PROFESSIONAL TRENDS IN ASIA

The Evolution of Occupational Therapy
Profession in Korea
Daehyuk KANG, MS, OTR1, Tackyoung LEE, MPE, OT1
1 Department of Occupational Therapy, Hanseo University

Abstract: In Korea, the first national occupational therapy licensing examination was
administered by the National Institute of Health in 1965 since it was introduced in theearly 1950’s. Although it has been a half century from its beginning, the actualcommencement of occupational therapy in Korean society was not until 1993 when the
Korean Association of Occupational Therapists (KAOT) was founded. It became a full
member of WFOT (World Federation of Occupational Therapists) in 1998. The
conventional educational program began in 1979 at Yonsei University. Within the last
four years, twenty-three new occupational therapy programs have launched nationwide,
and there are total of twenty-four occupational therapy programs as of December 2002.
From year 2006, nine hundred new graduates are expected to be licensed every year. The
KAOT is working on five projects to achieve a qualitative growth of the occupational
therapy profession.
Key words: Korea, Occupational therapy, History, KAOT
(Asian J Occup Ther 2: 3–9, 2003)

Introduction

occupational therapy profession in Korea.

Occupational therapy was introduced in
Korea by Americans at the end of the Korean War(1950–1953). Although it has been a half century
from its beginning, the actual commencement ofoccupational therapy in Korean society was not
until 1993 when the Korean Association of
Occupational Therapists (KAOT) was founded(Lee, 1998). This article briefly describes thedevelopment and the current status of the

The Beginning Stage

Received: September 30, 2002, Accepted: May 24, 2003
Corresponding to: Daehyuk Kang, (MS, OTR); Departmentof Occupational Therapy, Hanseo University, Choongnam
Seosanshi haemimyun, Daegokri 360, Republic of Korea
phone/fax: 82-41-660-1392
e-mail: daehyuk@hanseo.ac.kr

According to Dunton (1954), the firstoccupational therapy service was provided for the
Korean War veterans at the National
Rehabilitation Center in Busan, which was funded
by AKF (American Korean Foundation) and
UNKRA (United Nations Korean Reconstruction
Agency). In 1957, Esther Park, a KoreanAmerican occupational therapist, educatedmedical ancillaries of the US Navy, and they
provided occupational therapy at the militaryhospital. By 1968, three occupational therapy
clinics had opened and foreign occupational
therapists were providing services. Since most4

THE EVOLUTION OF OCCUPATIONAL THERAPY PROFESSION IN KOREA

Table 1. Occupational therapy training institutions
Training institutions

The year of inauguration

Number of trainee (s)Catholic University Yeoido Hospital
Catholic University Gangnam Hospital
Korea University Guro Hospital
Korea University Ahnam Hospital
Busan Merinol Hospital
Seoul National University Hospital
Yonsei University Hospital
Jeonju Jesus Hospital
Hanyang University Hospital

1980
1975
1985
1975
1975
1975
1975
1975
1975

2
3
3
2
1
2
3
3
1

Table 2. National occupational therapy licensing examination pass rates
Year

Count

# Passing% Passing

Total

1965
1969
1974
1976
1977
1978
1979
1980
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002

3
1
3
1
1
2
1
5
3
9
11
10
18
24
25
23
18
39
35
32
21
25
33
29
27
25
22
83
177

0
1
3
1
1
2
1
5
3
9
10
10
12
23
20
21
18
39
35
31
21
23
30
28
25
25
20
65
117

0
100
100
100
100
100
100
100
100
100
100
100
66.6
95.8
80.8
91.3
100
100
100
96.9
100
92.0
90.9
96.5
92.6
100
90.9
78.3
66.1

0
1
4
5
6
8
9
14
17
26
36
46
58
81
101
122
140
179
214
245
266
289
319
347
372
397
417
482
599

occupational therapy evaluation and treatment
tools were not available at that time, the therapists
had the clients make the tools and experience thereal works such as making stove pipes or water

pipes. They also tried to integrate traditional
Korean games into occupational therapy
intervention and even performed activity analysis
of Je-Gih-Cha-Gih (a kind of shuttlecock gameAsian J Occup Ther 2: 3–9, 2003

Kang D et al.

5

Fig. 1. Accumulated number of occupational therapists

played with the feet) reflecting the root philosophyof “occupation work” (O, 1994; Reed, 1993).

The Developing Stage
The first national occupational therapy
licensing examination was administered by the
National Institute of Health in 1965, but no one
had passed the examination until 1969 (Lee,1998). In 1969, Gui-Ja Choi, who was educatedb y E s t h e r P ar k , b e c a m e t h e f i r st K o r e a n
occupational therapist. Back then, the target
trainees for occupational therapy education were
physical therapists, and they became occupational
therapists by going through a one-year training
program and taking the national board
examination (Table 1). The conventional
educational program began in 1979 at Yonsei
University. By then, only nine Korean
occupational therapists had been licensed (Jeong,
Choi, & Lee, 2000). By year 2000, four hundred
seventeen occupational therapists had been
licensed, and about half of them were actively
practicing (Table 2, Fig. 1).
The Korean Association of Occupational

Therapists (KAOT) was founded in 1993, and it
joined the Asia-Pacific Occupational Therapy
Congress (APOTC) in 1995 and became a full
member of World Federation of Occupational
Therapists (WFOT) in 1998. Within the last four
years, twenty-three new occupational therapy
programs have been launched nationwide, and there
are total of twenty-four occupational therapy
programs (seven four-year programs and seventeen
three-year programs) as of December 2002 (Table 3& 4). From year 2006, approximately nine hundred
new graduates are expected to take the national
occupational therapy licensing examination every
year (Fig. 2). Also, the post-professional graduate
programs (Table 5) are currently offered by four
universities (Lee & Kang, 2002).

The Current StageAs mentioned before, occupational therapy
was introduced to Korea in the early 1950’s. This
period coincided with the time that the biomedical
perspective was dominating the health care systemworldwide (Kielhofner & Burke, 1977).
Consequently, Korean occupational therapists

6

THE EVOLUTION OF OCCUPATIONAL THERAPY PROFESSION IN KOREA

Table 3. The four-year occupational therapy programs
University
Yonsei University
Konyang University
Inje University
Hanseo University
Woosong University
Gaya University
Daebul University

Established year

Admitted student number per year

1979
2000
2000
2000
2001
2002
2002

40
25
30
40
40
30
30

Table 4. The Three-year occupational therapy programs
College
Gwanyang College
Kyungbok Collge
Dongnam Health College
Kyungbuk Science College
Daegu Health College
Jeju Halla College
Daejeon Health College
Kyungbuk Foreign Language
Technology College
Gunjang College
Seorabul College
Sungduk College
Sunghwa College
Sooncheon First College
Hanyeong College
Jeonnam Science College
Joosung College
Pohahng First College

Established year

Admitted student number per year

1998
1999
1999
2000
2000
2000
2001
2002

80
80
80
40
40
40
40
30

2002
2002
2002
2002
2002
2002
2002
2002
2002

30
30
30
30
30
30
30
30
30

have been mainly focusing on physical disabilities
under the atmosphere of scientific reductionism
until recent days. These days the paradigm ofoccupation, stemmed from the early occupational
therapy philosophy, is vastly accepted in theinternational occupational therapy society. In
Korea, occupational therapy is being recognized
more and more nationally as an integral part of therehabilitation process. We are in the middle of theemerging paradigm, and it is the right time for us
to refine the direction of our profession. In orderto ensure the qualitative as well as quantitative
growth of occupational therapy in Korea, theKAOT (Korean Association of Occupational
Therapists) is working on the following fiveprojects.
First, the KAOT is restructuring theassociation responding to a sudden increase ofoccupational therapy programs. The first national
occupational therapy licensing examination was
administered by the National Institute of Health in
1965. In 1998, the National Health Personnel
Licensing Examination Board assumed
responsibilities for the development,
administration, and implementation of thelicensing process based on current and valid
standards for occupational therapy practice. The
purpose of awarding license is to identify for the
public those persons who have demonstrated boththe knowledge and the skills necessary to provide

Asian J Occup Ther 2: 3–9, 2003

Kang D et al.

7

Fig. 2. The number of entry level occupational therapy program graduates

Table 5. The graduate occupational therapy programs
University
Yonsei University
Hanseo University
Daegu University
Dankook University

Program(s)Entry level offered

Master, Doctorate
MasterMaste
Master

Yes
Yes
No
No

occupational therapy service. In the effort todevelop, maintain, and defend the content validityof practice-based occupational therapy licensing
examination, the National Health Personnel
Licensing Examination Board sponsored andauthorized the occupational therapy practiceanalysis study in 2000. Based on the occupational
therapy practice analysis study, MinimumStandards for the Education of Occupational
Therapists By World Federation of Occupational
Therapists (WFOT, 1993), and The National
Occupational Therapy Practice Analysis in the
USA (Dunn & Cada, 1998), the Korean National
Board Examination Development Committee met
to review the content of the national board
examination for occupational therapists in July
2001. The test items were carefully reviewed andupdated. The significant change made at thismeeting was the “addition” of new test items
focusing on occupation-based practice since theoccupational therapy license examination was
instituted in 1967. A new task force composed ofexperienced clinicians and educators is working
on establishing a standard guideline for theapproval of an occupational therapy program andclinical fieldwork based on the WFOT minimum
standard.
Second, the KAOT is exploring diverse
occupational therapy areas such as hand therapy
and ergonomics with emphasis on occupationbased practice. In reality, occupational therapy
service is mainly focusing on ADLs (Activities of
Daily Living) training at most of the institutions in
Korea. The use of hands has been a symbol of the

8

THE EVOLUTION OF OCCUPATIONAL THERAPY PROFESSION IN KOREA

occupational therapy profession, which is wellreflected in Mary Reilly’s famous Eleanor Clark
Slagle lecture in 1962.
“Man, through the use of his hands as they areenergized by mind and will, can influence thestate of his own health” (Reilly, 1962, p. 2)
For attainment of optimal function (health),
according to Cynkin and Robinson (1990), it isimperative that every human being be “involved
consciously in problem-solving and creative
activity” (p. 5). Problem-solving and creative
activity are also linked with the use of hands.
Practically all activities devoted to self-care andthe care of one’s environment require involvementof the hands. Therefore, the hand therapists areencouraged to integrate occupation-based
interventions into clinical practice to emphasize
the unique contributions of occupational therapy.
In order to accomplish this objective, a wide
spectrum of continuing education programs suchas hand therapy, ergonomics, assistive technology,
and mental health need to be generated.
Third, the KAOT is trying to integrate theunique aspects of Korean culture into establishing
the concept of occupational therapy. Even though
the occupational therapy profession sprouted inwestern culture, it values meaningful occupationin the real environmental context. In general,maximizing independence in daily life is a priorityof occupational therapy. However, this principle
does not apply to every single case. Some Korean
culture highly values caring for the elderly (i.e.
domestic chores or basic self-care) rather thanhaving them be independent in all areas.
Therefore, the Korean occupational therapists arebeing encouraged to be sensitive to the changing
health care systems and reflect the social value intheir practice while maintaining the core constructof occupational therapy.
Fourth, the KAOT is striving to develop
community-based occupational therapy programs.
Currently, most occupational therapy programs
concentrate on metropolitan areas and local healthneeds that can be addressed by occupational
therapy are relatively ignored. The KAOT is
confident that a regionally balanced developmentof o ccupat ion al th erapy will ensure both

qualitative and quantitative growth of thispromising profession in Korea.
Fifth, the KAOT is making strenuous efforts toestablish a closer partnership with the international
occupational therapy community to ensure the highqua lit y o f servic e t hat is con siste nt w ith
international thinking about health and educational
practice. The World Health Organization’sInternational Classification of Functioning,
Disability and Health (ICF) addresses both thecomponents of health and the environmental
context of health (WHO, 2001). Accordingly, theKAOT is taking an active role in speaking forinternational factors such as the Disability Rights
movement and the rights of indigenous people.

Conclusion
The Korean occupational therapy society has
worked strenuously to expand its professional
domain and has achieved incredible quantitative
growth. Now, it is focusing on the qualitative
growth of occupational therapy. The Korean
Association of Occupational Therapists (KAOT) is
placing high priority on establishing accreditation
standards for the occupational therapy program toassure the quality of the program and to assist in thedevelopment of the program. To guarantee thequality of occupational therapists, and to makecircumstances better for them, and to predict a
promising future in the field of occupational
therapy, basic regulations and minimum standards
for educational institutions and practice institutions
are being established by a special task force
sponsored by the KAOT. This process will enhance
the reputation of an accredited program because of
public regard for accreditation while the KAOT isdeveloping a concrete system to proactively
advocate the roles and effectiveness of occupational
therapy to the public . At the same time, the KAOT
is seeking strong and ongoing links to theinternational occupational therapy community.
Through these efforts, the profession ofoccupational therapy in Korea will be strengthenedby contributing to the unity of the professions in an
activity directed at improving professional
preparation and professional practice.

Asian J Occup Ther 2: 3–9, 2003

References
Cynkin, S. & Robinson, A. M. (1990). Occupational
therapy and activities health: Toward healththrough activities. Boston: Little, Brown andCompany.
Dunn, W., & Cada, E. (1998). The national
occupational therapy practice analysis: Findings
and implications for competence. American
Journal of Occupational Therapy, 52, 721–728.
Dunton, W. R. (1954). History and development ofoccupational therapy. In H. S. Willard, & C. S.
Spackman (Eds.), Principles of occupational
therapy. 2 nd ed., pp. 1–10. Philadelphia: J. B.
Lippincott.
Jeong, W. M., Choi, H. S., & Lee, J. Y. (2000). The
demand and supply for occupational therapists in
Korea. The Journal of Korean Society ofOccupational Therapy, 8, 111–120 (in Korean).
Kielhofner, G., & Burke, J. P. (1977). Occupational
therapy after 60 years: An account of changing
identity and knowledge. American Journal of
Occupational Therapy, 31, 675–689.
Lee, M. J. (1998). The present condition ofoccupational therapy in Korea and its alternatives.
The Journal of Korean Society of Occupational

Kang D et al.

9Therapy, 6, 93–105 (in Korean) .
Lee, T. Y. & Kang, D. H. (2002). The alternatives forthe current occupational therapy licensing
examination. The Journal of Korean Society ofOccupational Therapy, 10, 163–170 (in Korean).
O, Y. T. (1994). The history of occupational therapy
in Korea. The Journal of Korean Society ofOccupational Therapy, 2, 63–71 (in Korean).
Reed, K. L. (1993). The beginning of occupational
therapy. In H. L. Hopkins, & H. D. Smith (Eds.),
Willard and Spackman’s occupational therapy. 8thed., pp. 26–43. Philadelphia: J. B. Lippincott.
Reilly, M. (1962). Occupational therapy can be oneof the great ideas of 20th century medicine, 1962
Eleanor Clark Slagle lecture. American Journal of
Occupational Therapy, 16, 1–6.
World Federation of Occupational Therapists.
(1993). Minimum standards for the education ofoccupational therapists. Retrieved September 20,
2001, from http://www.wfot.org.au
World Health Organization. (2001). Internationalclassification of functioning, disability and health.
Retrieved Octobe r 20 , 2002, fr om http://
www.who.int/classification/icf/intros/ICF-EngIntro.pdf

ORIGINAL ARTICLE

Using Problem-Based Learning (PBL) with
Hong Kong Occupational Therapy
Students: Opportunities and Challenges
Jenny C. C. CHUNG, Ph.D.1
1 Department of Rehabilitation Sciences, The Hong Kong Polytechnic University

Abstract: This action learning project aimed at exploring the feasibility, values andlimitations of implementing problem-based learning (PBL) with Hong Kong occupational
therapy (OT) students. The PBL methodology was implemented in a year-one subject in
the undergraduate occupational therapy curriculum, entitled ‘Sensation and Perception’.
During a 14-week period, 90 OT students, working in small teams of 6, studied three PBL
cases. Both quantitative and qualitative methods were used to examine the effects of thisPBL implementation. The Inventory of Learning Preferences (ILP) and Study Process
Questionnaire (SPQ) gauged the change in the students’ learning approach before andafter PBL implementation. Focus group interviews and non-graded reflective journals
were used to examine students’ perceptions of the PBL experience. Although theirlearning approaches and preferences did not differ significantly after the PBL experience,
the majority of students (84%) favored this learning method. The qualitative data
indicated that the students developed basic study skills such as the ability to brainstorm
and perform a literature search, and the experience of which they valued. The major
challenges identified were the heavy workload, insufficient learning resources to support
the new learning experience, and poor transfer of the acquired study skills to otherlearning situations. It is recommended that the PBL methodology be refined based on theopportunities and challenges identified, and that its application be extended to othersubjects in the teaching curriculum.
Key words: Hong Kong students, problem-based learning, study skills, undergraduate
occupational therapy program(Asian J Occup Ther 2: 10–22, 2003)

Introduction
Received: September 30, 2002, Accepted: May 24, 2003
Corresponding to: Jenny C.C. Chung (Ph D); Departmentof Rehabilitation Sciences, The Hong Kong Polytechnic
University, Hung Hom, Hong Kong, SAR China
phone: 85 2-2766-6752 fax: 85 2-2330-8656
e-mail: rsjchung@polyu.edu.hk

As with all healthcare professionals,
occupational therapists must possess good clinicalreasoning skills to solve clients’ individual
problems. Problem-based learning (PBL), since
its introduction to the McMaster Medical Schoolin the mid-1960s, has been documented for its

Asian J Occup Ther 2: 10–22, 2003

values in promoting critical thinking (Biggs, 1991;
Boud & Feletti, 1991), problem-solving (Dolmans& Schmidt, 1994) and independent learning(Norman & Schmidt, 1992). Depending on how
the problem is structured and the extent of teacher
direction, some PBL methodologies adopt a morestructured format, while others are less structured(Barrows, 1986). Despite the format differences,
all PBL approaches share a common
characteristic, namely that learning should begin
with a problem that students wish to solve (Boud,1985). Through the processes of understanding
and formulating strategies to solve the problem,
students acquire knowledge and content-related
skills, and develop skills of clinical reasoning andself-directed learning (Barrows, 1986; Biggs,
1999).
There has been a growing interest in adopting
PBL as an innovative teaching-learning strategy inoccupational therapy curriculums, notably inNorth America and Western Europe. Some Asian
countries, such as Singapore, Japan and Hong
Kong, are also keen to reform the education
system and encourage their students to develop a
more active learning attitude, because it is often
commented that their students are rote learners.
For instance, Hong Kong students are criticizedfor relying too much on teachers ’ inputs andseldom assume an active learning role (Biggs,
cited in Watkins, Reghi, & Astilla, 1991). The
Confucian beliefs held by many Chinese people
can partly explain the shaping of rote-learning
behaviors, because Confucianism teaches students
to respect knowledge and teachers (Chan, 1999).
Hence, Chinese students are largely obedient andseldom express personal opinions in classes. In
fact, a majority of the teaching curricula inprimary, secondary, and tertiary education adopts
a didactic teaching-learning mode in which active
questioning and creativity are not encouraged.
Moreover, Chinese parents tend to have highhopes concerning their children's academic
achievements. In order not to disappoint theirparents, most Hong Kong students use an‘achieving ’ learning strategy, in which theirprimary study objective is to obtain good grades
rather than search for knowledge (Stevenson &Lee, 1996).

Chung JCC

11

With few exceptions, the undergraduate
occupational therapy curriculum of Hong Kong islargely characterized by a conventional teachinglearning methodology that consists of lectures,
seminars and tutorials. Sometimes, when casestudies are used in tutorials to stimulate student
discussion on case management, the majority ofstudents are found to be passive in learning andexpect much input from their teachers (Chung,2001). Realizing that occupational therapists need
to be reflective and creative in formulating
strategies to solve clinical problems, the authors
therefore initiated an action learning project to
explore the opportunities and challenges of
implementing a PBL methodology with Hong
Kong occupational therapy (OT) undergraduate
students who have long been exposed to theconventional type of teaching-learning
methodology.

The Action Learning ProjectPreparation phase
A subject in the undergraduate occupational
therapy curriculum of The Hong Kong
Polytechnic University, entitled ‘Performance
Component: Sensation and Perception ’ , waschosen to pilot test PBL implementation with
Hong Kong OT students. Implemented in thesecond semester of the year-one curriculum, it is a
supporting subject that aims at developing
students ’ basic understanding of the nature,development and functions of sensation andperception in normal people, and theirappreciation of how to apply the basic knowledge
in clinical case management. It is a three-credit
subject, consisting of 10 lecture hours, 10 seminar
hours, and 22 tutorial hours.
The authors experienced two constraints
during the preparation stage. Firstly, typical PBL
sessions are run in small groups to promotemaximum student interaction and participation(Davis, 1995), but limited human resources (twofaculty members) and a large class size (90students) made such small-group sessions
impossible. Secondly, PBL was only introduced
to one one-semester subject in the three-year
curriculum, because the department was not ready12

PBL FOR OCCUPATIONAL THERAPY STUDENTS

for a complete change.
To address the issue of limited manpower, thePBL methodology was structured so as to be
implemented in three large-sized tutorial groups(30 students per group), in which students wereasked to study in small teams. Instead of working
with 30 individuals in a tutorial group, the tutor
facilitated student learning in five small teams. As
the PBL methodology was implemented in only
one subject in the whole curriculum, it was felt
important to prepare and orientate students to thisnew teaching-learning methodology in order tominimize learning anxiety and uncertainty. Afterconsulting educators who are experienced in PBL,
the authors drafted the philosophy, objectives andlearning modes of PBL, and the roles of students
and tutors in PBL sessions (refer to Appendix for
details). All this information was introduced andexplained to students in the first class.
Problems are central to the PBL approach andmust be carefully designed to meet both thelearning objectives and the educational objectivesof the study subject. Good problems are usually ill
defined, to incorporate the learning objectives,
capitalize on students’ interests, promote the use ofproblem-solving skills and critical thinking, andreflect real-life scenarios. Three clinical cases
were solicited and written as study cases based on
the occupational therapy process: initial interview
and assessment, problem identification, andtreatment planning and implementation. The OT
process was used because it would allow students
to analyze the case and identify learning issues in asystematic manner. After the first study case wasdeveloped, five former students were invited topilot test its ability to promote study skills such asproblem-solving, integration, and critical analysis
of information. The problem was also checkedagainst the learning objectives and students’interest. Modifications were made according to
the first case, which then became the basis offormulating the other two study cases.

Implementation phase
The PBL methodology was introduced in theselected subject, in which 90 OT students enrolledduring the academic year of 2000/01. In the firstsession, they were introduced to the PBL

methodology and the action learning project, andall gave their consent to participate. The genderdivide was as follows: 35.6% were males and64.4% were females. Their mean age was 20.6
(SD=6.32).
The PBL subject, consisting of both largegroup (lecture) and small-group (tutorial/seminar)
meetings, spanned over 14 weeks. The 90 students
were divided into working teams of 6, and eachteam worked on three open-ended problems.
Three tutorial groups, each comprising fiveworking teams, met weekly with their tutor, who
guided them through the essential stages of PBL
such as brainstorming, identification of learning
issues, study planning, and independent study.
Each working team presented their chosen
learning issues to their peers during the seminarsessions. The lectures were used to consolidate thekey concepts that students learned throughaddressing the problems. An electronic discussion
board was established to encourage students tocommunicate with tutors, share information, anddiscuss related issues with their classmates outside
the scheduled class contact hours.

Evaluation phase
Both quantitative and qualitative methods
were used to examine the learning outcomes,
values and limitations of using PBL methodology
with Hong Kong occupational therapy students. In
terms of the quantitative evaluation, all students
completed the Study Process Questionnaire (SPQ)
and the Inventory of Learning Preference (ILP)prior to and again after the PBL experience. The
SPQ, based on motive-strategy congruence theory,
was used to examine students ’ predisposition
towards learning (Biggs, 1993). Students
independently rated each of the 42 SPQ statements
on a 5-point scale- for example, “I have a strong
desire to excel in all my studies”, from 1 “never orrarely true of me” to 5 “always or almost always
true of me”. Three levels of learning (surface,deep, and achieving) can be identified from theanalysis of the statements. The 34-item ILP
probed into the student’s preferred learning mode,
which ranges from strongly favorable to notfavorable to PBL (Moore & Fitch, cited in Stokes,
Mackinnon, & Whitehill, 1997). Students wereAsian J Occup Ther 2: 10–22, 2003

asked to select 10 statements that best described
their ideal learning environment.
As for qualitative evaluation, all students
were requested to submit a non-graded reflective
journal at the end of the subject. They wereencouraged to reflect upon their learning
experiences by discussing the impacts of the PBL
methodology on their learning. In addition, two
focus group interviews were arranged to further
explore students’ perception of PBL as a teachinglearning strategy. Areas examined in theinterviews included students’ conception ofuniversity teaching and learning, their perceptionof PBL as a learning strategy, the positive andnegative aspects of PBL, and suggestions for
improvement. Fourteen students (15%) wererandomly selected and allocated to the interview
groups. One student was ill and could not attend
the interview, and therefore one interview groupconsisted of 6 students and the other had 7
students. Both focus group interviews lasted forabout 1.5 hours, and were audio-taped.

Data analysis
The SPQ was scored according to Biggs(1993). One-way ANOVA was used to investigate
whether the students’ learning approach changed
after the PBL experience. MANOVA was used tofurther analyze whether post-PBL changes
occurred in any of the students’ SPQ scores interms of the three levels (surface, deep, achieving),
two scales (motive, strategy), and six sub-scales(surface motive, deep motive, achieving motive,
surface strategy, deep strategy and achieving
strategy). The percentage of students selecting aparticular learning environment, as illustrated by
ILP, was compared before and after the PBL
experience (Stokes, Mackinnon, & Whitehill,1997).
Qualitative analysis of the interviews andreflective journals was based on a Model of
Human Occupation (MOHO; Kielhofner, 1995),
which is a theoretical model developed for
occupational therapy practice to understand theoccurrence and formation of human behaviors(one of which is study behaviors). The MOHO
consists of an input system (task andenvironment), human subsystems (performance,

Chung JCC

13

Fig. 1. Model of human occupation (Kielhofner, 1995)

habituation, and volition), and an output system(behaviors) (Fig. 1). An independent rater, who isexperienced in the area of student learning, coded
the scripts and journals, and the first author
performed a reliability check with a sub-sample ofseven reflective journals and two interview scripts.
The percentage agreement was between 82% and88%.

Results
SPQ and ILP
Only 51 pairs of pre- and post-test data wereanalyzed, because 39 students did not return the
SPQ and ILP in the post-test phase. Prior to the
PBL experience, the students’ preferences forstudy processes varied among the three learning
approaches: deep, surface and achieving (F=7.40,
p< .001). Post hoc analysis based on the Scheffe
Test revealed a difference only between the deep
and achieving approaches. The preferences for a
deep approach (M=3.32, SD=0.55) weresignificantly higher than those for an achieving
approach (M=2.97, SD=0.38), but not those for asurface approach (M=3.12, SD=0.42). When
comparing pre- and post-PBL implementation, the
MANOVA results showed that none of the SPQ
scores differed significantly at the .05 level. Table
1 presents the means, SD and F values of the
MANOVA analysis.
Of the 34 statements in the ILP, there was achange of more than 10% in seven items (See Fig.
2). Students showed an increased preference forindependent learning according to two items:“valuing classmates as sources of information”
and “allowing peers to have their own opinion”.
Similarly, students’ preferences for a surface
approach decreased according to one item:

14

PBL FOR OCCUPATIONAL THERAPY STUDENTS

Table 1. Mean, SD and MANOVA results of Study Process Questionnaire (SPQ; Biggs, 1993)
Pre-test
Surface approach
Deep approach
Achieving approach
MotiveStrategy
Surface motive
Deep motive
Achievement motive
Surface strategy
Deep strategy
Achieving strategy

Post-test

Mean

SD

Mean

SD

F

p

3.12
3.32
2.97
3.23
3.05
3.26
3.27
3.15
2.98
3.37
2.80

.42
.55
.38
.34
.31
.51
.62
.53
.50
.58
.52

3.12
3.35
2.96
3.22
3.07
3.25
3.25
3.18
2.99
3.47
2.74

.52
.47
.47
.37
.32
.62
.62
.59
.51
.51
.56

.001
.10
.02
.01
.10
.01
.14
.09
.004
1.03
.27

.98
.75
.90
.91
.75
.91
.71
.76
.95
.31
.61

N=51.

Fig. 2. Percent change in inventory of learning preference prior to and after the PBL implementation (ILP; Moore &Fitch, cited in Stokes, Mackinnon, & Whitehill, 1997). Note: * >10% difference, ** >20% difference.

“professor provides clear directions and guidance
for all course activities and assignments”. On theother hand, according to two other items there wasa decreased preference for independent learning:“classroom atmosphere of exploring and debating
new ideas” and “workshop or seminar atmosphere

to exchange ideas and evaluate own perspectives”.
There was also an increase in a surface approach in
two other instances: “while emphasizing classdiscussion, the professor tells us the right answer”
and “the professor is an expert who knows all theanswers”.

Asian J Occup Ther 2: 10–22, 2003

Reflective journals and interviews
In the reflective journals, 76 students (84.4%)
gave positive comments on their PBL experience.
The greatest number of positive comments was
related to students’ preference for a more
independent learning mode (n=1791). One student
expressed her joy at being a university student, “I
am given the opportunity to study independently.
...Though it is not easy, I am motivated to search,select and read according to my chosen learning
issues.” However, the PBL methodology was
unsettling for some students. One student said that
he paid the tuition fee but obtained few learningmaterials from the tutors.
The following sections present the qualitative
data based on the MOHO framework (refer to Fig.
1).

Human subsystems
Performance: Students reported on
developing basic study skills from the PBL
experience (n=146). As one student commented,“I only read the recommended textbooks andjournal articles in other subjects, but I read more
extensively in this PBL subject. Moreover, I havedeveloped literature search strategies and extended
my search to the Internet.” About half of thestudents claimed that the PBL methodology
provided them with structured opportunities topractice brainstorming of ideas, exchanging anddiscussing opinions, and performing a systematic
literature search (n=45). Some students foundthemselves more proficient at organizing materials
f o r p r e s e n t at i o n ( n = 5 6 ) , a n d h ad g r e a t e r
confidence when interacting with an audience(n=43).
Some students reported the attainment ofhigher-order learning skills such as problemsolving skills (n=21), critical analytical skills(n=19), and time management (n=12). One student
valued the study skills that she had acquired throughthe PBL process, “...these study skills are of greatuse in my future practice. I am now the fisherman
who fishes for myself rather than waiting to be fed.”
Students also expressed their more independent
approaches to learning (n=19) and the assumptionof greater responsibility for their learning (n=11).
One student claimed that the PBL methodology

Chung JCC

15

encouraged her to be an active learner because sheneeded to decide ‘what’ and ‘how’ to learn fromopen-ended problems. Some students said they had
developed active listening skills (n=23) and
improved questioning techniques (n=16).
Habituation: To be able to routinely apply
acquired study skills reflects a deep level oflearning. Although students reported thedevelopment of independent study skills, it wasless evident that they practiced the acquired skills
in other learning situations (n=18). The following
two excerpts may provide reasons for thisobservation. “As we receive comprehensive
handouts in the non-PBL subjects, I don’t feel theneed to look up additional information.” and “Thetimetable is so packed that I can hardly find time tofurther develop and consolidate the study skills
that I learned from the PBL experience.”
Volition: Some students reported anincreased motivation for learning (n=15) andconsidered the PBL experience a rewarding one(n=26). Data showed that som e students
developed a deeper (n=29) and wider (n=14)
understanding of the subject that reinforced theirlearning motives, and some reported their
willingness to put extra effort into the PBL moduledue to a sense of achievement (n=16). The
following excerpt demonstrates a student’s
motivation in the PBL subject:
Although the workload of this module isheavy, I like it. Unlike other subjects, I
participate in every part of the learning
process, just like baking a cake from its raw
ingredients. ...I feel good when I receive
positive comments from the tutor and peers,...and these are probably the forces that pushme forward.

Learning environment
Social aspect: Students favored the social
situations created by the PBL methodology, suchas group work, and appreciated the friendships
generated (n=42). They acknowledged thebenefits of PBL in promoting group work skills
through information sharing and the assumption of
1 The number of responses is greater than the number ofstudents, since each student can include more than one point.

16

PBL FOR OCCUPATIONAL THERAPY STUDENTS

responsibility. As one student stated, “What I likemost in PBL is the opportunity to work together
with peers who have different characters andlearning aspirations. I learn from their strengths
and weaknesses.” More specifically, students
valued the learning opportunities gained throughpeer modeling (n=14) and peer feedback (n=28).
For instance, a student treasured the brainstorming
sessions and peer discussions because she was able
to get a more comprehensive and critical appraisalof the study topic. In addition, negotiation (n=31)
and decision-making skills (n=18) were developed
through group work.
On a more personal level, many students(n=67) attributed the development of mutual
support, trust, respect and friendship to the PBL
process. One student shared her gratitude forestablishing trust with fellow classmates, “We
openly share the information and support eachother whenever in need. ...We also learn todistribute the workload fairly among ourselves.”
Having said that, a few students expressed theirdifficulty in working with classmates who were
uncooperative and avoided shouldering
responsibility (n=7).
Physical aspect: The time demands of the
PBL methodology within a traditional curriculum
distressed many students (n=53) because thetightly packed curriculum and the closely spaced
tutorials left students little time for self-study. One
student pointed out that the average of 30 hours’
class time every week put her in a very stressful
position, as she needed to cope with PBL
assignments and the assignments of other subjects
at the same time. An insufficient supply oflearning resources was another stressful learning
experience (n=46). Although the Internet
provided easily accessible information, students
were concerned (and rightly so) about the accuracyof the information. The following excerpt reveals
their frustration about the limited learning
resources:
The library has insufficient textbooks andlearning materials to share among us. With
90 students working on the same problem atthe same time, we usually end up withnothing. We search from the Internet, but it
often takes a long time to download theinformation. Moreover, we are uncertain
about the accuracy of the information because
everyone can upload information onto theInternet.
Learning tasks: Students commented that
open-ended problems were stimulating enough topromote learning (n=46) and increase theirawareness of the complexity of the clinicalproblems they will encounter in future practice(n=23). Only a few students were confident about
integrating information (n=12) and managing
conflicting information from the literature (n=7),
and many students found this very difficult to deal
with (n=41). The latter group was eager to look
for an absolute answer. Quite a number ofstudents were uncertain about the scope oflearning (n=27) and requested the provision of
specific study guidelines and ‘official’ reading
lists. Even though students valued the opportunity
for peer learning, they actually had little
confidence in the effects of learning from theirpeers (n=32). One student’s comment reflects thisconcern:
Some classmates are not serious about thelearning task. Their presentations are looselyorganized with a poverty of content materials.
It is a waste of my time to listen to theirpresentations. Although we can ask themquestions, we tend to keep quiet because we
don't have a clue of what they talked about inthe presentation. Moreover, they will be
unhappy if they have to do additional work,
after the presentation, to clarify our questions.

Discussion
Challenges
Kember and Gow (1991) argue that thelearning environment is more significant thanpersonal factors in shaping learning behaviors.
This study, however, identified the interactivity ofthese two factors in shaping students’ learning
perception and behaviors. The students in thisstudy primarily learned through an expository
teaching-learning methodology in their primaryand secondary educations, which aim to meet therequirements of the Hong Kong examination
syllabus (Morris, 1985). The learning behaviors ofAsian J Occup Ther 2: 10–22, 2003

this teaching-learning approach are characterizedby passive listening, note-taking and getting
teachers’ tips for examination (Biggs, 1991).
Stated another way, these occupational therapy
students have been conditioned to a relatively
passive and spoon-fed mode of learning for at least
13 years. Thus, a sweeping change to an active
and deep learning approach can hardly be expectedfrom students who have merely been introduced to
the PBL methodology for 14 weeks.
The students’ attachment to the spoon-fed
learning pattern also accounts for their uncertainty
about the scope and accuracy of learning. Whenplaced in a new learning environment that requires
active learning, students felt insecure and out ofcontrol. This finding is consistent with theobservations of Stokes, Mackinnon, & Whitehill(1997) and Woods (1994), that the PBL
methodology can be an anxiety-provoking
learning experience, particularly in its first cycleof implementation. Adequate support is therefore
essential to nurture a new learning experience, or
students may lose confidence, direction andmotivation in learning (Tang et al., 1997). This
study identified some unfavorable factors, such as
insufficient textbooks and learning resources, andthe heavy workload, which need to be addressed infuture implementation.
As the PBL methodology was introduced
only to one subject in the whole occupational
therapy curriculum, it is not surprising that thestudents compared the PBL methodology with thedidactic mode of other subjects in terms ofworkload and teaching-learning methods. In
particular, when the learning environment does notfavor an independent learning mode, such as
during periods with heavy workloads andassessments, the students’ preference for a lessdemanding didactic teaching-learning
methodology is understandable.

Opportunities
Despite the challenges, this study identified
some favorable factors of implementing PBL
methodology with Hong Kong occupational
therapy students. Instead of working on an
individual basis as in typical PBL modes, thestudents in this study worked through the problems

Chung JCC

17

in small groups. The group work experience wasstrongly favored by the students. This finding
echoes the observations of Biggs (1991) andStokes, Mackinnon, & Whitehill (1997) that
Chinese students favor group learning andperceive it as a form of collective work thatenables them to achieve good academic results. In
other words, the use of group work in this PBL
methodology matches quite well with thecharacteristics of Chinese learners. Moreover, thegroup work experience enabled the students todevelop study skills such as information sharing,
communication skills, and critical analysis ofdifferent perspectives, which are considered
important for healthcare professionals (Salvatori,1999).
Although students’ brief exposure to PBL
methodology did not change much of theirlearning approach, it gave a positive push to thethree human subsystems of learning (Kielhofner,1995), most notably the performance subsystem.
Evidently, the students were able to develop theirstudy skills when provided with the appropriate
learning environment. This observation lends
additional support to Kember and Gow’s (1991)
finding that the quality of learning environments
influences the shaping and development oflearning behaviors. The transfer of study skills
gained from the PBL experience to other learning
situations was not evident in this study, indicating
the need to develop integrated pedagogicalstrategies to promote students’ habitual transfer of
new learning behaviors to various learning
situations.

Limitations of the study
The lack of a control or comparison grouprepresents a major limitation of this action learning
project. Since only one 14-week subject was
included in the PBL implementation and only one
group of students was included in the study,
substantial and solid conclusions cannot be drawn
based on this form of research design. A quasiexperimental study design consisting of a control
group or a comparison group is suggested to
improve the rigor of future study. Moreover, thelow return rate of SPQ and ILP post-test may havewarped the data interpretation, so caution is

18

PBL FOR OCCUPATIONAL THERAPY STUDENTS

needed not to over-generalize the findings.

Conclusion
One cannot expect learning behaviors to be
developed or changed overnight: the shaping oflearning behaviors takes place cumulatively.
Hence, the fact that students’ learning approachand learning preferences do not demonstrate asignificant change after exposure to a PBL
experience over a 14-week period isunderstandable, and students’ complaints of aheavy workload and insufficient learning
resources to support a new learning experience aretotally valid. If the identified challenges areproperly addressed, the potential benefits of PBL
observed in this study, such as promoting an active
learning attitude and developing core study skills,
are positive signs for future PBL implementation
with Hong Kong OT students. Moreover, thegroup work experience, which is highly valued by
the students, should be further reinforced in future
implementation.
As this was an explorative study examining
the feasibility and potential values and limitationsof PBL implementation for Hong Kongoccupational therapy students, further studies canbe geared towards refining the PBL methodology
so as to address the challenges identified, andextending the PBL methodology to other subjectsof the occupational therapy curriculum toreinforce the shaping of learning behaviors anddevelopment of study skills that are essential forreflective occupational therapists.
Acknowledgement: The project was supported
by a Learning-Teaching Development Grant(#4620) of the University Grants Committee,
Hong Kong.

References
Barrows, H.S. (1986). A taxonomy of problem-basedlearning methods. Medical Education, 20, 481–
486.
Biggs, J.B. (1987). The Study Process Questionnaire(SPQ): Manual. Hawthorn, Vic: AustralianCouncil for Educational Research.

Biggs, J.B. (1991). Approaches to learning insecondary and tertiary students in Hong Kong:
Some comparative studies. Educational Research
Journal, 6, 27–39.
Biggs, J.B. (1993). What do inventories of students’learning processes really measure? A theoreticalreview and clarification. British Journal of
Educational Psychology, 63, 3–19.
Biggs, J.B. (1999). Teaching for quality learning atuniversity. Australia: Society for Research into
Higher Education and Open University Press.
Boud, D. (1985). Problem-based learning in
education for professions. Australia: Higher
Education and Development Society of Australia.
Boud, D. & Feletti, G. (1991). The challenges ofproblem-based learning. London: Kogan Page.
Chan, S. (1999). The Chinese learner: A question ofstyle. Education and Training, 41, 294–304.
Chung, J.C.C. (2001). Active learning of geriatricrehabilitation: Deliberations of an occupational
therapy program. Scandinavian Journal of Caring
Sciences, 15, 250–256.
Davis, S.S. (1995). Improving the PBL small groupprocess: Suggestions from a qualitative study.
Research and Development in Problem-based
Learning, 3, 109–123.
Dolmans, D.A., & Schmidt, H.G. (1994). What
drives the student in problem-based learning?
Medical Education, 28, 372–380.
Kember, D. & Gow, L. (1991). A challenge to the
anecdotal stereotype of the Asian student. Studies
in Higher Education, 16, 117–128.
Kielhofner, G. (Ed.). (1995). A model of humanoccupation: Theory and application (2 nd ed.).
Baltimore, MD: William & Wilkins.
Morris, P. (1985). Teachers’ perception of thebarriers to the implementation of a pedagogic
innovation: A South East Asian case study.
International Review of Education, 31, 3–18.
Norman, G.R. & Schmidt, H.G. (1992). The
psychological basis of problem-based learning: A
review of the evidence. Academic Medicine, 67,
557–565.
Salvatori, P. (1999). Meaningful occupation foroccupational therapy students: A student-centeredcurriculum. Occupational Therapy International,
6, 207–223.
Stevenson, H.W. & Lee, S.Y. (1996). The academic
achievement of Chinese students, in Bond M.H.
(ed.), The handbook of Chinese psychology. HongKong: Oxford University Press, 124–142.
Stokes, S.F., Mackinnon, M.M., & Whitehill, T.L.

Asian J Occup Ther 2: 10–22, 2003

Chung JCC

(1997). Students’ experiences of PBL: Journal andquestionnaire analysis. Austrian Journal of Higher
Education, 1, 161–179.
Tang, C., Lai, P., Tang, W., Davis, H., Frankland, S.,
Oldfield, K., Walters, M., Ng, M. L., Tse, P.,
Taylor, G., Tiwari, A., Yim, M., & Yuen, E.
(1997). Developing context-based PBL model.
Integrity, Innovation, Integration, 4, 579–595.
Watkins, D., Reghi, M., & Astilla, E. (1991). The

19

Asian learner as a rote learner stereotype: Myth orreality? Educational Psychology, 11, 21–34.
Watkins, D., Biggs, J.B. & Reghi, M. (1991). Does
confidence in the language of instruction influencea student’s approach to learning? Instructional
Science, 20, 331–339.
Woods, D.R. (1994). Problem-based learning: Howto gain the most from PBL? Waterdown, Ontario:
D.R. Woods Publishers.

Appendix

TEACHING-LEARNING METHOD
What is problem-based learning?
Problem-Based Learning (PBL) is any
learning activity in which problems drive learning.
In order to facilitate learning, students are given a
problem. The problem is so designed that students
develop learning issues that are required to solve
the problem.

Benefits of problem-based learning
Through problem solving, students
accumulate knowledge and develop flexible andcognitive strategies that help analyze unanticipated,
ill-structured situations to produce meaningful
solutions. Indeed, this is an essential skill needed totackle problems of today's complex issues.
Through PBL, students encounter problems inwhich they need to transfer their learning to new
domains; such skills enable the independent learner
to function effectively in society.
Real life problems seldom parallel wellstructured problems, but present an ever-changing
variety of goals, contexts, contents, obstacles, andunknowns that influence how each problem should
be approached. And in real life, we seldom repeat
exactly the same steps to solve problems.
Therefore, students need critical thinking skills tointeract with life. Moreover, to be successful intheir career, students require practicing skills insolving ill-structured problems that reflect life
beyond the classroom.
In PBL, students may work independently orin small groups to create viable solutions for a
problem. Owing to a reduced amount of direct
instruction in PBL, students assume a greater

responsibility for their own learning (Aspy, Aspy
& Quimby, 1993). Moreover, students develop
group work skills such as communication anddivision of labour.

Are there any secondary gains?
As noted from comments of retrospective
students, most of them acquired the skills of
information/literature search, reading anddiscussing articles, and presentation (Chung &Chow, 2000). Some developed skills of asking
questions, critical thinking and analysis of
information from different sources. A majority ofstudents treasured the friendship and trustdeveloped through group work. Students also
learned the negotiation and discussion skills
through teamwork. Through feedback, students
learned how to give constructive evaluation on
peers’ performance and accept comments frompeers and tutors.

Performance Components: Sensation
and Perception
Principles
Normal development of the sensory-perception
systemThe seven sensory-perception modalities(visual, auditory, gustatory, olfactory, tactile,
vestibular, and proprioceptive modalities)
develop across the life span. Occupational
therapists are particularly interested in visual,tactile, vestibular and proprioceptive systems.
The understanding of the developmental changes

20

PBL FOR OCCUPATIONAL THERAPY STUDENTS

of these four sensory modalities helps
occupational therapists to discriminate
dysfunction from immaturity and senility.
Nature of four sensory-perception modalities
Occupational therapists are interested in two
important functions, discrimination andmodulation, of the sensory systems. Discriminationis the ability to compare and select the appropriate
incoming sensory and perception information.
Modulation is the capacity of the nervous system toregulate its responses to sensory stimulation, so thatit neither over- nor under- responds (Spitzer, Roley,
Clark, & Parham, 1996). Sensory discrimination isimportant for motor planning, while sensory
modulation is essential for arousal.
Sensor y-perce ptual assess ment used in
occupational therapy practiceOccupational therapists use a variety ofevaluation methods to identify function anddysfunction in sensory-perceptual modalities.
Such methods include interview, observation andstandardized assessment battery. Accurateinterpretation of assessment data helps informulating a sound base for occupational therapy
interventions.
Occupational therapy management of clientswith sensory-perceptual dysfunction
Occupational therapists utilize a number ofinterventions to maximize clients' functional
independence. Two common treatment approaches
adopted are remedial and compensatory. The
analysis of the application allows occupational
therapists to select the most appropriate treatment
approach to meet clients’ needs.

modalities on the performance of occupationalroles.
3. Discuss two main functions of the sensoryperceptual modalities: discrimination andmodulation.
4. Conduct assessment related to sensoryperceptual functions, and interpret sensitively
the assessment results in the context of clients'
physical and psychosocial environments.
5. Integrate the knowledge on normal development
and results of occupational therapy assessment
to analyze therapeutic values of occupational
therapy interventions.

Educational objectives
In addition to learning objectives, students
should be able to achieve the following
educational objectives:
1. The learner should be able to develop basic
clinical reasoning skills, which include
hypothesis generation, inquiry, data analysis,
problem synthesis, and decision-making(Barrows, 1986).
2. The learner should be able to develop effective
self-directed learning skills, such as being moresensitive to personal learning needs, locating
and using appropriate information resources.

Roles of Students in PBL Classes
PBL is a student-centered learning processthat facilitates students to assume responsibility of
the learning process. Students are therefore
encouraged to actively participate in tutorials, andaid the learning of others in the group. Also, PBL
promotes students’ integration of their priorknowledge and experiences to the problems
studied.

Learning objectives
After the completion of the module, students
should be able to:
1. Describe the normal development of four
sensory-perceptual modalities, namely, visual,tactile, vestibular and proprioceptive, which are
typical of different life stages: childhood,
adulthood and old age.
2. Understand the implications of function anddysfunction of four sensory-perceptual

During each session of PBL tutorial, students
should have different roles,
Problem start* Find out the terms which are unclear* Identify key words
Brainstorming questions* Be creative* Raise questions relating to the key words* Identify concepts that needs to be learned

Asian J Occup Ther 2: 10–22, 2003

Chung JCC

Leaning issues* Identify important learning issues in the
problem* Learn how to work together* Categorize questions raised into the relevant
learning issues* Prioritize learning issues in relation to thelearning objectives
Presentation* Adequate preparations on assigned learning
issues* Present materials in an organised and concise
manner* Listen attentively and raise constructive
questionsFeedback* Be appreciative of the contribution of yourgroup members* Learn how to evaluate knowledge* Decide if the problem is completed byconsidering if what you want to learn about
the issues are all done
Overall Performance* Be more engaged, and show moreparticipation in class* Be an active participant in order to contribute
unique knowledge and ideas to the learning
process* Learn to listen well. Let others speak without
interrupting them
* Develop effective communication skills* Learn from each other, share knowledge,
expertise, and ability* Learn to consider time, resources andobjectives and set priorities regarding therelative importance of each learning issue* Create own summaries of what they learnt
between sessions which gives practice inorganizing knowledge and they willremember what they have learned. Also
make study and review easier* Return the references/study material once
finished using
On the other hand, students should not,* Rely on the tutor* Attend the PBL tutorial without
preparation

any

21

* Keep silence and seldom voice out opinions* Privately discuss with colleagues. They
should openly discuss in front of the tutorialgroup and facilitator.

Roles of Tutors in PBL Classes
The tutor is an educator who facilitates a taskoriented group to successfully achieve theobjectives of a teaching program. She facilitates
students to identify key issues in the problem andfind ways to learn the identified areas inappropriate breadth and depth. Moreover, shemust be clear about the learning process so as toassure that the group stays on the targeted
objectives and makes reasonable choices on key
learning issues. In other words, she has to bringout the best in the group.
During each session of PBL tutorial, tutor plays
different roles at different stages,
Problem start* Focus the group by introducing terms todescribe what the discussion is about* Remind students of relevant topics previously
discussed but not fully understoodBrainstorming questions* Ask open-ended questions so as to help thestudents explore the richness of the situationand to help them develop their criticalthinking* Challenge students’ thinking so as to nurture
deep learning and a search for meaning* Encourage student-directed discussion andthe development of both knowledge and skills
in critical thinking
Learning issues* Facilitate students to categorize questions
into key learning issues* Advise students on methods of searchingappropriate resources
Presentation* Raise appropriate questions to keep the groupfocused* Encourage students to present informationand concepts in a precise and concise manner
Wrap up/ feedback* Facilitate students to discuss concepts or

22

PBL FOR OCCUPATIONAL THERAPY STUDENTS

learning issues that are not clearly andproperly addressed* Promote students' competence to integrate
learning issues into the problem studied* Help students to see their contribution
Overall performance* Join the groups as participant, and pay
attention to each student's contribution* Develop trust with students, that in turncreates a safe and stimulating atmosphere inwhich students are willing to discuss
experiences and ideas without fear of being
ridiculed* Give assistance to students if the learning
process is not productive.
* Monitor progress as to ensure that students
are still on track and understand where they
are in the process
On the other hand, the tutor SHOULD NOT,
* Dominate the group with his/her opinion but
rather facilitate the group dynamics* Be the group’s expert resource who provides
facts or concrete answers to questions* Keep too silent that may lead to students’
confusion. Respond to direct inquiries if
students have not exhausted their own logic
and that there are other profitable learning
experiences in suggesting an independent
search.

References
Aspy, D. N., Aspy, C. B., & Quimby, P. M. (1993).
What doctors can teach teachers about problembased learning? Educational Leadership, 50 (7),22–24.
Barrows, H. S. (1986). A taxonomy of problembased learning methods. Medical Education, 20,
481–486.
Chung, J. C. C. & Chow, S. M. K. (2000). Meeting
challenges: Imbedded PBL in large classes.
Implementing problem-based learning,
Proceedings from the 1st Asian-Pacific Conference
on Problem-Based Learning, pp. 35–46.
Spitzer, S., Roley, S.S., Clark, F., & Parham, D.
(1996). Sensory integration: Current trends in the
United States. Scandinavian Journal of
Occupational Therapy, 3, 123–138.

ORIGINAL ARTICLE

Factors Affecting Hand Function Following
Reconstructive Thumb Operation (RTO):
A Report of Eight Cases
Kazuo SAITO, OTR1, Miyako OMORI, OTR2,
Fumiko MORI, OTR1, Yoshie ISHIWARI, OTR1,
Reiko OKUDAIRA, OTR1, Megumi NAGAMITSU, OTR1,
Shinichi NOTO, MS, OTR3
1 Fuchinobe General Hospital
2 St. Marianna University School of Medicine Hospital
3 Niigata University of Health and Welfare

Abstract: Eight cases that had a reconstructive thumb operation (RTO) and were able toreturn to work were presented. In the present study, the functions of RT, the influenceof the thumb on return to work, and how the recovered hands were used at work were
investigated. The reconstructed thumb was evaluated based on the following 6 functions:“aspects of full return to work” (3 items), “thumb motion” (5 items), “sensibility” (3items), “wrist range of motion (ROM)” (4 items), “strength” (3 items) and “dexterity” (3items). Subsequently, the relation between the frequency of hand use based on subjective
evaluation and each function was investigated. We observed significant correlations of
the frequency of hand use with thumb opposition, thumb angle, pinch strength, 2-point
discrimination (2PD), and the result of the Moberg picking up test (p<0.05). It wasthought that the improvement of pinch strength and dexterity of the thumb as well as thatof sensory function was the factor to increase the frequency of hand use based on
subjective evaluation, and the active hand therapy was necessary even before theoperation.
Key words: Reconstructed thumb, return to work, hand therapy(Asian J Occup Ther 2: 23–29, 2003)

Introduction
The role of the thumb in hand function istremendous, and a reconstructive thumb operation
Received: September 30, 2002, Accepted: May 24, 2003
Corresponding to: Kazuo Saito (OTR); Fuchinobe General
Hosp ita l, 1 –5 4–2 2 Fu chin ob e, Sag am iha ra-City,
Kanagawa, 229-0006, Japan
phone: 81-42-754-2222 fax: 81-42-758-8740
e-mail: kazuosaitoh@hotmail.com(RTO) is often performed when the thumb is cut
and lost due to external injury. RTO has been
carried out by several methods with significant
developments of microsurgery. Especially, theW r a p Ar o u n d F l a p M e t h o d ( W A F M ) c a nreconstruct the ungual, well-shaped thumb, andhas little influence on the donor sites (Morrison etal., 1980; Doi et al., 1985). One of the major aimsof hand therapy under RTO is recovering theeffective functions of the hand along with

24

FACTORS AFFECTING HAND FUNCTION FOLLOWING RTO

Table 1. Parameters of case evaluation
Case
Sex
Operativeage (years)

Diagnosis

Follow-up
period Handness(years)Thumbamputation level

Occupational category(details of occupation)

Businessman
Skilled laborer(stone processing industries)
Skilled laborer(press processing industries),
self-employed
Skilled laborer (a plumber)

A
B

43
18

M
M

Right thumb amputation
Left thumb amputation

7.3
8.8

Right
Right

Proximal phalanx
Proximal phalanx

C

61

M

7.8

Right

Proximal phalanx

D

50

M

8.3

Right

Proximal phalanx

E

55

M

Right thunb amputation,
Right Galeazzi fracture
dislocation
Right thumb amputation,
Right middle finger
amputation
Right thumb amputation

6.3

Right

Proximal phalanx

F

28

M

Right

Metacarpophalangeal
joint

G

37

M

Right thumb amputation,
8.9
Right metacarpomultangular
joint dislocation
Right thumb amputation
0.7

Right

H

41

M

Right thumb amputation,
Right Index–little finger
amputation

Right

Metacarpophalangeal
jointInterpharangeal joint

7.1

acquiring original thumb functions. Some
investigators perform the long-term follow up
after RTO using WAFM (Lee and Hahn, 1995;
Songcharoen, 1995), and the importance ofsensory re-education is confirmed (Wei and Ma,
1995; Blomgren et al., 1988). However, there
have been few reports on the function of thereconstructed thumb (RT), the aspects of return towork, and how the recovered hands are used atlong-term work (Bear-Lehman, 1983). In thepresent study, the functions of RT, the aspects ofreturn to work, and how the recovered hands wereused at long-term work were investigated in thepatients who had received RTO and could return towork. In addition, the relation between thefrequency of hand use based on subjective
evaluation and these clinical measures of handfunction was investigated.

Materials and Methods
Among 14 patients receiving RTO, the 8
right-handed males (8 fingers) who could be
followed up were enrolled in the present study.

Skilled laborer( press processing industries)
Skilled laborer(construction machinery operator)
Skilled laborer(construction machinery operator)
Skilled laborer( press processing industries)

Out of these 8 patients, 7 had an injury in the righthand, and 1 in the left hand. Between May 1988
and January 1997, the patients underwent wraparound procedures for thumb reconstruction at St.
Marianna University School of Medicine Hospital.
Full return to work was achieved, and the adequate
follow-up was completed between August 1997
and January 1998. All the patients were diagnosed
as having traumatic amputation of the thumb, andcomplications included Galeazzi fracture
dislocation (case C) and injuries in the multiple
fingers. Five patients had amputation at the levelof the proximal pharanx, two at the
metacarpophalangeal joint (MP joint), and one at
the interphalangeal joints. MP joints were fixed infour patients (Cases D, E, F, and G) and not in
residual patients (Cases A, B, C, and H). All thepatients received WAFM in which the great toe
was transferred to the thumb. In addition, in 1
patient (Case H), the second toe was transferred to
the ring finger. One of the subjects was abusinessman, and the others were skilled laborers(Table 1).
The items investigated are shown in Table 2.

Asian J Occup Ther 2: 23–29, 2003

Saito K et al.

25

Table 2. Clinical measures of hand function
I. State of Full Return to Work
➀ Operative age (years)➁ Full return to work (mounth)➂ Percentage of useful hand (%)
II. Thumb Motion➀ % Total active motion ; %TAM (%)➁ Opposition distance; Opp (mm)
➂ % Palmar abduction; %PA (%)➃ % Thumb length; %TL (%)➄ % Thumb angle; %TA (%)
III. Sensibility➀ Semmes-Weinstein mono filament test ; SWT➁ Static two point discrimination; S-2PD (mm)➂ Moving two point discrimination; M-2PD (mm)Fig. 1. Thumb angle is the angle which the intersecting
point of the line of the distal palmar crease underthe maximum palmar abductionforms with theline connecting the radical and of the thumbnail
toits ulnar end. This angle was measured bytracing it on the photos according to the method
described by Beppu(1995).

To investigate “Aspects of full return to work”, thefollowing three items were observed: 1) age at thetime of operation, 2) the time period between
completion of operation and full return to work,and 3) ratio (%) of frequency of hand use after
surgery, which was subjectively evaluated, to that
before injury (hereafter, Frequency of hand use).
To investigate “Range of motion (ROM) of thewrist”, the 4-type ROMs of the wrists proposed by

IV. Wrist and Finger Range of Motion➀ % Wrist flexion; %WF (%)➁ % Wrist extension; %WE (%)➂ % Wrist radial deviation; %RD (%)➃ % Wrist ulnar deviation; %UD (%)
V. Strength➀ %Grip strength (%)➁ %Key pinch strength; % Key pinch (%)➂ %Three-fingered pinch; %3 pinch (%)
VI. Dexterity➀ Simple test for evaluating hand function; STEF (score)➁ %Moberg picking up test opened; M-opened (%)➂ %Moberg picking up test closed; M-closed (%)

Cambridge (1995) were observed. To investigate“Thumb motion”, the following 5 items wereobserved: 1) ROM of thumb, which was the ratio(%) of total active motion (TAM) range in theaffected hand to that in the unaffected hand; 2)
Thumb opposition distance, measured when the
thumb was moved out of the plane of palm while
approaching the fifth finger (mm); 3) Thumb
palmar abduction, measured in a plane
perpendicular to the palm (%); 4) Thumb length,measured from the carpometacarpal (CMC) joint
to the tip or the point of the distal phalanx using
radiography (%), and 5) The thumb angle was theangle which the intersecting point of the line of
distal palmar crease under the maximum palmar
abduction formed with the line connecting theradical end of the thumbnail to its ulnar end (%)(Fig. 1). All the measurements of the parametersdescribed in 3) to 5) were expressed as the ratio(%) of the values in the affected hand to those in
the unaffected hand. According to Beepu (1995),
the thumb angle is used to determine the rotation
angle of the thumb pulp in order to make RT easily
pinch the objects. The large thumb angle indicatesthat the pulp of the affected thumb abducted to thepalmer side compared with that of the unaffected
thumb. The thumb angle was measured by tracing
it on the photo (Fig. 1).
To investigate “Sensibility”, 1) SemmesWeinstein mono filament test (SWT), 2) Static 2point discrimination (2PD), and 3) Moving 2PD
were performed based on the sensibility test

26

FACTORS AFFECTING HAND FUNCTION FOLLOWING RTO

Table 3. Case result 1 : State of full return to work and thumb motion
Case

Full return towork (months)

Percentage ofuseful hand

%TAM

OPP (mm)

%PA

%TL

% TA

A
B
C
D
E
F
G
H

1
18
3
12
6
12
7
12

100%
90%
90%
80%
60%
30%
20%
10%

23%
92%
25%
0%
0%
0%
0%
33%

15
0
30
35
64
66
60
35

90%
100%
80%
41%
98%
65%
89%
104%

95%
91%
100%
97%
100%
85%
101%
107%

33%
109%
126%
79%
102%
194%
182%
152%

TAM; Total active motion, TL; thumb length, Opp; Opposition distance, TA; thumb angle, PA; Pamar abduction.

Table 4. Strength, sensibility test and dexterity test
Case

% Gripstrength

% Key
pinch

% 3 pinch

SWT

S-2PD
(mm)

M-2PD
(mm)

STEF
(score)%M
opened%Mclosed

A
B
C
D
E
F
G
H

106%
77%
83%
65%
94%
71%
93%
18%

80%
88%
87%
85%
74%
32%
50%
39%

100%
96%
100%
79%
80%
29%
47%
–

PurpleBlue
PurplePurplePurpleRed
Red
Purple

6
4
7
15
7
19
19
12

5
3
6
13
5
18
17
10

94
98
83
81
98
90
83
65

90%
104%
113%
104%
108%
117%
120%
119%

109%
115%
120%
134%
109%
124%
151%
199%

SWT; Semmes-Weinstein monofilament test. (Blue-diminished light touch, Purple-diminished protective sensation, Red-Lossof protective sensation). STEF; Simple test for evaluating hand function. M opened; Moberg picking up test and opened the eye.
M closed; Moberg picking up test and closed the eye.

proposed by Bell (1995). To investigate ROM of
the wrists, 1) Wrist flexion (%), 2) Wrist extension(%), 3) Wrist radial deviation (%), and 4) Wrist
ulnar deviation (%) were perform ed. To
investigate “Strength”, 1) Grip strength, 2) Key
pi n ch, an d 3) Th ree -fi ng ered p i nc h w ere
measured. To investigate “Dexterity”, 1)
According to Kaneko (1990), Simple test forevaluation of hand function (STEF) and 2) Moberg
picking up test were performed.
Subsequently, the correlation between
Frequency of hand use and the clinical measures ofeach hand function was analyzed using theSpearman rank correlation test. P values of lessthan 0.05 were considered to be significant. The
functional evaluation was carried out by two
occupational therapists, while the questionnaire
was performed by one occupational therapist.

Results
Regarding Aspects of full return to works, themean age of the subjects at the time of operation
was 42 years. The follow-up period ranged from 7
to 104 months (mean: 80 months). Case A (abusinessman) showed remarkably early full return
to work (one month), while it was observed within
3 to 18 months (mean: 8.8 months) in other
patients. Frequency of hand use ranged from 10 to
100% (mean: 60%). No problems in particularwere found in ROM of the wrists.
Regarding Thumb motion, Thumb ROM
ranged from 0 to 92% (mean: 20%), and mean
thumb opposition distance was 3.8 cm. The thumbpalmar abduction was conserved (mean: 83%).
The thumb length ranged from 84 to 107% (mean:97%), which indicated the affected thumb wasAsian J Occup Ther 2: 23–29, 2003

Saito K et al.

27

Table 5. Correlations between parcentage of useful hand and clinical measures of function
Spearman rank correration
State of full return to work

Wrist range of motion

Thumb motion

Strength

Sensibility

Dexrerity

Operative age
Follow-up period
Full returen to work
%WF
%WE
%RD
%UD
%TAM
Opp
%PA
% TL
% TA
% Grip strength%Key pinch strength%Three-fingered pinch
SWT
S-2PD
M-2PD
STEF
M opened
M closed

0.26
0.36
–0.33
–0.01
–0.39
–0.29
–0.29
0.33
0.70
–0.14
–0.52
–0.70
0.49
0.78
0.89
–0.35
–0.70
–0.65
0.51
–0.84
–0.74

p value
0.51
0.34
0.33
0.83
0.27
0.08
0.87
0.46
0.05*
0.70
0.16
0.05*
0.19
0.03*
0.01*
0.14
0.05*
0.05*
0.19
0.02*
0.04*

*p<0.05. %TAM; % Total active motion, %WF; % Wrist flexion (%), Opp; Opposition distance, %WE; % Wrist
extension, %PA; % Palmar abduction, %RD; % Wrist radial deviation, %TL; %Thumb length, %UD; % Wrist ulnar
deviation, %TA; % Thumb angle, STEF; Simple test for evaluating hand function, SWT; Semmes-Weinstein mono
filament test, %M-opened; %Moberg picking up test opened the eye, S-2PD; Static two point discrimination, %Mclosed; %Moberg picking up test closed the eye, M-2PD; Moving two point discrimination.

slightly shorter than the unaffected thumb. The
thumb angle was 122% (ranged from 33 to 194%),
which indicated that the pulp of the affected thumb
abducted to the palmer side. Concerning
Sensibility, 5 patients had “diminished protective
sensation” and 2 had “loss of protective sensation”
in SWT. The number of patients who showed “notmore than 6 mm” in static 2PD was 2, and that inmoving 2PD was 4. Mean grip strength, key pinch
strength, and three-fingered pinch strength were76%, 67% and 76%, respectively. The mean scoreof STEF was 86. In the Moberg picking up test,
the mean value of the test results with open eyes
was 109% and that with closed eyes was 123%,
which indicated the affected hand took a longer
time than the unaffected hand.
Subsequently, the relation between
Frequency of hand use (based on subjective
evaluation) and each function was investigated.
As shown in Table 5, we observed significant

correlations of Frequency of hand use with thumb
opposition distance, thumb angle, pinch strength(key and three-fingered strength), 2PD (static andmoving), and the result of the Moberg picking up
test (open and close eyes) (p<0.05).

Discussion
In the present study, the functions of thethumb reconstructed using WAFM in 8 malepatients (8 fingers) who returned to work were
investigated. There were differences in the timerequired to return to work among subjects due tothe differences of job categories, but most of thepatients returned to work 6 months or later after
operation. Tamai (1982) suggests that RT shouldhave the following qualities: a certain range of freeROM, strength, a certain length, sensibility close
to that of the normal thumb, and subjective
satisfaction. In the present study, TAM and28

FACTORS AFFECTING HAND FUNCTION FOLLOWING RTO

opposition distance of RT were limited (20% and
3.8 cm, respectively). This might be becauseinterphalangeal joints were fixed in WAFM. On
the other hand, both grip strength and pinch
strength ranged from 65 to 75%, which was similar
to the results of Blomgran et al. (1988) and Lee(1995, 2000). A small number of patients showed“not more than 6 mm” in static 2PD, whichindicated the unfavorable result. This result
corresponded to that of Dellon (1981).
In addition, among such many estimations ofhand function, which hand function had a close

Fig. 2. Postoperative hand therapy approaches using apilot splint

relation with Frequency of hand use (based on
subjective evaluation) was investigated. We
observed significant correlations of Frequency ofhand use with thumb opposition distance, thumbangle, pinch strength, 2PD, and the result of theMoberg picking up test. These results suggested
that the improvement of Strength including pinch
strength and Dexterity , as well as the
improvement of sensory function as generally
reported, was the factor to increase Frequency ofhand use.
In the hand therapy before and after theoperation, the exercise to improve dexterity using
a pilot splint that determined thumb length, thumbangle and palmar abduction of the affected orreconstructed thumb was performed (Fig. 2). In
addition, as one of the sensory re-education
exercises and the dexterity exercises, handicraft
activities were performed from the early stage
after the operation to make RT be actively used
(Fig. 3).
It is proposed that, despite the insufficient
recovery after RT, the increase of opportunity toutilize proper activities raises the possibility ofacquiring smooth pinch performance andenhancing the frequency of hand use. According
to Jenmals et al. (1997), in order to adjust thefingers’ abilities to pinch and pick up objects,
either optical sensation or somatic sensation isneeded to function, and tactile clues come to be

Fig. 3. Postoperative hand therapy approaches using handicraft activities. Right shows a net
fancywork, macramé, and left shows a stick fancywork.

Asian J Occup Ther 2: 23–29, 2003

effective 0.1 second after the fingers touch theobject. This is regarded as a requisite for
improved frequency of hand use. Therefore,
employing handicraft activities in the hand therapy
is important to recover patients’ hand function inv a rio us way s. F ur ther s tud ies s hou ld b e
performed to investigate the effect of handicraft
activities. In addition, the relation of thesubjective outcome measures using questionnairesthat were oriented to patients (e.g., the disabilitiesof the arm, shoulder, and hand (DASH) proposedby Hudak, et al. (1996)) with function of thethumb would be investigated in the further studies.

Conclusion
In the present study, function of the thumbreconstructed using WAFM in the patients who
returned to work, and the relation between thefunctional estimation and the frequency of handuse based on subjective evaluation, were
investigated. We observed significant correlationof the frequency of hand use with thumb
opposition distance, thumb angle, pinch strength,
2PD, and the result of the Moberg picking up test.
It was thought that the improvement of pinch
strength and dexterity of the thumb as well as thatof sensory function was the factor to increase thefrequency of hand use, and the active hand therapy
was necessary even before the operation.

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