Rehabilitation Research

Abstract

The Centennial Vision of the American Occupational Therapy Association (AOTA; 2007a) marks a significant step forward in occupational therapy by creating a clear statement about what the practice of occupational therapy will look like in the future. In 2007, several ad hoc work groups were assigned the task of translating this vision into actionable goals for key areas of practice. The panels met to answer key questions that would provide a road map to guide research and practice in those areas. Each panel produced a report for the AOTA Board of Directors. In its report, the Ad Hoc Work Group on Rehabilitation, Disability, and Participation concluded that to achieve the Centennial Vision, occupational therapists in rehabilitation need to focus on supporting lifelong participation through implementation of context-based assessments and interventions. The work group determined that occupational therapy’s essential skills and knowledge must be used to address individual and environmental issues that impede a person’s ability to engage in occupations and, ultimately, to fully participate in society. To meet this goal, the profession will need to continue to develop evidence-based interventions and assessment tools that are focused at the level of activity and participation and that occur in context-rich environments (AOTA, 2007b). The work group praised the alignment of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008) with the International Classification of Functioning, Disability and Health (World Health Organization, 2001) and the importance of an expanded view of functional performance to include “freedom and citizenship … contributing to communities of choice” (Hammel, Jones, Gossett, & Morgan, 2006, p. 43). It suggested that in the future, occupational therapy would need to develop an expanded focus on access to the community and barriers to participation, which will require an increased emphasis on regaining occupational skills in real-world environments and research that focuses on developing and testing participation-level outcomes and interventions.Activity- and participation-level interventions that focus on developing skilled performance in the context of everyday activities and environmental modifications will increasingly require that therapy explore and exploit the similarities and differences between real-world and therapy environments. The field of motor control is examining the role of adaptation, that is, calibrating the brain’s prediction of how the body will move and how learning transfers between therapy environments, such as treadmills and robotic reaching devices, and real-world environments (Bastian, 2008).Several measures of underlying capacity are widely used in occupational therapy (e.g., dynamometers, pegboard tests). Such assessments are often easily administered in any environment and require little equipment. Activity- and participation-level assessments can be more challenging to administer and interpret because they are more influenced by the environment and contextual factors. For example, even simple tub transfers can be influenced by the height and width of the tub, the availability of handrails and tub chairs, and the presence or absence of water. With respect to patient-reported measures, if the therapist asks an individual to rate his or her difficulty with dressing, is the person thinking about putting on work clothes or sweatpants? Are the clothes already laid out, or do they need to be retrieved from the closet? To date, most assessments of activity and participation either ignore the role of context or control it to such a degree that relevance to real-life situations may be limited.Clinicians also frequently comment that the rating scales associated with activity- and participation-level assessments do not always capture the changes in performance being achieved in therapy. Because impairment-level assessments tightly control the performance requirements and