engage people inmeaningful occupations within their communities.
WFOT initiated a major project in humanrights to address issues of human rights in relation
to our profession. Integral to the work ofoccupational therapists is the right of all people tooccupational engagement (participation), meaninga person’s right to take part in necessary or
meaningful occupations.
Within the human rights master project plan,
two projects have emerged with prominence. Oneis ‘voices of people with disabilities-consumer
interface’ which focuses on the involvement ofAsian J Occup Ther 7: 31–33, 2009

occupational therapy service consumers in thedevelopment of the future vision for occupational
therapy. Another project ‘Inclusive Occupational
therapy Education’ has been completed. Its teamgathered data on access to admissions and accessto learning in occupational therapy education
program worldwide.
A discussion paper on human rights leading
to a position statement from WFOT was in theworks for over two years. The position paper onhuman rights ratified in 2006 was also developed
over this period with much e-discussion as it isimportant to include global and cultural
perspectives (WFOT, 2006). The position paper
challenges the profession to address accessibility
through universal design, to address healthpromotion needs of groups, communities andpopulations with a wider recognition of people’s
rights to meaningfully and purposefully occupied.
The project on ‘Community Based
Rehabilitation (CBR) data collection and analysis’
was very fruitful in establishing the extent and levelof occupational therapy involvement in community
based rehabilitation. The results of this project will
provide a foundation for education modules,
promotion of international fieldwork exchange
programs and advancement of occupational
therapy involvement in CBR around the world.
Major projects are also taking place in the
support of development of professional services
and education in both Egypt and Mongolia. The
Egypt based project has really taken off. Regular
newsletters have been published to promote
coordination and collaboration between project
members and a network of supporters. The
newsletters were published on the WFOT website
and stimulate a lot of international attention. Outof that project, two occupational therapy education
programs have evolved in Egypt which are alreadyadmitting students.
Other projects include development of global
competencies, translation of the WFOT glossary
into Chinese, and many other areas which support
the profession’s continuing advancement. The
number of successful projects has increased
dramatically with individual members taking up
leadership roles. We commend those who havevolunteered their time and energy to these

Sinclair K

33

noteworthy tasks.
Regional groups produce synergies throughgeographically proximity of conferences,
workshops and consultations. An example is theregional conference of the Occupational Therapy
Africa Regional Group (OTARG) in August 2005.
The Occupational Therapy Latin American
Regional Group (CLATO) held the VI th LatinAmerican Occupational Therapy Congress and
XIVth Colombian Occupational Therapy
Congress, also at the end of August 2005. The
Council for Occupational Therapy in the European
Community (COTEC) holds regular congresses,
the past in Athens in September 2005 and the next
in Hamburg in 2008. The Asia Pacific region(APOT) held their congress in June 2007.
The Japan Association of Occupational
Therapy’s Conference and WFOT Symposium
held in June 2008 in Nagasaki are part of thecontinuing opportunity to share and develop
occupational therapy for the 21st century.

References
World Bank. (2006). Summary Report on “Disabled
and other Vulnerable People in Natural Disasters”
e-mail discussion. Retrieved January 10, 2009,
fr om htt p: //web .wor ld ban k.o r g/W BSI TE/
EXTERNAL/TOPICS/
EXTSOCIALPROTECTION/EXTDISABILITY/
0,,contentMDK:20922979~pagePK:210058~piPK:210062~theSitePK:282699,00.html
World Federation of Occupational Therapist.
(2006). Position statement on human right.
Retrieved January 10, 2009, from http://
www.wfot.org/office_files/
Human%20Rights%20Position%20Statement%20
Final%20NLH(1).pdf
World Federation of Occupational Therapists.
(2007). Disaster Preparedness & Response
Information & resource Package. Forrestfield,
Western Australia: World Federation of
Occupational Therapists.
World Health Organization: Inter-Agency Standing
Committee. (2007). IASC Guidelines on Mental
Health and Psychosocial Support in Emergency
Settings. Retrieved January 10, 2009, from http://
www.who.int/mental_health/emergencies/
guidelines_iasc_mental_health_psychosocial_jun
e_2007.pdf

WFOT SYMPOSIUM IN THE 42nd JAOT, BUIDLING AND REBUILDINGCOMMUNITY THROUGH OCCUPATION

Culture and Psychosocial Elements
Impacting on Disaster Recovery:
Response in Indonesia
E Sharon BRINTNELL1, Dip P&OT, BOT MSc, FCAOT, CDMP,
Buwana CAHYA2, Dip, OT, RI, Tri Budi SANTOSO3, BScOT, MOT
1Professor, University of Alberta, Edmonton Canada
2Program Team Leader, Handicap International, Yogyakarta, Indonesia
3Faculty Member, Research & Development Unit Surakarta Health Polytechnic, Solo,

Indonesia

Abstract: Natural disasters are common place in the world but the 2004 tsunami createda critical mass of WFOT member countries confronted by the monumental destructive
forces of nature. Destroyed were environments and the natural occupations central to thelifestyle of citizens. Working within the WFOT Disaster Preparedness and Recovery
Framework, two Indonesia occupational therapists one working in Aceh, Sumatra and theother responding to a major earthquake in south central Java (2006) were confronted bypsychosocial and cultural issues which affected their assistance efforts. The uniquecultural perspectives of these two distinct Indonesian geographic areas presented somevery different and unique challenges. The first author worked with the two therapists to
identify the critical phenomena experienced in accommodating psychosocial barriers. The
analysis serves to increase knowledge transfer. Highlighted is the important contribution
the profession makes to interpreting more sensitively social phenomena and its impact on
disaster recovery process.
Key words: psychosocial, disaster response, culture, occupational performance(Asian J Occup Ther 7: 35–42, 2009)

Introduction
Received: July 23, 2008, Accepted: February 27, 2009
Corresponding to: E Sharon Brintnell, Professor andDirector, Occupational Performance Analysis Unit,
Department of Occupational Therapy, Faculty of
Rehabilitation Medicine, University of Alberta, 2–64
Corbett Hall, U of A campus, Edmonton AB T6G 2G4CanadaPhone: 1-780-492 2067 fax: 1-780-492 9599
E-mail: sharon.brintnell@ualber.ta.ca

The tsunami of 2004 was a major wake up
call for the world. Even with natural disasters
occurring annually around the world, few had theimpact that tsunami did in alerting global citizensof their collective vulnerability andinterconnectedness. The magnitude of the event’s
destruction was highlighted by expansiveness ofthe geographic footprint of Mother Nature’s
violent action.

36

Culture and Psychosocial Elements Impacting on Disaster Recovery: Response in Indonesia

Four member organizations of the World
Federation of Occupational Therapists (WFOT),
India, Indonesia, Thailand and Sri Lanka were hit
by the monumental forces of nature, which
destroyed lives, environments, and disrupted thenatural occupations central to the lifestyle of theircitizens.
Many citizens of the world live undercircumstances of constant “disaster”: natural andman made. They lack the resources and theopportunities to avoid being in harm’s way andtheir lives are a constant struggle in anticipation of
the next assault on their living state. For them,
their usual occupational focus is on subsistence
and survival. Their occupational performance isseen as extraordinary to many, but in the face ofthe tsunami and accompanying earthquakes thebest of their well honed survival skills were notenough. Occupational therapy, as a profession
focusing on individuals interacting with theirenvironment, needs to be proactive in gathering its
resources to support the life sustaining activities ofall people responding and living in disastercircumstance. Two disaster situations in Indonesia
are analyzed by the first author to increaseknowledge transfer to other occupational
therapists developing disaster preparedness andresponse plans and to alert them to psychosocial
considerations, which can impact on service
effectiveness. Furthermore, this discussion
highlights a “taken for granted” skill set ofoccupational therapists relating to cultural
sensitivity. Taken together, culture andpsychosocial issues influence response strategies
and can make the difference in the successful
acceptance of assistance from disaster survivors.
The paper’s context is the experiences of two
Indonesia occupational therapists in greatly
different areas of a country made up of over
17,500 islands and 237,000,00 million people(Central Intelligence Agency, 2008). The
Indonesian lessons learned by these occupational
therapists’ interactions with local residents andtheir application of strategic adaptation of disaster
response program to fit social needs will be shared.
One therapist assisted with the post tsunami
recovery work in Aceh, Sum atra throughinvolvement with a well known international nongovernmental organization (NGO). The second
therapist contributed to a regional response to theearthquake disaster in the south of Central Java
(Yogyakarta) using students to assist the process.
The experiences of both therapists are exploredfrom the unique cultural perspectives of these two
distinct Indonesian geographic areas.

Background
The World Federation of Occupational
Therapist (WFOT) took a leadership role inpreparing occupational therapy professionals fordisaster response. Following the December 2004
tsunami, the WFOT coordinated a regional
environmental scan in April 2005 and later
developed and offered a training workshop fortherapists from the affected countries (WFOT,2006). This information can be found elsewhere in
the form of reports and documents (WFOT, 2007).
Following this initial event sponsored by Direct
Relief International (DRI), the WFOT and various
other donors including DRI, initiated national
training workshops for member organizations in
the affected four countries.
The Indonesian Association of Occupational
Therapists (IAOT) conducted its National
Workshop in Disaster Preparedness & Response(DP & R) in Jakarta April 6–8 2006. There were
40 participants including the authors and it was
supported by a coalition of funders: Direct Relief
International (Washington DC), the WFOT, theMinistry of Health, Republic of Indonesia, theIndonesian Association of Occupational
Therapists and specifically the Surakarta Health
Polytechnic.
The national workshops built on theframework developed for the regional workshop
by WFOT’s consultant Kerry Thomas ofAustralia. This included developing specificproject/action proposals for priority areas to bepart of the Occupational Therapy National Action
Plan such as identifying project activities andconsiderations for implementation strategies (e.g.
resources needs, funding sources, approval,
support etc). More specifically it drew on
occupational therapy knowledge and thinking
processes. The focus was on the profession’sAsian J Occup Ther 7: 00–00, 2009

unique “tool kit” based on occupation within aholistic and environmental approach to evaluationand intervention. A response strategy wasformulated to meet the local cultural and social
perspectives.
The outcomes of the national workshops were
to be integrated with the country’s national
disaster preparedness and response strategy. One
major objective was to prepare occupational
therapists to be leaders and contributing membersof disaster response teams. Though able toprovide assistance to any disaster situation, theprimary consideration for the profession was toensure that the needs of minority and vulnerable
groups particularly persons with disability werebeing addressed within the general response
strategy.
Indonesia is an Island nation and due tointernal cultural diversity (34 acknowledged
ethnic groups), developing a DP & R nation plan ischallenging. As previously noted, the principles
from the regional workshop helped shape theplanning process and prepare for future responses.
Indonesia offers unique challenges in that it isa country where the tensions of different dialectics
must be negotiated along with other culturaldifferences from secular and traditional, insularand open, transcendence and immanence and mostimportantly nature and culture (Manzoor, 2003).
As the largest Islamic nation in the world, Islamtranscends all forms of interaction and forms of“being and doing.” From a secular perspective or iffrom a more fundamentalist one, there will be an
impact on the response of citizens based on their
particular culture and the Islamic practices of theirindigenous social group (Manzoor, 2003). The
history of Indonesia has been characterized byforced national unification (Sarsito, 2006).
Indonesia is held together by a set of fiveprinciples (Pancasila): a unifying language (Bahsa
Indonesian) and a strong “hand”: first that of
Sukarno who lead the revolt against the reestablishment of Dutch colonialism and thenSuharto up to 1998. Ethnic identity and cultural
norms can be stronger than a national identity(Chandra, 2004).

Brintnell ES et al.

37

Case Scenario Number One—Sumatra
The first scenario is based in Banda Aceh; theclosest land mass to the ocean epi-centre of theearthquake that precipitated the December 2004
tsunami. Entire communities where wiped fromthe map including their infrastructure and services.
The reader needs to be familiar with the special
circumstances that enveloped this north westernarea of the island of Sumatra. A number ofsituational and cultural considerations existed,which would impact on the usual disaster response
strategies and the acceptance of aide by the
citizens of the area. But at the time of theemergency these were not major considerations.
Banda Aceh is a very conservative Islamicarea. Before the disaster, it was an area of
prolonged armed conflict between thoseembracing these former views and the Jakartabased Indonesian national government. Thus theimmediate response of survivors to relief efforts
and ultimately to the recovery process wereaffected.
In keeping with more traditionalist values,
there existed specific gender roles limiting
women’s participation in the community,
including the restriction of the succession ofproperty titles.
Given the absolute destruction or severe
incapacitating damage to large portions of thetransport system and other civilian infrastructuresand services, the Indonesian army was given thetask of disaster response. They were already in theregion and had the resources to respond. Military
involvement in national disaster responses is acommon strategy in many parts of the world. But
in this case, the survivors were reluctant to takeassistance from soldiers who earlier were seen to
be the aggressors during the many years ofconflict. With the monumental state of thedamage, there was a lack of coordination of
response activities across the government and themany NGO that quickly mustered resources to thearea. Few health facilities remained in operation
to treat survivors. Many members of the region’s
health manpower network expected to respondalso died There was limited local health manpower
to offer health services (Java Reconstruction Fund,

38

Culture and Psychosocial Elements Impacting on Disaster Recovery: Response in Indonesia2007).
In the long term joblessness in bothtraditional areas (fishing) and general services
would add additional stressors. Also there was agreater focus on the physical recovery of people,
things and processes as there was a lack ofunderstanding of psychosocial rehabilitation needsof survivors by rescue teams.
T he l o s s o f h u m a n c o nn e c t i on s w e r edevastating as extended family networks andgenerational ties were lost. Social looting took
place by people claiming to be survivors. People
taking advantage of the relief efforts came fromother areas unaffected by the present disaster but
suffering from longstanding economic depression.
They sought food as well help to obtain living
allowances and housing support not formerly
availbale to them. Based on records from the four
districts, 126 disabled persons were identified
including only one who was disabled before thetsunami.
As is often the case during catastrophic times,
people also resolved conflicts during this time ofneed. Conflicts between the Aceh Independence
Movement and Indonesian Army were reduced
and finally an agreement to end the war was
signed. Members of the movement went tovillages and cities from their camps to look fortheir families. The central government establisheda Board of Tsunami Recovery and Reconstruction
and began building infrastructures in unaffectedareas in all of the Aceh province. But themagnitude of physical devestation and state ofsurvivors was alarming.
The World Health Organization expected thatthe psychological state of survivors would reflect
an increase in certain psychiatric disorders such as
depression, anxiety, and sleep disorders ( WHO,
2005) but there were few available services to
respond to mental health needs. Aid workers
attempted to provide psychosocial support
indirectly through empowering women, children,
families and the communities in order to restore
their resilience capacity. Even the public press
reported psychosocial issues.
Adding to the acute trauma of the tsunami
was the pre existing context of the environment
and the results of a culture of suppression due tocentral government policies. The area ismountainous and travel is difficult. Earthquakes
are frequent. As a conflict zone there is fear ofboth the Rebels and the Army. A constant fear
exists about outsiders and sensitivity to new
persons (Non governmental organizations(NGOs), local & international) who have different
religious backgrounds. This state of lack of trust
made it difficult to take assistance especially fromthe Army who controlled supplies and wereissuing coffee and food. Few would leave theirhome go to distribution centres. Poverty andmalnutrition were already common.
One Indonesian occupational therapist wasrecruited by Handicapped International to assist
with the rehabilitation and recovery phase. He
provided physical rehabilitation services in six
primary healthcare facilities (remote areas),
worked on capacity building and developing
livelihood support such as pre-vocational training.
He used occupation related to recovery needs asinterventions and dealt with psychosocial issues hefound coexisting with physical phenomena.
The social experiences associated withdisasters focus on losses of family connections,networking opportunities and changes in theperformance of traditions and habits.
Examples of social Losses are:Withdrawal for social contacts
Disruption of support networks
Family deaths: immediate & extended
Friends, coworkers & neighbors gone
Gathering at Mosque, coffee house,market, well, etc. is no longer possible
These losses and disruptions in social habitscreated problems for survivors in their new roles
as widows and widowers and as persons withdisability. The role changes impacted on intimacyneeds, ability to earn a living and to accesssupport. The occupational therapists in Aceh dealt
with some of these issues by running grouptherapy sessions for survivors through an NGO;
raising community awareness regarding disability
to refocus attention in helping others duringreco very. Occupation was central to theinterventions such as encouraging home
modifications to decrease the barrier for disabled
person. The occupational therapist also worked toAsian J Occup Ther 7: 00–00, 2009

support public health needs through education totake steps to prevent outbreaks of polio. He didskills training and hygiene education (animals outof houses) to increase effective health promoting
habits for all while focusing on enabling thequality of life of persons with disability.
When asked how he did his job he noted
using environmental and holistic approaches infinding persons with disability and providing themwith services. He worked with families, religious
leaders, local authorities, traditional Healers,
anyone available to assist and participate in therecovery process. He used local/ natural resources(designed splint from palm tree) as supplies werelimited. Working through local NGOs, he went
door to door, sent out fliers and contacted his own
network of Javanese to promote awareness andencourage contact.
He travelled long distances for many hours on
poor roads for short visits and professionalsessions. Though he stayed in a larger centre,
there were feelings of isolation due to the lack ofpossibilities to communicate with otherprofessional’s and his own family. He had to use
satellite communications and was able to return toJava every two months, which he paid for himself.
Consequently, high stress levels ensued. As ateam leader, he also had the support of two
physical therapists with whom he debriefed.
Eventually after a year he returned home, where hepractices in a large oncology facility. The contract
in Banda Aceh was a challenging personal andprofessional experience.

Case Scenario Number Two—Java
Approximately one month after the Jakarta
Disaster Preparedness and Response Workshop in
April 2006 an earthquake hit the heavily populated
Yogyakarta district in Central Java. This is an area
known for volcanoes and tremors. The
occupational therapy faculty of the Surakarta
Health Polytechnic (SHP) occupational therapy
program were able to contribute to relief efforts ina timely manner, in part due to their participationin the aforementioned Disaster Preparedness &Response workshop. The faculty joined others infirst responding to the needs of victims and those

Brintnell ES et al.

39visibly suffering from trauma. The faculty thenorganized a team, which included students who
worked to assist the emergency teams to look after
trauma victims. In a parallel effort, the teamfocused on identifying and assisting persons withdisabilities. As an aside, Surkarta where theSurakarta Health Polytechnic (SHP) is located, isapproximately 60 kilometres north of Yogyakarta
but was not greatly affected by the shock waves.
The Islamic and socio-cultural context ofCentral Java is thought to be different from thepre-tsunami Banda Aceh. Although Java too is
primarily Islamic, its religious practice andcultural roots are in old animistic origins and its
integration of old religious mysticism is mixed
with the practices of modern day Islam. These oldbeliefs predate Islam and Hinduism and speak tothe spirits and or Gods of the natural world.
Java’s culture is also based on a hierarchicalsociety (Chandra, 2004). Individuals respond toauthority but leaders are held responsible through“wahyu”: disasters and events can be attributed toa lack of integrity and living according to Javanesespiritual traditions. This belief is still held bysome and complimentary to the Islamic view ofnature (Adcock, 2006).
Fewer of the social and interpersonal barriersof Aceh: paranoia, fear and suspicion of strangers
existed. Survivors accepted the first wave ofassistance as it came from other Javanese and thus
they were able to help each other. The
occupational therapy students participated in
distributing food to survivors in response to thebasic needs for survival and support.
Thousands of survivors lost their homes andbusinesses. Restoring shelters was very importantto address immediately, because extended families
frequently lived together in compounds made up
of several buildings. After helping the criticallyinjured, the work began to find and assist people
with disability.
Given the closeness of the earthquake to
Surakarta many students had their own transportand being familiar with the area was a majoradvantage in making personal contact withsurvivors. Some had family and friends in the area
unlike the Aceh region, where the relief workers
were “foreigners”. The “OT” Team assisted with

40

Culture and Psychosocial Elements Impacting on Disaster Recovery: Response in Indonesia

the set up of a disaster relief post in a village halland then after a debriefing, the students began
home visits in search of persons with disabilities(PWD). Within the disaster relief post they servedin access of 50 to 60 clients everyday. Home visits
gave the opportunity to problem solve first handand provide consultations directly in the social
context of the problem. The destruction though
not as environmentally catastrophic as Banda
Aceh still disrupted livelihoods, social patterns
and daily habits. Working, tending the home,going to school were stopped as the physicalstructures were destroyed and all effort and freehands went to creating emergency shelters and reestablishing physical order.
As the schools were destroyed, classes were
held outside. It was easy in this social gathering ofyoung peers for the OT to offer play therapy
sessions for the children as a means to relate theirexperiences and fears. Though the literature on
adults is mixed on the benefits of debriefing(Raphel, 2003) the children settled with thenormalizing activities of familiar games. Social
gatherings were instigated for the adults. Many of
the adult survivors were taken to the Orthopaedic
Hospital in Surakarta as there was a lack oftreatment space in Kalten one of the major quake
sites. This put additional stress on the family unit.
The family is a primary social group; themoving of the injured to another city meant that a
relative had to go with the patient to provide careand meals. This is customary in the region. As aresult some “helpers” were lost to the area but thisalso gave some peace to the family members left
behind who had to deal with the physical recovery
process and the construction of temporary tent
shelters.
Students assisted with the record keeping on
persons with disabilities. Use of their “expert”
knowledge helped to provide relief to local healthcare practitioners. By teaming up with local
NGOs, the students facilitated access anddistribution of materials such as medicines,
blankets and some building supplies. With theshared cultural values and habits of the local
residents, there was a compatible mix of values
and concerns of helpers and those helped.
The challenges in Central Java were lessabout culture and more about the disruptions tosocial institutions. There was an initial lack of
coordination in the disaster relief strategies.
Government emergency response with the services
they controlled was delayed and or lacking insome areas but not to the degree found in Aceh andfor some different reasons:· Unequal local services and distribution ofrelief· Bureaucratic system of oversight delayed
action· Legal aspect of those who could provide
assistance (Certified/competency)· Suspiciousness on the part of somesurvivors about non Javanese relief workers· Environment was inaccessible due tomountainous terrain
The citizens were quick in starting to restore
their lives by cleaning debris and engaging in tradethrough their micro industries where possible.
International aid helped restore destroyed
structures, homes and service facilities(JavaReconstruction Fund, 2007).

How Occupational Therapists Helped
In this second disaster case scenario, theoccupational therapists (OT) and the OT students
played multiple roles in the disaster response
phase and later in the recovery. The disaster relief
worker role was one shared with other emergency
response providers as was the health services
providers but some aspects of the roles wereunique. With their ecological perspective of theperson and their environment, the OT was a aninterpreter of the barriers related to cultural norms
for external relief workers, a therapist andclinician in detecting high levels of stress andanxiety states and physical rehabilitation and acommunity member sharing the disaster
experience with friends and family. The OT
professional was a “filter of behaviour” but thisrole required additional sensitivity of local
conditions and expressions of religious and social
practices. As community members sharing thecultural values it was easier to be accepted andthey had less adjustment as a response worker inentering the community.

Asian J Occup Ther 7: 00–00, 2009

The knowledge and skills of the professional
occupational therapist in dealing withpsychosocial phenomena was of great assistancein dealing with the burden of loss felt by the family
ccompounded by the cultural expressions of roles:
Some of these issues were experienced as: (1)Responsibility for family cohesion and the burdenof financial losses, (2) Wife or husband unable toearn money or work because must stay withpartner (survivor in bed or in a wheelchair), (3)Physical & emotional burden of taking care ofsurvivors, (4) Social burden of helping others, (5)Feeling isolated (unable to go visit around), and(6) No answers to needs through networking.
Sexuality was a major concern for many.
Therapists helped persons explore reasons why
sex no longer was satisfying or providing pleasure.
Clients talked about:· Lack of privacy generally· Anger & denial of interruptions in sexual
performance· Being ignored by spouse· Bed (emergency cots) were too small forsexual activity· Private space and time was not available toengage sexual activities
For persons with disability there weredifferent needs and issues. Some existed before
the earthquake and others were a direct result of
the changes in health status following theearthquake:· Afraid to engage sexual activity because of
injuries· Husband/wife thinking of exchanging
partner· Taking a longer time to engage sexual
activity· Sexual organ must be cleaned and cleanwater limited.
· Interruptions in require bladder/bowel
management· Divorced and no sexual partner· Love affair/cheating perceived thus
disrupting thinking and sexual expressions· No sexual desire because hygiene is bad(pressure sore, bladder/ bowel incontinent)or trauma· Couple unaware of alternative sexual

Brintnell ES et al.

41

activities (oral sex, petting, etc)
Many of the items above could be addressedby education. The occupational therapists wereable to bring up intimacy roles because of their
specific education and shared cultural values.
These factors made it easier to connect to people
and speak of these very personal needs. In somecases their age (young students speaking to older
people) was a barrier due to hierarchical structureof society. If the student felt there was an issue
from the initial interaction, they would get a moresenior person to assist.

Conclusions
These two cases from the same country
highlight our need to base our practice soundly on
theory and context, because of the uncertainties
that emerge as people’s lives unfold. Moreover,
local cultural expressions and social phenomena
colour interactions, perceptions and responses.
Th eory pro vi de s a t oo l on wh i ch to ba se
evaluations and services so that interventions canbe more culturally sensitive.
The ecological approach of occupational
therapy provides a framework to systematicallyanalyze the persons’ action and reaction in relation
to the various aspects and forces of theirenvironment. The focus of everyone’ activities are
therefore broader than the immediate desired
output as it is then becomes the outcome ofcultural and social exchanges and interactions.
The world is becoming increasingly diverse and all
health practitioners are being challenged tounderstand illness and trauma experiences frommultiple perspectives. Failing to do so will further
increase the disparities in service provision noted
between ethnic groups (Srivastava, 2008).
Occupational therapists are underutilized by
the health system for addressing psychosocial
phenomena and occupational therapists
themselves tend to deal more easily with physicalstates. Reports to the World Federation of
Occupational Therapists (WFOT) indicate acontinued decline in occupational therapists
indentifying with psychosocial or mental healthpractice in some countries (Brintnell, Haglund,
Larsson & Piergrossi, 2005). This latter behaviour

42

Culture and Psychosocial Elements Impacting on Disaster Recovery: Response in Indonesia

pattern perpetuates the lack of awareness by other
health professionals and policy makers of theutility of the occupational therapy professional insituations where both physical and psychologicalinjuries interact with changes in social structureand supports. This is also a description of theaftermath of disaster states.
Focusing on the physical to the almost
exclusion of psychological and social issues also
contradicts our own statements about being
holistic in our practice. Nor does it support ourclaims of integrating a mind, body and spirit
perspective in our approach to occupational
performance and behavioural issues.

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