Relapses 0.94 (1.40) 0.389 (0.698) 0.067

ALR 30 (43.9) 8.2 (19.3) 0.017\*

*p* < 0.05 level, \*\* = significant at the *p* < 0.01 level.

manage stress during the intervention.

**3.3. Substance use**

**Measure Clean time**

*3.3.1. Clean days*

The 21 clients in the SM experimental group achieved an average of 77% of the total number of objectives possible in SM on the days they attended. The average number of goals related to stress management achieved by each client during the SM was four. The average attendance throughout the 4 months was 63%. Ninety‐one percent of the clients reported that they learned new material, and 86% reported that they made changes in their lives as a result of the SM training. The staff observed that 73% of the clients showed improvement in their ability to

For the results of the #CD, see **Table 4**. For 18 individuals in the SM, the mean #CD 4 months before treatment was 84.4 (*SD* = 44.1). This increased to 108.9 (*SD* = 23.6) during intervention. This increase in value was statistically significant (*t*[17] = −3.01, *p* = 0.008) within the experimental group as per paired samples t test. The 95% confidence interval for the mean difference between the two was −41.58 to −7.30. There was a slight drop in the #CD 4 months after intervention (*M* = 102.2, *SD* = 38.1). This drop was not significant when compared to the #CD 4 months before treatment (*t*[17] = 1.69, *p* = 0.11, 95% CI −4.46 to 40.02) or the #CD during

4MB 4MD 4MA P1 P2 P3

84.40 (44.10) 102.20 (38.10) 0.110

0.94 (1.40) 0.50 (0.86) 0.104

30 (43.9) 16.1 (37.4) 0.217

**Table 4.** Clean time comparisons before, during, and after treatment through paired t tests, *N* = 18.

Notes: P1 = the magnitude of difference (*p*) between 4MB and 4MD, P2 = the magnitude of difference (*p*) between the magnitude of difference between 4MD and 4MA, P3 = the magnitude of difference (*p*) between 4MB an 4MA, 4MB = 4 months before treatment began, 4MD = 4 months during treatment, 4MA = 4 months after treatment, \* = significant at the

108.90 (23.60) 102.20 (38.10) 0.460

0.389 (0.698) 0.50 (0.86) 0.682

8.2 (19.3) 16.1 (37.4) 0.343

For the results of the #R, see **Table 4**. For 18 individuals in the SM experimental group, the mean #R 4 months before intervention was 0.944 (*SD* = 1.4). This decreased to 0.389 (*SD* = 0.698) during intervention. This decrease in value was marginally significant (*t*[17] = 1.97, *p* = 0.066) within the experimental group as per paired samples t test. The 95% confidence interval for the mean difference between the two was −0.04 to 1.15. The mean #R 4 months after intervention was 0.500 (*SD* = 0.857). The difference between the average #R 4 months before intervention and 4 months after intervention was not significant (*t*[17] = −1.72, *p* = 0.104, 95% CI −0.99 to 0.10), nor was the difference between the average #R during intervention as compared to 4 months after intervention (*t*[17] = 0.42, *p* = 0.682, 95% CI −0.452 to 0.674).

#### *3.3.3. Average length of relapses*

For the results of the ALR, see **Table 4**. For 18 individuals in the SM experimental group, the ALR 4 months before intervention was 30 days (*SD* = 43.9). This decreased to 8.2 (*SD* = 19.3) days during intervention. This decrease in value was statistically significant (*t*[17] = 2.65, *p* = 0.017) within the experimental group as per paired samples t test. The 95% confidence interval for the mean difference between the two was 4.45 to 39.1. The ALR 4 months after intervention was 16.1 days (*SD* = 37.4). The difference between the ALR 4 months before intervention as compared to after intervention was not significant (*t*[17] = −1.28, *p* = 0.217, 95% CI −36.87 to 8.98), nor was the difference between the ALR during intervention and 4 months after intervention (*t*[17] = 0.97, *p* = 0.343, 95% CI −9.12 to 24.78).

#### **3.4. Correlations**

For the results of correlations between SM outcomes in the experimental group see **Table 5**. In the SM experimental group, the following positive correlations were significant at the *p* < 0.05 level: attendance and number of objectives met, attendance and number of goals met, attendance and MRLNM, attendance and MRMCL, number of objectives met and MRLNM, number of objectives met and SO, MRLNM and MRMCL, MRLNM and SO, MRMCL and SO. All other correlations in the stress management experimental group were not significant at the *p* < 0.05 level. There were no significant correlations between the demographics of the experimental group and any of the outcome measures.



Notes: \*\*Correlation is significant at the 0.01 level (2‐tailed). \*Correlation is significant at the 0.05 level (two‐tailed). MRLNM = members report that they learned new material as a result of SM, MRNCL = members report that they made changes in their lives as a result of SM, and SO = staff observations.


#### **4. Discussion**

The experimental group significantly increased their knowledge of stress management information after completing the SM, demonstrating the ability to learn, store, and recall new information, whereas the control group did not show a significant increase. However, the increase noted in the experimental group when compared to the control group was no longer significant. Since there were improvements in so many other aspects of stress management in the experimental group, it could be that stress management is best learned and utilized through hands on experience and talking about feelings instead of obtaining knowledge about the subject. It is one thing to "know about" stress reduction, but a different experience to "feel it in one's bones." The fact that the SM does both could account for the difference in outcomes. For instance, the objectives for each session of the SM incorporate knowledge about stress management with hands on experience. The objective for day 26, "clients will use biofeedback as a stress management technique," presents the knowledge of how to count breaths and gives the client the physical experience that respiration rate can be controlled and decreasing respiration rate can be calming. Clients did very well in achieving the objectives for each session (an average of 77% of the objectives was met in the SM). The fact that clients achieved on the average of four stress management goals that they set during the SM demonstrates that the material learned and experienced generalized to their lives outside the clinic.

The other outcome measures also support the efficacy of the LSRC's SM. Clients in the experimental group (91%) reported that they learned new material and 86% reported that they made changes in their lives as a result of the SM. This is consistent with staff members reporting that 73% of their clients in SM were better able to manage stress. Clients who participated in the SM significantly improved their #CD and their ALR. Four months after SM ended, they experienced a slight decrease in #CD and ALR. Although this decrease was statistically insignificant when compared to their clean time during SM, it was also statistically insignificant when compared to before SM, indicating that clients were almost back to where they started before intervention. In order for stress management for recovery intervention to be effective, it should be longer than 4 months. Clients showed no significant change in the #R before, during, or after SM. This could be because the average #R was and remained one, so there was not a lot of improvement to be made. Correlations indicated that newly learned material was not lost over time (percentage of objectives met x post‐test scores). This may be due to repetition, review, and multiple modes of training (visual, auditory, bodily sensations, and eliciting prior experiences), which have been built into the curriculum. Attendance was an important factor in clients' progress. The more clients came to SM, the more objectives and goals they met, the more they reported that they learned new material, and the more staff observed improvements in their ability to manage stress. Even though the attendance rate of 63% achieved by the experimental group is standard for what is reported in psychiatric clinics, it may be beneficial, given the significance of attendance, to generate ways to improve it.

Staff's observations correlated positively with members' self‐report of progress and the number of objectives met. Staff's sensitivity to improvement is necessary to encourage and provide positive feedback to clients and provide continuity across intervention modalities throughout the clinic, just as their sensitivity to ongoing needs of the clients can be helpful in referring future clients to the LSRC. Members' self‐report of progress correlated with one of two objective findings. There was a positive correlation between member's reporting that they learned new material and achieving objectives, but not with the number of goals met outside the clinic. Perhaps the clients in answering this question did not consider goal achievement an indicator of change. If so, this would be an important connection to help the clients make in order for their self‐esteem to fully benefit from their progress. The number of goals met on the outside did positively correlate with the amount of material each patient learned throughout the session. Patients who report having learned new material also tend to report that they made changes in their lives due to the SM.

#### **4.1. Limitations**

**4. Discussion**

The experimental group significantly increased their knowledge of stress management information after completing the SM, demonstrating the ability to learn, store, and recall new information, whereas the control group did not show a significant increase. However, the increase noted in the experimental group when compared to the control group was no longer significant. Since there were improvements in so many other aspects of stress management in the experimental group, it could be that stress management is best learned and utilized through hands on experience and talking about feelings instead of obtaining knowledge about the subject. It is one thing to "know about" stress reduction, but a different experience to "feel it in one's bones." The fact that the SM does both could account for the difference in outcomes. For instance, the objectives for each session of the SM incorporate knowledge about stress management with hands on experience. The objective for day 26, "clients will use biofeedback as a stress management technique," presents the knowledge of how to count breaths and gives the client the physical experience that respiration rate can be controlled and decreasing respiration rate can be calming. Clients did very well in achieving the objectives for each session (an average of 77% of the objectives was met in the SM). The fact that clients achieved on the average of four stress management goals that they set during the SM demonstrates that the material learned and experienced generalized to their lives outside the clinic. The other outcome measures also support the efficacy of the LSRC's SM. Clients in the experimental group (91%) reported that they learned new material and 86% reported that they made changes in their lives as a result of the SM. This is consistent with staff members reporting that 73% of their clients in SM were better able to manage stress. Clients who participated

**Attendance Objectives Goals MRLNM MRMCL**

*N* = 22 *N* = 18 *N* = 22 *N* = 21 *N* = 21 *p* = 0.218 *p* = 0.022 *p* = 0.311 *p* = 0.017 *p* = 0.002

Notes: \*\*Correlation is significant at the 0.01 level (2‐tailed). \*Correlation is significant at the 0.05 level (two‐tailed). MRLNM = members report that they learned new material as a result of SM, MRNCL = members report that they made

MRLNM *r* = 0.710\*\* *r* = 0.618\*\* *r* = 0.330

*N* = 21 *N* = 18 *N* = 21 *p* = 0.000 *p* = 0.006 *p* = 0.144 MRMCL *r* = 0.645\*\* *r* = 0.414 *r* = 0.393 *r* = 0.795\*\*

76 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

changes in their lives as a result of SM, and SO = staff observations.

*N* = 21 *N* = 18 *N* = 21 *N* = 22 *p* = 0.002 *p* = 0.09 *p* = 0.078 *p* = 0.000 SO *r* = 0.274 *r* = 0.535\*\* *r* = 0.226 *r* = 0.513\* *r* = 0.647\*\*

**Table 5.** Correlation matrix of LSRC outcomes using Pearson‐product moment coefficient.

This study was a quasi‐experiment. The author used a sample of convenience that followed the selection/referral procedure found in most clinics. Although the demographic profile of these clients closely approximated those in the literature for dual diagnosis outpatient clinics, caution should be used if generalizing the results to other settings because of a possible sample bias. Validity and reliability of the pre‐/post‐test had not been established.

#### **4.2. Conclusion**

The LSRC's SM is an effective method for improving stress management skills and clean time in DD clients in this DD clinic. Clients significantly increased their number of clean days, decreased their average length of relapse, and were able to learn, store, and recall information on stress management. They achieved over three‐fourths of the daily objectives, reported learning new material, and were able to make changes in their lives by generalizing what they learned/experienced to their environment outside the clinic. These results lend support for future randomized controlled experiments to investigate the efficacy of this SM with DD clients and also for the use of this module by occupational therapists working with the DD population.

#### **Acknowledgements**

This research was supported by a grant from the Metropolitan New York District of the New York State Occupational Therapy Association.

#### **Author details**

#### Patricia Precin

Address all correspondence to: patricia.precin@touro.edu

Occupational Therapy at Touro College, Licensed Psychoanalyst in Private Practice, Faculty of the National Psychological Association for Psychoanalysis and Stony Brook University, New York, NY, USA

#### **References**


[7] Jerrell JM, Ridgely MS. Comparative effectiveness of three approaches to serving people with severe mental illness and substance abuse disorders. The Journal of Nervous and Mental Disease. 1995;**183**(9):566‐576. DOI: 10.1097/00005053‐199509000‐00002

learning new material, and were able to make changes in their lives by generalizing what they learned/experienced to their environment outside the clinic. These results lend support for future randomized controlled experiments to investigate the efficacy of this SM with DD clients and also for the use of this module by occupational therapists working with the DD

This research was supported by a grant from the Metropolitan New York District of the New

Occupational Therapy at Touro College, Licensed Psychoanalyst in Private Practice, Faculty of the National Psychological Association for Psychoanalysis and Stony Brook University,

[1] Chaney E, O'Leary M, Marlatt G. Skill training with alcoholics. Journal of Consulting

[2] Jones S, Kanfer R, Lanyon R. Skills training with alcoholics: A clinical extension. Add‐

[3] Marlatt G, Gordon J, editors. Relapse Prevention: Maintenance Strategies in the Treat‐

[4] Hodgson S, Lloyd C, Schmid T. The leisure participation of clients with a dual diagnosis. British Journal of Occupational Therapy. 2001;**64**(10):487‐492. DOI: 10.1177/03080226010

[5] Abrams D. Psychosocial assessment of alcohol and stress interactions: Bridging the gap between laboratory and treatment outcome research. In Pohorecky L, Brick J, editors.

[6] Monti P, Abrams D, Kadden R, Cooney N.. Treating Alcohol Dependence: A Coping

Stress and Alcohol Use. New York: Elsevier Biomedical; 1983. pp. 61‐86.

Clinical Psychology. 1976;**46**:1092‐1104. DOI: 10.1037/0022‐006X.46.5.1092

ictive Behavior. 1982;**7**:285‐290. DOI: 10.1016/0306‐4603(82)90057‐0

ment of Addictive Behavior. New York: Guilford; 1985

Skills Guide. New York: Guilford; 1990

population.

**Acknowledgements**

**Author details**

New York, NY, USA

**References**

6401003

Patricia Precin

York State Occupational Therapy Association.

Address all correspondence to: patricia.precin@touro.edu

78 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation


### **Community Participation in People with Disabilities**

Gokcen Akyurek and Gonca Bumin

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68470

#### **Abstract**

Despite the fact that participation is an important building and a valuable target, the conceptualization, identification and measurement methods vary widely. This chapter tried to gain an insider's perspective from the obstacles that summarize what meaning participation means, how to characterize it, and what prevents and supports participation. Participation is seen as a right and a responsibility attributed to and attributed to both the person and the community. Participation does not take place in a vacuum; the environment dynamically influences participation. The effects of this conceptual framework are discussed for change at the level of evaluation, research and systems to support the participation of the people with disability.

**Keywords:** participation, disability, occupation, function and quality of life

#### **1. Introduction**

Being disabled is defined as being out of "normal" as a biological sense, while in social sense, it is defined as the social and cultural obstruction of the individual's ability to live independently and easily in society [1]. Therefore, appropriate sociocultural environment is essential to enable disabled people to develop their skills and gain a place in social life. For example, the parent of person of a disability does not have an interest in him because he does not trust him or herself and shows an extreme protectionist attitude [2].

In order to enable individuals with disabilities to find jobs, marry, spend their leisure time, and continue their education and vocational training in the society they live in, relations with various social institutions, social status gains and integration with society are important factors [3]. Community participation activities are those that relate to organizing behaviors that arise during interaction with others in a particular social system: family, peers, or friends [4, 5].

The quality of life, which is defined as the way people perceive health as a result of the constraints of social and professional life, is also negatively affected [6–8]. In addition, the limitation of daily life activities due to functional disabilities also affects the community participation negatively [9]. It should not be forgotten that the physical, psychosocial and economic level of the people with disabilities affects the quality of life and there is a relationship in which the degree of dependence of the person is inversely related to the quality of life [10] (**Picture 1**).

Adolph Mayer, the author of occupational therapy "People organize themselves to participate in activities throughout their lifetime and use their time" [11]. Participation from the perspective of occupational therapy is to be a part of everyday life. Participation is the main goal of occupational therapy. The World Health Organization (WHO) also focuses on participation as an important goal for all the people. The World Health Organization has defined areas of participation as knowledge learning and practice, general tasks and desires, communication, movement, self‐care, interpersonal interaction, home and work habits, community life, social life and citizenship [12].

The nature, quality and/or duration of participation are personality and, even if it has the same health status, two different people cannot be compared at all. Participation examines the situation in the social environment rather than activity. The main problem of participation is the limitations bring to life of certain health problems and environment [13]. Community participation is sufficient for the individual to participate in the activities in his/her field. There are those who say that social skills are participation of everyday life, but according to the experts, social participation is more complicated than communication [14].

**Picture 1.** Health and well‐being negatively affected of the inappropriate environment.

#### **2. Philosophy of occupational therapy and community participation**

The quality of life, which is defined as the way people perceive health as a result of the constraints of social and professional life, is also negatively affected [6–8]. In addition, the limitation of daily life activities due to functional disabilities also affects the community participation negatively [9]. It should not be forgotten that the physical, psychosocial and economic level of the people with disabilities affects the quality of life and there is a relationship in which the degree of dependence of the person is inversely related to the quality of life [10]

82 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Adolph Mayer, the author of occupational therapy "People organize themselves to participate in activities throughout their lifetime and use their time" [11]. Participation from the perspective of occupational therapy is to be a part of everyday life. Participation is the main goal of occupational therapy. The World Health Organization (WHO) also focuses on participation as an important goal for all the people. The World Health Organization has defined areas of participation as knowledge learning and practice, general tasks and desires, communication, movement, self‐care, interpersonal interaction, home and work habits, community life, social

The nature, quality and/or duration of participation are personality and, even if it has the same health status, two different people cannot be compared at all. Participation examines the situation in the social environment rather than activity. The main problem of participation is the limitations bring to life of certain health problems and environment [13]. Community participation is sufficient for the individual to participate in the activities in his/her field. There are those who say that social skills are participation of everyday life, but according to

the experts, social participation is more complicated than communication [14].

**Picture 1.** Health and well‐being negatively affected of the inappropriate environment.

(**Picture 1**).

life and citizenship [12].

The philosophy of a profession is based on three components; first, the metaphysical component "What is human nature?" deals with the question. Second, etymology component "nature of human science, the starting point and the boundaries of" dealing with "How do we know everything?, How do we know what we know?" search for answers to their questions. Third, value teaching component, two types of questions One is "what is beautiful or valuable" which is related to esthetics, and the other is "what are the standards or rules of correct behavior" related to ethics? [15].

Occupational therapy is a scientific discipline that uses purposeful and meaningful activities therapeutically. Activity is the essence of being good. Meaningful activity is used to develop the capacity for internal motivation. Human life is in a continuous adaptation process. Adaptation is the change in the functions and directs the person to survive and develop. Biological, psychological, and environmental factors can disrupt adaptation in the life cycle. Decrease in function occurs when adaptation is impaired. Meaningful activity helps the adaptive process to regenerate [16].

The main goal of occupational therapy is to ensure that people participate in daily life activities and improves their performance. Occupational therapy provides a client‐centered approach to health and well‐being. At the same time, occupational therapy focuses on increasing the competence of people by organizing people, activities, the environment or some or all of them in order to increase social participation [16].

The handling of occupational therapy in all directions of humankind is called *holistic approach*. Holistic approach emphasizes the organic and functional relationship between whole and parts. This approach assumes the person as a whole as biological, psychological, sociocultural and spiritual [17].

Occupational therapy sees man as an active being. Man can determine and control his own behavior and even change it at will. Moreover, there is constant interaction between the human and environment. To survive, everyone has to do certain activities for himself or someone else, such as feeding himself or someone else [18].

According to occupational therapy, every person has the ability to be adaptive. Adaptation is the change in function for survival and self‐renewal [11]. Occupational therapy also increases activity adaptation [19]. When Gail Fidler and Jay Fidler describe adequacy, they say that "adapting, the ability to cope with problems in daily life and fulfill roles depends on the richness of one's relationships with both people and the environment" [20]. Adaptation depends on the person. The role of the occupational therapist in this process is to regulate the environment in order to facilitate the emergence of a specific adaptive response [21].

Occupational therapy aims to increase the quality of life of people whose functional ability is limited or impaired. To this end, it helps to improve performance independence in any area of the person: Strengthening the person's body for the necessary roles, improving the coordination for activities, improving the hobbies to make the person happy, or improving the social skills of the person to increase their participation in these aims. Thus, the meaning and value of the activity and the quality of life will increase [17].

Occupational therapy is based on the philosophy of humanism, which sees the applicants as human rather than as an object. The humanistic point of view is the basic approach of this profession. Today, this approach is called person‐centered approach. The therapist understands the importance of the person, family, and other individuals in his/her life in the treatment approach. The person has an active role both in the treatment modalities and in defining the goals and preferences for the treatment [17].

#### **3. International classification of functioning, disability and health‐ICF and community participation**

International classification of functioning, disability and health (ICF) is a system that forms a standard language for defining health and health‐related situations for the measurement, classification and conceptualization of disability and functioning [13].

In the past, the disability began at the place where the health had ended and anyone with any kind of heart was seen as second class. This way of thinking has evolved to support and improve the collective participation of the person with a disability who changes over time. ICF is a measure of the functioning of the individual in society, regardless of the cause of the disorder [22].

In the ICF classification, factors affecting the health status of a person are stated to be body functions and structures, activity, participation and environment. The consequences of these factors are functional and structural disorders, activity and participation limitations [23].

ICF reveals body function and structure, activity, participation, and personal and environmental factors. The content of occupational therapy is performance components, activity performance, participation and environmental factors [24].

ICF can be used for evaluation, intervention, and in service. The occupational therapist examines body functions and structures so performance components, to evaluate the primary target according to the individual. It interferes with functional impairment by focusing on the occupational performance. If malfunctions are encountered, it affects the person's participation and quality of life. Therapists should be familiar with these principles and should use them when planning services [24].

The language and content of ICF and Occupational therapy Frame of Reference are very similar. The frame is based on the ICF. This is particularly evident when the classification system in the ICF and the classification of the body functions in the frame are compared. The relationship between the activity areas of the frame and the activity participation areas of the ICF is indirect but overlaps with each other. Moreover, the ICF includes activities and areas of participation that can be compared to the performance capabilities listed in the frame. Most of the performance abilities in the frame have parallel codes in ICF [25].

The mobility field in the ICF is parallel to the motor skills. The communication/interaction skills and social interaction skills in the frame and the communication, interpersonal interaction and relationships in the ICF are parallel. Finally, the activity and performance areas of the framework and the ICF's activities and areas of participation are similar [25].

### **4. Occupational therapy models for evaluation of participation**

Models provide people with a sense of how they choose their activities and their experiences with them. It also specifies the problems of the people's activities and the rational solutions that can be brought to them [26].


Occupational therapy is based on the philosophy of humanism, which sees the applicants as human rather than as an object. The humanistic point of view is the basic approach of this profession. Today, this approach is called person‐centered approach. The therapist understands the importance of the person, family, and other individuals in his/her life in the treatment approach. The person has an active role both in the treatment modalities and in defining the

**3. International classification of functioning, disability and health‐ICF** 

International classification of functioning, disability and health (ICF) is a system that forms a standard language for defining health and health‐related situations for the measurement,

In the past, the disability began at the place where the health had ended and anyone with any kind of heart was seen as second class. This way of thinking has evolved to support and improve the collective participation of the person with a disability who changes over time. ICF is a measure of the functioning of the individual in society, regardless of the cause of the disorder [22]. In the ICF classification, factors affecting the health status of a person are stated to be body functions and structures, activity, participation and environment. The consequences of these factors are functional and structural disorders, activity and participation limitations [23].

ICF reveals body function and structure, activity, participation, and personal and environmental factors. The content of occupational therapy is performance components, activity per-

ICF can be used for evaluation, intervention, and in service. The occupational therapist examines body functions and structures so performance components, to evaluate the primary target according to the individual. It interferes with functional impairment by focusing on the occupational performance. If malfunctions are encountered, it affects the person's participation and quality of life. Therapists should be familiar with these principles and should use

The language and content of ICF and Occupational therapy Frame of Reference are very similar. The frame is based on the ICF. This is particularly evident when the classification system in the ICF and the classification of the body functions in the frame are compared. The relationship between the activity areas of the frame and the activity participation areas of the ICF is indirect but overlaps with each other. Moreover, the ICF includes activities and areas of participation that can be compared to the performance capabilities listed in the frame. Most

The mobility field in the ICF is parallel to the motor skills. The communication/interaction skills and social interaction skills in the frame and the communication, interpersonal interaction and relationships in the ICF are parallel. Finally, the activity and performance areas of the

of the performance abilities in the frame have parallel codes in ICF [25].

framework and the ICF's activities and areas of participation are similar [25].

classification and conceptualization of disability and functioning [13].

formance, participation and environmental factors [24].

them when planning services [24].

goals and preferences for the treatment [17].

84 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**and community participation**

A model involves a dynamic knowledge development process. A model is a way of thinking about applications, always reviewing and developing them [26].

#### **4.1. Model of human occupation (MOHO)**

This model was developed from Reilly's activity behavior model. This model focuses on function and activity. It guides in restructuring the activity, because this model focuses on person's roles and habits and determines the person's perspective and will. Person is seen as a dynamic system influenced by the physical and social environment. This model provides information on the occupational therapist's performance capacity [12].

Main elements of this model;


**Figure 1.** Model of human occupation scheme.

Habituation: Habits arise when organizing behavior in repetitive patterns keeps pace with the social world. Repeated movements in special cases constitute a habit pattern. The habit pattern grows with time and strengthens the organization and communication habits of the person with daily, weekly and seasonal routines [27]. Every person has one or more roles, and they have to do with those roles. Sometimes a person is a worker, sometimes a parent. This role guides other people's anticipations and how the natural person of the social system should behave. The roles are shaped by behavior. The person can reflect on their role activities, movements or clothing style [30–32].

Volition: The volition of the person for activities and duties depends the activity of the person, the importance of the activity for the person, and the satisfaction from this activity. Motivation is shaped by one's previous experiences and is closely linked to the future. It also influences motivation, causes, values and interest [27].


Performance capacity: It is influenced by body systems (such as musculoskeletal system, cardio‐pulmonary system, neurological system), mental and cognitive abilities (such as memory and planning abilities) [27].

MOHO also emphasizes how to use the body to maintain daily performance and how to benefit from body experiences [27].

#### **4.2. Ecology of human performance model (EHP)**

The ecology of human performance model assumes that environmental factors and/or natural phenomena such as physical, temporal, social and cultural influence the performance of the person [33]. The structure of this model includes human, environment and performance variables and the interaction between them. This model defines the person as a three‐dimensional model we have observed in his environment of him. The client‐cantered approach defines the activities and tasks of the person. This model helps the therapist to develop special strategies for overcome the barriers that limit the performance of the person.

The main elements of this model are as follows:

Habituation: Habits arise when organizing behavior in repetitive patterns keeps pace with the social world. Repeated movements in special cases constitute a habit pattern. The habit pattern grows with time and strengthens the organization and communication habits of the person with daily, weekly and seasonal routines [27]. Every person has one or more roles, and they have to do with those roles. Sometimes a person is a worker, sometimes a parent. This role guides other people's anticipations and how the natural person of the social system should behave. The roles are shaped by behavior. The person can reflect on their role activi-

Volition: The volition of the person for activities and duties depends the activity of the person, the importance of the activity for the person, and the satisfaction from this activity. Motivation is shaped by one's previous experiences and is closely linked to the future. It also influences

**1.** Personal reasons reflect the importance of the activity to the person and the capacity of the person. The person uses capacity in relation to cultural observations and demands of the environment. Because people think about doing the activity when they are confident in their physical, social and mental abilities. Some people are talented in sports, music, while others are successful in human relationships. After all, people shape their activities using

**2.** The choice of activity is also influenced by the values. Values consist of beliefs and concepts of well right importance as defined by society [29] and are felt by the individual as necessity. This obligation turns into a sense of belonging and social righteousness for the

**3.** Activity brings together the fulfillment and satisfaction of interest [30]. Each individual has different interests, depending on the opportunities for dealing with the activity and

Performance capacity: It is influenced by body systems (such as musculoskeletal system, cardio‐pulmonary system, neurological system), mental and cognitive abilities (such as memory

MOHO also emphasizes how to use the body to maintain daily performance and how to ben-

The ecology of human performance model assumes that environmental factors and/or natural phenomena such as physical, temporal, social and cultural influence the performance of the person [33]. The structure of this model includes human, environment and performance variables and the interaction between them. This model defines the person as a three‐dimensional model we have observed in his environment of him. The client‐cantered approach defines the activities and tasks of the person. This model helps the therapist to develop special strategies

person when he or she acts according to the value of the person [27].

ties, movements or clothing style [30–32].

86 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

motivation, causes, values and interest [27].

their environment and capacities [27].

the mood [27].

and planning abilities) [27].

efit from body experiences [27].

**4.2. Ecology of human performance model (EHP)**

for overcome the barriers that limit the performance of the person.


This model has expanded the range of interventions by addressing the environment. This model offers five intervention approaches: restoration, adaptation, replacement, prevention, and creation. Restoration intervention indicates changing the skills and abilities of the person. Adaptation and change are for the conditions and tasks. Prevention and creation strategies can focus on person, circumstances or relative but must be used before the problem arises. These forms of intervention remove the therapist from focusing solely on the individual and reveal a wide range of situations in which the environment can affect participation [4] (**Picture 2**).

The difference between other models and EHP is the use of terminology. In this model, authors preferred to use the term "task" rather than activity. The first reason is to work and collaborate with other disciplines. Second, the task word is more common on the day‐to‐day basis. In this model, there are three main structures: person, task and environment [28].

The *person* is in a dynamic and specific environment. So it is not possible to understand a person without knowing the environment of the person. The person affects the environment, and the environment also affects the person. The activity performance of the person determines the interaction between the person and the environment, environmental stimuli and the obstacles in the environment [28].

In the EHP model, the *task* is a series of behaviors. When tasks are combined, the person participates in the activity they want to achieve. The task is to determine the specific behavior required for successful participation. The person's skill, ability and interest will be combined with the characteristics of the participation and conditions to determine which task to use [34].

**Picture 2.** A leisure activity of a woman in adaptive environment.

There are two aspects of the environment in terms of time and environment. The temporal orientation is due to social and cultural connections. It is chronological. And it is maintained at every stage of development, affected by the phases of life and disability. The environmental aspect influences the performance of the physical environment (accessibility to unmanned environmental conditions), the social environment (the individual's accessibility to meaningful expectations), and the cultural environment (dressing, life patterns, beliefs, behavioral standards). As a result, the ecology model provides a way for the individual to understand their natural affairs, activity performance and environment. Finally, according to this model, the performance of a person depends on the person (ability, skill and motivation) and the environment (support and obstacle) [34].

#### **4.3. Person‐environment‐occupation (PEO)**

This model assesses the person, environment, activity, and interaction with each other. This is one's own daily life. Developers of this model have indicated that activity performance cannot be separated from environmental influences, temporal factors, physical and psychological characteristics of a person. They also define that in this model, environments, tasks, activities, and roles change constantly. They clearly stated the importance of focusing on the client's goals and creating a partnership that would help him/her to give his rehabilitation responsibility to the patient [12].

The main elements of this model are;


In this model, *human* beings are considered as part of every role and change. The importance, duration and meaning of these roles are very different according to environment and time. The human mind is a whole with a composition of body and spirituality. Human's qualities are physical, cognitive, emotional, and life experiences [29].

In this model, the *environment* is equally balanced in terms of cultural, social, physical, institutional, political and economical. It is the environment where environmental behaviors are practiced and provides personal information about what to do with expectations. These components may be supporting or limiting activity performance. With this model, it is also important how the individual perceives the environment [29] (**Figure 2**).

*Activity* encompasses all self‐care, producers and leisure activities. These represent the activities that one is engaged in for life [29]. When the activity is analyzed, the characteristics of the tasks, the duration of the activity, the complexity, and the need are examined [34].

Activity performance occurs at the intersection of these three conglomerates and is dynamic, and the performance experience varies according to the variation of these three components.

**Figure 2.** Person‐environment‐occupation scheme.

There are two aspects of the environment in terms of time and environment. The temporal orientation is due to social and cultural connections. It is chronological. And it is maintained at every stage of development, affected by the phases of life and disability. The environmental aspect influences the performance of the physical environment (accessibility to unmanned environmental conditions), the social environment (the individual's accessibility to meaningful expectations), and the cultural environment (dressing, life patterns, beliefs, behavioral standards). As a result, the ecology model provides a way for the individual to understand their natural affairs, activity performance and environment. Finally, according to this model, the performance of a person depends on the person (ability, skill and motivation) and the

This model assesses the person, environment, activity, and interaction with each other. This is one's own daily life. Developers of this model have indicated that activity performance cannot be separated from environmental influences, temporal factors, physical and psychological characteristics of a person. They also define that in this model, environments, tasks, activities, and roles change constantly. They clearly stated the importance of focusing on the client's goals and creating a partnership that would help him/her to give his rehabilitation responsi-

• Social, cultural, physical and institutional environmental factors affecting performance

In this model, *human* beings are considered as part of every role and change. The importance, duration and meaning of these roles are very different according to environment and time. The human mind is a whole with a composition of body and spirituality. Human's qualities

In this model, the *environment* is equally balanced in terms of cultural, social, physical, institutional, political and economical. It is the environment where environmental behaviors are practiced and provides personal information about what to do with expectations. These components may be supporting or limiting activity performance. With this model, it is also impor-

*Activity* encompasses all self‐care, producers and leisure activities. These represent the activities that one is engaged in for life [29]. When the activity is analyzed, the characteristics of the

Activity performance occurs at the intersection of these three conglomerates and is dynamic, and the performance experience varies according to the variation of these three components.

tasks, the duration of the activity, the complexity, and the need are examined [34].

environment (support and obstacle) [34].

bility to the patient [12].

The main elements of this model are;

• Time orientation and stages of life [12].

• Choosing the person's choices and goals for the activity • Physical and psychological characteristics of the person

are physical, cognitive, emotional, and life experiences [29].

tant how the individual perceives the environment [29] (**Figure 2**).

**4.3. Person‐environment‐occupation (PEO)**

88 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

The change of these three components in the PEO model over time determines the area of activity performance. If the closeness of these components is appropriate, the performance of the activity is optimal. Therefore, the basis of occupational therapy intervention is the adjustment of the activity performance of the changes in these components [29] (**Figure 3**).

**Figure 3.** Development of person‐environment‐occupation in life span.

#### **4.4. Person‐environment‐occupation‐performance (PEOP) model**

The person‐environment‐occupation‐performance model acknowledges that the activity performance of a person cannot be separated from the client‐centered and environmental effects. This model uses internal factors (psychological, cognitive, physiological, and neurobehavioral) and environmental factors (physical, cultural, social, social policies, and attitudes) to perform important activities, roles and tasks for the person and to understand the capacity of the person [12] (**Figure 4**, **Picture 3**).

In addition, one's own image, abilities, self‐understanding and motivation are assessed in a dynamic partnership with the therapist [perhaps family and cat, others involved in his/her life]. This approach requires the therapist to determine the person's roles, duties and activities. This model predicts intervention by meaningful activities during health or recovery [12].

The main elements of this model are as follows:


#### **4.5. Canadian model of occupational performance (CMOP)**

It is known as the model that sets the basis of client‐centered treatment. This model defines the relationship between person, person's environment and occupation, and intervention. Spiritually, the innate essence of man is the center of this model [12].

**Figure 4.** Person‐environment‐occupation‐performance (PEOP) model scheme.

**Picture 3.** Environment: the determinates of participation for people with disabilities.

The main elements of this model are as follows:


This model has two focal points: The first is the treatment process and the client‐centered practice that expresses the relationship between the treatment and the person. The second is the occupational performance which is done for self‐care, enjoyment of life, participation in social and economic life, organize and satisfy them with respect to age, culturally appropriate and meaningful work [35].

This model includes factors that affect occupational performance and beliefs that affect the conceptualization of occupational therapy. Values and beliefs influence person's environment, health and client‐centered practices [35].

Examples of values related to the activity are as follows:


**4.4. Person‐environment‐occupation‐performance (PEOP) model**

90 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

The main elements of this model are as follows:

tural, social environment, social policies and attitudes [12].

Spiritually, the innate essence of man is the center of this model [12].

**4.5. Canadian model of occupational performance (CMOP)**

**Figure 4.** Person‐environment‐occupation‐performance (PEOP) model scheme.

(**Figure 4**, **Picture 3**).

his activity.

robehavioral factors.

[12].

The person‐environment‐occupation‐performance model acknowledges that the activity performance of a person cannot be separated from the client‐centered and environmental effects. This model uses internal factors (psychological, cognitive, physiological, and neurobehavioral) and environmental factors (physical, cultural, social, social policies, and attitudes) to perform important activities, roles and tasks for the person and to understand the capacity of the person [12]

In addition, one's own image, abilities, self‐understanding and motivation are assessed in a dynamic partnership with the therapist [perhaps family and cat, others involved in his/her life]. This approach requires the therapist to determine the person's roles, duties and activities. This model predicts intervention by meaningful activities during health or recovery

• Activities, tasks and roles are important for people, organization and society. His image is

• Inner factors supporting performance are psychological, cognitive, physiological and neu-

• External factors that support or hinder the occupational performance are the physical, cul-

It is known as the model that sets the basis of client‐centered treatment. This model defines the relationship between person, person's environment and occupation, and intervention.


### **5. Factors affecting community participation**

#### **5.1. Personal factors**

When these structures deteriorate, it is very important to intervene and evaluate the intervention. Performance constructs include *habits, roles, and routines*. *Habits* are the models and talents that will engage the individual on a daily basis. Habits tend to automate and are usually automated at the subconscious level. This saves energy and allows us to focus on higher‐level tasks. Habits can be useful for individual support. Occupational therapists con-Figure it to intervene [36].

*Routines* are things that an individual usually does in a regular order. Routines bring order sensibility and an individual or a group forms the framework for their daily lives. Studies have shown that routines are made at certain times of the day and somehow provide daily rhythm or biological rhythm according to the individual's biological clock. Routines are also shaped by society and culture at the same time. When children return from school, doing homework is a routine shaped by society and culture [36].

Both habits and routines provide daily activities for the individual. Habits and routines help an individual to have a certain lifestyle. Lifestyles are a sign of health and well‐being. Individuals with routine preventive measures, habits, and daily walking or non‐smoking routines will have a healthier lifestyle. The occupational therapists should be aware of the work of their patients and the meaning of these things in relation to the patient [14].

#### **5.2. Performance skills**

It defines certain abilities and features that the person typically combines to complete a functional ability. These include sensory, motor, emotional, cognitive, and communication/interaction skills [14].

The main examples are as follows:


individual must use small muscle groups for controlled movements such as object manipulation, speed or hand skill [36].

**5. Factors affecting community participation**

92 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

homework is a routine shaped by society and culture [36].

occupation, or with the objects in the environment [14].

with an apparatus and to tilt the body according to the task [36].

When these structures deteriorate, it is very important to intervene and evaluate the intervention. Performance constructs include *habits, roles, and routines*. *Habits* are the models and talents that will engage the individual on a daily basis. Habits tend to automate and are usually automated at the subconscious level. This saves energy and allows us to focus on higher‐level tasks. Habits can be useful for individual support. Occupational therapists con-

*Routines* are things that an individual usually does in a regular order. Routines bring order sensibility and an individual or a group forms the framework for their daily lives. Studies have shown that routines are made at certain times of the day and somehow provide daily rhythm or biological rhythm according to the individual's biological clock. Routines are also shaped by society and culture at the same time. When children return from school, doing

Both habits and routines provide daily activities for the individual. Habits and routines help an individual to have a certain lifestyle. Lifestyles are a sign of health and well‐being. Individuals with routine preventive measures, habits, and daily walking or non‐smoking routines will have a healthier lifestyle. The occupational therapists should be aware of the work

It defines certain abilities and features that the person typically combines to complete a functional ability. These include sensory, motor, emotional, cognitive, and communication/inter-

• **Motor and praxis skills***:* The ability of an individual to interact with his environment and

• *Posture:* The ability to achieve a steep position even if the balance and balance of the individual is disturbed. This ability includes body trunk stabilization, alignment of the individual's body in a vertical position, and bringing the body to a safe and controlled position

• *Mobility*: Ability of the individual to act to complete an occupation or activity. This ability includes walking on rough surfaces without stumbling, using foot tools or ancillary tools such as walking sticks, walkers or wheelchairs. If the individual is able to walk, the ability can also include situations such as being able to successfully reach the object with arms or

• *Coordination:* The capacity to use more than one extremity in relation to the task or activity. This ability includes the use of two or more limbs to stabilize or manipulate the object. The

of their patients and the meaning of these things in relation to the patient [14].

**5.1. Personal factors**

Figure it to intervene [36].

**5.2. Performance skills**

The main examples are as follows:

after completing the activity [36].

action skills [14].


**Cognitive skills:** To use ideas or behaviors to design an activity or task [36]:


**Communication/social skills**: It is enough to explain the needs and ideas of the individual to others in a social environment and in an acceptable way [14].


#### **5.3. Performance areas**

• *Visualizing:* The ability to use visuals to interpret information.

94 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

tion to relocate objects. This ability is about stereognosis.

• *Timing*: The individual is able to self‐adjust for a motor task or activity.

that an individual can tell the difference in temperature between foods.

when interacting with individuals or groups, or to deal with them [36]:

• *Responding*: It is the ability to understand and react to others' feelings. • *Persisting*: Despite the difficulties, it is the capacity to continue the tasks.

• *Controlling*: Controlling feelings or anger about other individuals.

experience.

• *Locating:* This ability comes into play when the individual begins to use sensory informa-

• *Discerning*: Using sensory ability to describe the differences between objects. An example is

• **Emotional regulation skills:** The ability to use movements or behaviors to express feelings

• *Recovering*: The individual is used when he is disappointed or when his feelings are hurt. • *Displaying*: To have the ability to express appropriate feelings about a situation or

• *Utilizing:* The ability to use some skills and techniques to resist emotional situations.

• *Organizing*: Having the ability to complete the activity in the given order and time. • *Prioritizing*: The ability to define the steps and solutions needed to complete a task.

• *Judging*: the task is the ability to decide what is important or necessary for completion. An example is when an individual decides not to prioritize jobs that run the length of time.

**Communication/social skills**: It is enough to explain the needs and ideas of the individual to

• *Physicality*: The ability to use the individual's body or body language for communication. This skill involves physically touching others, bringing your body into a position or turn-

• *Information exchange*: Ability to inform others and get information from them. This skill includes explicit self‐expression, asking for information, and being able to include a meaningful word. Thus, the individual can communicate his/her feelings in the direction of information they share.

• *Relations*: Ability to continue relationships. This skill requires that the individual has the ability to interact with other people, to connect with people who have ordinary interests, or to have the ability to catch relationships at a certain level with everyday interactions [36].

**Cognitive skills:** To use ideas or behaviors to design an activity or task [36]:

• *Selecting*: Ability to select appropriate tools for a specific task.

• *Multitasking:* At the same time, the ability to do multiple jobs.

others in a social environment and in an acceptable way [14].

ing it into a direction in relation to eye contact and others.

• *Creating*: Can participate in fun activities.

Different living spaces were defined in the social participation of the individual. These include activities of daily living (ADL), instrumental activities of daily activities (IADL), work, education, play and leisure. The occupational therapist should take into account the person's role, social support, and occupational performance in different time and space [37].

The activities of the individual affect the activity of the roles in determining the role of his life. Christiansen and Baum have defined roles as "expected responsibilities and privileges in society" [34]. For example, in a reading activity, a mother reads a book for a 5‐year‐old child and has different activities to read a report. while she is in a job. That is, both the content and the printing scales of the material to be read will be different. While reading a book requires reading, a voice reading a report does not require it [38].

Activities can be divided into smaller tasks. For example, the account payment activity includes a series of tasks such as calling a waiter, requesting an account, reading the amount, putting the required amount in the account box. One uses the abilities and skills when doing these tasks. The skills required for these tasks include good motor skills, visual perception, selection, and oral motor function [38].

**Activities of daily living (ADL):** ADL skills include self‐care, functional mobility, communication, and management of pharmaceutical and health routines. While defining activities of daily living, different terms can be used, such as simple daily life activities and personal daily life activities. Despite the different definitions of the ADL definition, it is people take care of yourself. ADL is an example of bathing, bowel control, dressing, eating, functional mobility, personal care, sexual activity, and toilet cleaning. Bathing activity, for example, is the acquisition and use of bathroom accessories such as soap, towels. The essence of this activity is to transfer into and out of the bath or bath with the ability to get the proper bath position and adjust the safe water temperature. Dressing activity includes the ability to dress up and choose clothes according to time, season and activity in our mind. Eating activity is the ability to graze, chew, and swallow food. Functional mobility is the ability to move from one position to another or from one place to another. Personal care activity is the provision and use of tools for the care of skin, ear, eye and nails. It is also necessary for this activity to scan the person's hair, use a toothbrush and toothpaste for mouth cleaning, toilet hygiene activities, in‐and‐out transfer, preparation of toilets, and post‐toilet cleaning activities [37, 38]

**Instrumental activities of daily living (IADL):** Lawton and Brody have described "secondary tasks necessary for independent living in the community" as instrumental activities of daily living. IADL, consist of money management, telephone use, medication use, travel, shopping, food preparation, laundry and housework. It is recognized that IADL is important for the quality of life and well‐being of the disabled individual. But there is no consensus about what activities are needed for independent community life. Barer and Nouri classify leisure activities (gardening and other hobbies) as transportation (use of transportation vehicles, walking on the street, getting in and out of the car and driving), home activities (laundry jobs, food preparation and housework) [37].

The application of IADL is complex multi‐step activities. It requires the use of special tools such as telephones. Practices can occur inside and outside the house. Independent practice requires mental, physical and social skills such as decision‐making, problem solving, initiation and sequencing. The evaluation of IADL is especially important for those who are prepared to return to community life. In addition, this assessment provides meaningful information about a person's cognitive status. In persons with cognitive impairment, disturbances are observed in IADLs, especially in telephone use, transportation, drug use, and money management [37].

**Work/school activities:** Job‐based activities are the focus of one's life. Work‐related activities are an important way to demonstrate the "adequacy" of an individual. The occupation as an employee depends on a successful interaction with the interpersonal, environment and business. The job evaluation of the person leads the therapist to specific tasks in the business area. The assessments in this area are used as an important source of information for the state. The best person to do the same job analysis as the job analysis can be identified [37].

Assessing the child, adolescent or young adult's ability to provide education is important [22]. It provides information about the child's participation in school activities, occupational performance and supports the child uses [37].

**Leisure activities/play:** Leisure activities are non‐essential activities that are freely chosen, mostly occurring in nature, and providing individual satisfaction, relaxation, recreation and self‐ expression. Individuals are delightful and rewarded with inner rewards. Individuals with experience in leisure activities believe that events are on their control and will result in free choices of the outcome of the activity. These events and characteristics affect the person's ability to make choices. It has also been shown that participation in leisure has a positive impact on health [37].

The play is the first activity in childhood and youth. The play is a versatile phenomenon. The play improves internal motivation while providing relaxation and entertainment. Factors such as what players do, how players like the selected game activity, how the players' approach to the activities are, how the players play the games, and how the game supports the play are important [37].

#### **5.4. Environmental conditions**

In previous years, it was thought that the person with a disability had a disability in daily activities, participation in education, play and work, and these problems were related to the person. Later, awareness of environmental factors has also led to difficulties experienced by people with disabilities [39, 40].

First, the focus was on the physical and structural environment, and a lot of effort was spent on ramps, elevators, etc. on the pavements. The people with disabilities began to participate more in collecting [37].

Environmental conditions include three major factors:


**Physical conditions:** Physical conditions are classified in the building (man‐made environment), technology (auxiliary devices, fixtures and software) and natural environment categories used by ICF [13].

The application of IADL is complex multi‐step activities. It requires the use of special tools such as telephones. Practices can occur inside and outside the house. Independent practice requires mental, physical and social skills such as decision‐making, problem solving, initiation and sequencing. The evaluation of IADL is especially important for those who are prepared to return to community life. In addition, this assessment provides meaningful information about a person's cognitive status. In persons with cognitive impairment, disturbances are observed in IADLs, especially in telephone use, transportation, drug use, and money management [37]. **Work/school activities:** Job‐based activities are the focus of one's life. Work‐related activities are an important way to demonstrate the "adequacy" of an individual. The occupation as an employee depends on a successful interaction with the interpersonal, environment and business. The job evaluation of the person leads the therapist to specific tasks in the business area. The assessments in this area are used as an important source of information for the state. The

best person to do the same job analysis as the job analysis can be identified [37].

performance and supports the child uses [37].

96 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**5.4. Environmental conditions**

people with disabilities [39, 40].

Environmental conditions include three major factors:

**1.** Physical conditions (structural, natural and technological environment),

**3.** Social conditions (socio‐economic, cultural and political environment) [37].

more in collecting [37].

**2.** Social support,

Assessing the child, adolescent or young adult's ability to provide education is important [22]. It provides information about the child's participation in school activities, occupational

**Leisure activities/play:** Leisure activities are non‐essential activities that are freely chosen, mostly occurring in nature, and providing individual satisfaction, relaxation, recreation and self‐ expression. Individuals are delightful and rewarded with inner rewards. Individuals with experience in leisure activities believe that events are on their control and will result in free choices of the outcome of the activity. These events and characteristics affect the person's ability to make choices. It has also been shown that participation in leisure has a positive impact on health [37]. The play is the first activity in childhood and youth. The play is a versatile phenomenon. The play improves internal motivation while providing relaxation and entertainment. Factors such as what players do, how players like the selected game activity, how the players' approach to the activities are, how the players play the games, and how the game supports the play are important [37].

In previous years, it was thought that the person with a disability had a disability in daily activities, participation in education, play and work, and these problems were related to the person. Later, awareness of environmental factors has also led to difficulties experienced by

First, the focus was on the physical and structural environment, and a lot of effort was spent on ramps, elevators, etc. on the pavements. The people with disabilities began to participate


**Support, relevance and effectiveness of occupation**: The use of social support as both formal (programs and services) and informal (family and friends) is a strategy used to compensate for environmental barriers. In a therapeutic perspective, social support for people with disabilities is often defined by their care, their love, and their ability to trust others. Social support is a concept that includes practical support, informative support and emotional support. *Practical support* is a physical support. Supporting transfers, preparing meals, or taking them to a doctor are examples of practical support. This type of support may be informal (if given by a family member or loved one) or formal (if given by a paid caregiver or someone interested in personal care). *Informative support* is generally considered to be advice or guidance. For example, an individual can be referred to as advice or information to teach ways of saving energy or to take supplies for the bathroom. Family or friends, as well as professionals or peers, provide this kind of information. Emotional support generally includes feelings of belonging or respect. Despite the fact that the professionals provide this kind of support, *emotional support* is a role that falls on the family and peers to become a group member or morale in difficult times [37].

Social support can improve physical fitness, harmony between person and environment. For example, the activity of eating in the life of an individual who temporarily uses a wheelchair for mobility may be disrupted. The person may not be able to move enough in the kitchen due to the narrow space in the kitchen, the lack of space for return, unreachable cabinets, and environmental obstacles such as not being able to see what is being cooked in the kitchen. By increasing the surface area, it can be a strategy to change the area of motion by removing furniture, cabinets, and an angled mirror over the oven to create more space. Teaching to use a microwave oven set at a level that can reach the person is also an alternative. A third solution would be to use a home‐cooked meal service (official practical support). The fourth alternative might be to inform the family or friends of the individual and provide assistance (unofficial practical support) to the disabled individual during the preparation and preparation of food [37].

**The effect of socio‐economic and political direction on environment and occupation**: *Culture* is values, norms, beliefs, traditions, behaviors and perceptions shared by a group or society. Culture can be related to people, organization, community, and community level. Individually, the culture can determine the level of independence of the individual's wishes. For example, the exchange of an elder's clothes can be accepted for the culture. The culture is also influential in home modifications. In Turkey, for example, when entering the house, the shoes are removed and the house is one step higher than the area from which the shoe is removed. This tradition creates difficulties for the wheelchair user to enter the home [37].

*Policies* that provide funding for programs that help people with disabilities, services, may play a role in whether there is funding. In the United States and some European countries, individuals with disabilities regulate home modifications. Insurance schemes in these countries cover home caregivers, home health benefits, and regulations that will increase the freedoms of people with disabilities. Many practical programs and attitude changes affecting the environment have been carried out to a large extent as a result of legislation. These laws shape the programs and policies affecting participation, as well as profoundly affecting the professional productivity of people with disabilities [37].

The Turkish Institute of Statistics has established the "Turkey Disability Survey" in order to solve the problems of people with disabilities in Turkey and disability issues. According to the results of the research, it is seen that the proportion of the disabled population is 12.29% of the total population. Accordingly, there are approximately 8.5 million people with disabilities in our country. The most disadvantaged part of the society, the disabled, health, education, employment, care, rehabilitation, accessibility and so on. It is important that many socio‐cultural and economic problems are resolved. With this in mind, Law No. 5378 on the Amendment of Decrees on Disability and Some Laws and Decrees on the Law has entered into force on 07.07.2005. On December 3, 2008, the Assembly approved the United Nations Convention on the Rights of Persons with Disabilities, which is World Disability Day. Thus, the right of all disabled citizens to live equal, free and dignified is guaranteed [41].

Persons with disabilities are less likely to receive education and work than healthy people. The cost of non‐income disability is twice as expensive as the disability. In this case, even laws cannot save from the obstacle of social exclusion. In a survey conducted, it was reported that the employer did not have the courage to give obstructive employment and some of them refused to do business [37] (**Picture 4**).

*Beliefs* about disabled people also affect the occupational performance. Laws, policies and beliefs, shape society and beliefs are the most influential external factor in the lives of the disabilities. In the past, there were practices that discriminated in the workforce, in public participation, and in education. Negative beliefs against disability affected participation in all phases of life. Protecting and increasing the reputation of the disabled will be provided by changing social attitudes, lifting social barriers and legal approaches [37].

#### **5.5. Quality of life and community participation**

concept that includes practical support, informative support and emotional support. *Practical support* is a physical support. Supporting transfers, preparing meals, or taking them to a doctor are examples of practical support. This type of support may be informal (if given by a family member or loved one) or formal (if given by a paid caregiver or someone interested in personal care). *Informative support* is generally considered to be advice or guidance. For example, an individual can be referred to as advice or information to teach ways of saving energy or to take supplies for the bathroom. Family or friends, as well as professionals or peers, provide this kind of information. Emotional support generally includes feelings of belonging or respect. Despite the fact that the professionals provide this kind of support, *emotional support* is a role that falls on the family and peers to become a group member or morale in difficult times [37]. Social support can improve physical fitness, harmony between person and environment. For example, the activity of eating in the life of an individual who temporarily uses a wheelchair for mobility may be disrupted. The person may not be able to move enough in the kitchen due to the narrow space in the kitchen, the lack of space for return, unreachable cabinets, and environmental obstacles such as not being able to see what is being cooked in the kitchen. By increasing the surface area, it can be a strategy to change the area of motion by removing furniture, cabinets, and an angled mirror over the oven to create more space. Teaching to use a microwave oven set at a level that can reach the person is also an alternative. A third solution would be to use a home‐cooked meal service (official practical support). The fourth alternative might be to inform the family or friends of the individual and provide assistance (unofficial practical sup-

98 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

port) to the disabled individual during the preparation and preparation of food [37].

sional productivity of people with disabilities [37].

**The effect of socio‐economic and political direction on environment and occupation**: *Culture* is values, norms, beliefs, traditions, behaviors and perceptions shared by a group or society. Culture can be related to people, organization, community, and community level. Individually, the culture can determine the level of independence of the individual's wishes. For example, the exchange of an elder's clothes can be accepted for the culture. The culture is also influential in home modifications. In Turkey, for example, when entering the house, the shoes are removed and the house is one step higher than the area from which the shoe is removed. This tradition creates difficulties for the wheelchair user to enter the home [37]. *Policies* that provide funding for programs that help people with disabilities, services, may play a role in whether there is funding. In the United States and some European countries, individuals with disabilities regulate home modifications. Insurance schemes in these countries cover home caregivers, home health benefits, and regulations that will increase the freedoms of people with disabilities. Many practical programs and attitude changes affecting the environment have been carried out to a large extent as a result of legislation. These laws shape the programs and policies affecting participation, as well as profoundly affecting the profes-

The Turkish Institute of Statistics has established the "Turkey Disability Survey" in order to solve the problems of people with disabilities in Turkey and disability issues. According to the results of the research, it is seen that the proportion of the disabled population is 12.29% of the total population. Accordingly, there are approximately 8.5 million people with disabilities in our country. The most disadvantaged part of the society, the disabled, health, education, Aristotle, who defines happiness as a virtuous activity of the soul, states the concept of quality of life. Happiness is said to be for a short time, a feeling of goodness temporarily felt by daily affairs. There may be many areas to describe the quality of life. These are cultural, psychological, social, religious, economic, political, temporal and philosophical fields. The quality of life is a dynamic perception because it changes with people and the environment [42].

**Picture 4.** Sports affects participation as a work and leisure activities.

World Health Organization (WHO) has defined the quality of life as "Positive perception of person's aims, expectations, standards and values related to it and its life in culture." This definition clearly shows that occupational therapists believe that the quality of life will increase in meaningful connection with the person, family and society and occupation. That is, meaningful community participation is associated with good quality of life [42].

**Occupation and quality of life**: A meaningful activity is directly associated with a good quality of life. Because the activity encourages the person, at the same time, it changes and strengthens the character of the person. Constrained activity also limits the potential for activity remaining for the individual. People are prevented from participating in necessary activities and contributing to the meaning of life with the reasons of disability and occupational deprivation. The effect of occupational deprivation includes feelings of loneliness, emotional distance from one's self and others, and despairs that will distract the person from the quality of life. As a result, meaningful occupation significantly affects person's quality of life [42].

Not long ago, many people with disabilities encountered great obstacles to meaningful occupation and there were limited occupational available to them. These constraints in activism stemmed from the prejudices of the society about superstitions, disaggregation in institutions and the capacity and potential of people with disabilities. Such barriers have significantly reduced the chances of eliminating the abilities, and self‐potential of disabilities. In today's society, many people with disabilities are still faced with such occupational obstacles that lower quality of life. For this reason, the search for quality of life may present additional difficulties, especially in the area of occupational. Therefore, occupational therapists pay particular attention to the quality of life for the handicapped [42, 43].

#### **6. Evaluating of community participation**

We understand the forms of community involvement by gathering experiences of our clients' occupations that make up their daily lives. Community participation, as defined, is a versatile and contextual phenomenon. These basic attributes of community participation imply that there is more than one way to determine whether our customers are involved (i.e., whether they are multi‐dimensional) and that our clients' participation may actually vary depending on what they are doing and where they are doing it. It happens (i.e., it depends on the content). For this reason, it is best to gather useful information about how our different clients are involved among all relevant occupations and settings.

The assessment approaches addressed in this chapter support the use of a top‐down and customer‐focused approach to our clients' professional performance needs. When using a bottom‐ up approach, it first focuses on getting the client's community participation profile by defining what the customer wants to do, what to do, or what to expect. And then they organize services that deal with distortions, functional limitations, and contextual factors that limit levels of participation in the context of a particular activity. While the assessments in this section will enable us to systematically acquire the community participation profiles of our customers, we do not concentrate on the subset of activities that have the most restrictions on their participation.

Many of these measures have been developed over the past decade and have provided ideas for thinking and measuring lifelong involvement of people with disabilities. These measures differ in terms of their completeness, how they are implemented, how long they are completed, the intended population of the target population, and their intended purposes. In this section, we will consider the participation assessments developed for young children, children and adolescents, adults and older adults. The table below gives an overview of what each assessor can do to help you collect information as you start the assessment process with your clients [42, 43] **[Tables 1, 2]**.


**Table 1.** Selected Participation Measures for Young Children.


**Table 2.** Selected Participation Measures for Adults and Older Adults.

#### **Author details**

World Health Organization (WHO) has defined the quality of life as "Positive perception of person's aims, expectations, standards and values related to it and its life in culture." This definition clearly shows that occupational therapists believe that the quality of life will increase in meaningful connection with the person, family and society and occupation. That is, mean-

**Occupation and quality of life**: A meaningful activity is directly associated with a good quality of life. Because the activity encourages the person, at the same time, it changes and strengthens the character of the person. Constrained activity also limits the potential for activity remaining for the individual. People are prevented from participating in necessary activities and contributing to the meaning of life with the reasons of disability and occupational deprivation. The effect of occupational deprivation includes feelings of loneliness, emotional distance from one's self and others, and despairs that will distract the person from the quality of life. As a result, meaningful occupation significantly affects person's quality of life [42]. Not long ago, many people with disabilities encountered great obstacles to meaningful occupation and there were limited occupational available to them. These constraints in activism stemmed from the prejudices of the society about superstitions, disaggregation in institutions and the capacity and potential of people with disabilities. Such barriers have significantly reduced the chances of eliminating the abilities, and self‐potential of disabilities. In today's society, many people with disabilities are still faced with such occupational obstacles that lower quality of life. For this reason, the search for quality of life may present additional difficulties, especially in the area of occupational. Therefore, occupational therapists pay particu-

We understand the forms of community involvement by gathering experiences of our clients' occupations that make up their daily lives. Community participation, as defined, is a versatile and contextual phenomenon. These basic attributes of community participation imply that there is more than one way to determine whether our customers are involved (i.e., whether they are multi‐dimensional) and that our clients' participation may actually vary depending on what they are doing and where they are doing it. It happens (i.e., it depends on the content). For this reason, it is best to gather useful information about how our different clients are

The assessment approaches addressed in this chapter support the use of a top‐down and customer‐focused approach to our clients' professional performance needs. When using a bottom‐ up approach, it first focuses on getting the client's community participation profile by defining what the customer wants to do, what to do, or what to expect. And then they organize services that deal with distortions, functional limitations, and contextual factors that limit levels of participation in the context of a particular activity. While the assessments in this section will enable us to systematically acquire the community participation profiles of our customers, we do not concentrate on the subset of activities that have the most restrictions on their participation.

ingful community participation is associated with good quality of life [42].

100 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

lar attention to the quality of life for the handicapped [42, 43].

**6. Evaluating of community participation**

involved among all relevant occupations and settings.

Gokcen Akyurek\* and Gonca Bumin

\*Address all correspondence to: gkcnakyrk@gmail.com

Department of Occupational Therapy, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey

#### **References**


**References**

2009

[1] Burcu E. Türkiye'de Özürlü Birey Olma Temel Sosyolojik Özellikleri ve Sorunları

[2] Polat ÇS. Engelliliğin Atasözü ve Deyimlere Yansımasının Sosyolojik Analizi Ulıslararası Türkiye‐Mısır ilişkileri Sempozyumu ve Güzel Sanatlar Sergisi, 2‐7 Kasım, Kahire/Mısır.

[3] Burcu E. Özürlülük Kimliği ve Etiketlemenin Kişisel ve Sosyal Söylemleri, Hacettepe

[4] American Occupational Therapy Association. Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy. 2002;**56**(6):609‐639

[5] Mosey AC. Applied Scientific Inquiry in the Health Professions: A Epistemological

[6] Bullinger M, Schmidt S, Petersen C. The Disabkids Group. Assessing quality of life of children with chronic health conditions and disabilities: A Europen approach. International

[7] Küçükdeveci AA. Rehabilitasyonda Yaşam Kalitesi. Türkiye Fiziksel Tıp ve Rehabilitasyon

[8] Uyanik M, Kayıhan H, Düger T, Bumin G, Ergun A. Hemiplejik hastaların günlük yaşam aktivitelerini değerlendirmede standardize dört testin karşılaştırması. Fizyoterapi ve

[9] Kimler DD, Abresch TD, Fowler WM. Serial manuel muscle testing in duchenne muscular dystrophy. Archives of Physical Medicine and Rehabilitation. 1993;**74**(11):1168‐1171

[10] Spilker B. Quality of Life. Assessments in Clinical Trials. New York: Raven Press; 1996

[11] Meyer A. The philosophy of occupation therapy. Archives of Occupation Therapy. 1922;**1**(1): (Reprinted in American Journal of Occupation Therapy. 1977;**31**(10))

[12] Law M, Baum C Measurement in Occupational Therapy. In: Law M, Baum C, Dunn W. Measuring Occupational Performance: Supporting Best Practice in Occupational Therapy.

[13] World Health Organization (WHO). International Classification of Functioning,

[14] O'Sullivan B. Practice framework and activity analysis. 2nd ed. In: Sladyk K, editor. OT

[15] Shannon PD. Philosophy and core values in occupational therapy. 4th ed. In: Sladyk K, Ryan SE, editors. Ryan's Occupational Therapy Assistant: Principles, Practice Issues,

Study Cards in a Box. Thorofare, NJ: SLACK Incorporated; 2003;**2**:1‐32

Üzerine Bir Araştırma. Ankara: Hacettepe Üniversitesi Yayınları; 2007

Üniversitesi Edebiyat Fakültesi Dergisi. 2006;**23**(2):61‐83

Orientation. 2nd ed. Bethesda, MD: AOTA; 1996

102 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Journal of Rehabilitation Research. 2002;**25**:197‐206

Derneği. 2005;**51**(B):23‐29

Rehabilitasyon. 2001;**12**(2):67‐74

2nd ed. Thorofare, NJ: Slack Inc. 2005.

and Techniques, Thorefare: Slack; 2005

Disability and Health. Geneva, Switzerland: 2001; p. 18


[47] McWilliam RA, Casey AM, & Sims J. The Routines‐Based Interview (RBI) A method for gathering information and assessing need. Infants & Young Children 2009: 22 (3): 224-33.

[32] Matsutsuyu JS. The interest chech list. American Journal of Occupation Therapy.

[33] Dunn W, Brown C, McGuigan A. Ecology of human performance: A framework.

[34] Dunn W. Ecology of human performance model. In: Dunbar SB, editor. Occupational Therapy Models for Intervention with Children and Families. Thorofare, NJ: Slack

[35] Law M, Polatajko H, Baptiste S, Townsend E. Core Concepts of Occupational Therapy; In: Townsend E, editor. Enabling occupation: An occupational therapy perspective.

[36] Sladyk K, Jacobs K, MacRae N. Occupational therapy essentials for clinical competence. Occupation, Activity, Skills, Patterns, Demands, Context and Balance. Thorofare, NJ:

[37] Christiansen C, Baum C, Bass‐Haugen J. Occupational therapy: Performance, participa-

[38] Oksuz C, Akel S, Bumin G. Effect of occupational therapy on activity level and occupational performance in patients with neuromuscular disease. Fizyotrapi Rehabilitasyon.

[39] Cook AM, Polgar JM. A framework for assistive Technologies. In: Cook AM, Polgar JM, editors. Cook and Hussey's Assistive Technologies: Principles and Practice. 3nd ed. St.

[40] Bumin G, Akyürek G. Environmental perception and social participation of amateur and professional athletes with disabilities. 16th congress of the World Federation of Occupational Therapists in Collaboration with the 48th Japanese Occupational Therapy

[42] Pizzi MA, Renwick R. Quality of life and health promotion. In: Scaffa ME, Reitz SM, Pizzi MA. Occupational therapy in the promotiong of health and wellness. Philadelphia,

[43] Akyürek G, Bumin G. Investigation of factors that affect community participation of people with disabilities. The 13th International Conference on Mobility and Transport for Elderly and Disabled Persons (TRANSED 2012); September 17‐20, 2012; New Delhi; India

[45] Wilson LL, Mott DW, & Batman D. The Asset‐Based Context Matrix (ABCM). TECSE

[46] Law M, King G, Petrenchik T, Kertoy M, & Anaby D. The Assessment of Preschool Children's Participation (APCP) scale: Internal consistency and construct validity. Physical

[41] http://www.ozida.gov.tr/yenimezuat/mevzuat.pdf Erişim tarihi: 11.02.2017

[44] Berg C, LaVesser P. The preschool activity card sort. Fall. 2006; 26 (4): 143-51.

and Occupational Therapy in Pediatrics 2012; 32 (3): 272-87.

American Journal of Occupation Therapy. 1994;**48**(7):595‐607

tion and well being. Thorofare, NJ: Slack Incorporated; 2004

1970;**24**:93‐101

Incorporated; 2007. pp. 127‐157

SLACK, Incorporated; 2010.

Louis, MO: Mosby Elsevier; 2008.

Congress and Expo, 18‐21 June 2014; Japan

2011;**22**(3):231‐239

FA Davis Plus, 2010

2004; 24(2): 110-20.

Ottawa, ON: CAOT Publications ACE; 1997

104 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation


## **Measurement of Participation: The Role Checklist Version 3: Satisfaction and Performance**

Patricia J. Scott, Kelsey McKinney, Jeff Perron, Emily Ruff and Jessica Smiley

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69101

#### **Abstract**

Participation in society is an area of interest to both clinicians and population researchers. Measurement of participation is therefore important, yet differences in definition, in terms of both content and scope, have made general agreement on one instrument tool elusive. What is recognized is the need for a theoretically based tool that captures both the insider and the outsider perspective. The outsider perspective, inclusive of the generally held views of a society, supports the utility for aggregating population data, whereas the insider perspective provides the internally held views of an individual needed for client-centered treatment planning. The Role Checklist Version 3 modifies one of the most commonly used assessment tools in occupational therapy practice, has good preliminary psychometric properties, and is theoretically consistent with both the ICF and the Model of Human Occupation. The Model of Human Occupation is the most widely used theoretical model in occupational therapy. This chapter provides an overview of the theoretical development, empirical testing, and implications for use of this participation measure by occupational therapists along with implications for population researchers.

**Keywords:** role checklist, measurement, participation, Model of Human Occupation, occupational therapy

#### **1. Introduction**

Humans interact with each other in consistent and scripted ways. *This interaction is known as participation and takes the form of roles*. These roles have specific meaning both to the person performing: the insider, and to those around them: the outsiders. A person's identity and

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

sense of competency are tied inextricably to this role participation. Role participation is both persistent and changes over time, as people go through both planned and unplanned life transitions. Clinically, a person's role participation becomes the focus of the occupational therapist when disability-related limitations affect a person's capacity to participate in desired and meaningful roles.

Occupational therapists aim to assure that persons with disabilities have the motivation, opportunities, and capacity to overcome disability-related limitations and participate in social life. The International Classification of Health, Disability and Function (ICF) seeks to establish uniform definitions worldwide [1]. The American Occupational Therapy Association includes the ICF definition of participation in their practice framework [2] (see Box 1). The ICF is a classification system that "conceptualizes a person's level of functioning as a dynamic interaction between her or his health conditions, environment, and personal factors" [1]. Haglund et al. [3] found that the ICF classification aides occupational therapists in their practice; however, it alone does not encompass all that is needed for good practice. Therefore, it was found to be important to discover a tool consistent with the ICF that also is grounded in the theory of occupational therapy.

The ICF defines participation as "involvement in life situation" different than it defines activities which are "the execution of a task or action by an individual" [1] (p. 10). Despite the difference in definition, the ICF places both activities and participation together in one chapter and specifies four ways for ICF users to distinguish between the two. This ambiguity has resulted in an entire thread of literature as rehabilitation researchers seek to identify ways to approach measurement of participation. For if there is no agreement around the definition and scope, how can there be agreement on how to measure? This difficulty does not, however, make the task any less important.

#### **BOX 1.**

*"Achieving health, well-being, and participation in*

*life through engagement in occupation is the overarching*

*statement that describes the domain and process of occupational*

*therapy in its fullest sense."*

*"Participation—"involvement in a life situation" (WHO, 2001, p. 10). Participation naturally occurs when clients are actively involved in carrying out occupations or daily life activities they find purposeful and meaningful. More specific outcomes of occupational therapy intervention are multidimensional and support the end result of participation."*

*AOTA Occupational Therapy Framework*

*(March/April 2014, Volume 68 Supplement 1, p. S4)*

The Model of Human Occupation (MOHO) is the theoretical approach used most commonly commonly worldwide [4–6]. Developed by Kielhofner [7] and colleagues, Kielhofner's vision for MOHO is to support practice that is occupation focused, client centered, holistic, evidence based, and complementary to practice based on other occupational therapy models and interdisciplinary theories [8]. In this chapter, therefore we use the approach of differentiating between activities and participation by using the theory of MOHO to provide a framework that explains how participation in occupation is achieved.

sense of competency are tied inextricably to this role participation. Role participation is both persistent and changes over time, as people go through both planned and unplanned life transitions. Clinically, a person's role participation becomes the focus of the occupational therapist when disability-related limitations affect a person's capacity to participate in desired

Occupational therapists aim to assure that persons with disabilities have the motivation, opportunities, and capacity to overcome disability-related limitations and participate in social life. The International Classification of Health, Disability and Function (ICF) seeks to establish uniform definitions worldwide [1]. The American Occupational Therapy Association includes the ICF definition of participation in their practice framework [2] (see Box 1). The ICF is a classification system that "conceptualizes a person's level of functioning as a dynamic interaction between her or his health conditions, environment, and personal factors" [1]. Haglund et al. [3] found that the ICF classification aides occupational therapists in their practice; however, it alone does not encompass all that is needed for good practice. Therefore, it was found to be important to discover a tool consistent with the ICF that also is grounded in the theory of occupational

The ICF defines participation as "involvement in life situation" different than it defines activities which are "the execution of a task or action by an individual" [1] (p. 10). Despite the difference in definition, the ICF places both activities and participation together in one chapter and specifies four ways for ICF users to distinguish between the two. This ambiguity has resulted in an entire thread of literature as rehabilitation researchers seek to identify ways to approach measurement of participation. For if there is no agreement around the definition and scope, how can there be agreement on how to measure? This difficulty does not, however,

*"Participation—"involvement in a life situation" (WHO, 2001, p. 10). Participation naturally occurs when clients are actively involved in carrying out occupations or daily life activities they find purposeful and meaningful. More specific outcomes of occupational therapy intervention are multidimensional* 

*AOTA Occupational Therapy Framework*

*(March/April 2014, Volume 68 Supplement 1, p. S4)*

and meaningful roles.

108 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

therapy.

**BOX 1.**

make the task any less important.

*therapy in its fullest sense."*

*"Achieving health, well-being, and participation in*

*and support the end result of participation."*

*life through engagement in occupation is the overarching*

*statement that describes the domain and process of occupational*

**Figure 1.** Underlying concepts and their influence on Role Checklist revisions.

The Role Checklist, theoretically grounded in MOHO, was developed by Frances Oakley in 1981 to capture occupational performance by measuring role incumbency and value [8]. However, over time the concepts of MOHO have evolved. In 2002, Kielhofner introduced the dimensions of doing [7]. Scott responded to this new concept by revisiting the Role Checklist, and began the process of revising the Role Checklist (see **Figure 1**). The latest MOHO text, the 5th edition, places the Role Checklist Version 3: Participation and Satisfaction (RCv3) among measures of occupational participation [8]. This chapter describes the process of revision and establishment of the psychometric properties needed to prepare the RCv3 as a cross-culturally valid measure of participation.

#### **1.1. Role Checklist revisions: history and timelines**

The Role Checklist, developed in 1981, is a short, two-part assessment tool that captures a person's perceived incumbency and role value in relation to the following 10 roles: student, worker, volunteer, caregiver, home maintainer, friend, family member, religious participant, hobbyist/amateur, and participant in organizations. Each role is provided with a brief definition followed by examples. The definitions contained a criterion of at least weekly involvement as occupational therapists who employ MOHO are interested in how these roles do or do not structure the respondent's occupational participation. For each of these 10 roles, Part 1 of the assessments asks respondents to indicate whether they have previously held the role, are currently in the role, and/or expect to be in the role in the future. More specifically, Part 1 is assessing perceived incumbency, defined as the respondent's belief that he or she occupies a role [9]. Once Part 1 is completed, Part 2 asks respondents to indicate how much they value the role. To determine role value, the degree of importance the role has to the respondent, he or she must rank each of the 10 roles as "very valuable," "somewhat valuable," or "not at all valuable." The Role Checklist is available now in 20 languages [10], and available at http://www.cade.uic.edu/ moho.

#### *1.1.1. Role Checklist Version 2: quality of performance*

The Role Checklist, as it was created in 1981, was developed around current MOHO concepts of the time. However, as MOHO has articulated the dimensions of doing, revisions were needed to respond to these changes. In a first step, Patricia Scott, in coordination with Frances Oakley, responded to both clinical experience with the instrument and the established standards in the field of measurement of participation [11]. The result was the establishment of the Role Checklist Version 2: quality of performance (RCv2:QP). This revision retains the same 10 roles as the original Role Checklist and prompts respondents to rank their satisfaction with quality of performance on a scale from "very dissatisfied" to "very satisfied." In a 2014 study, Scott and colleagues found the RCv2:QP to have high levels of test-retest reliability and consistency between paper and electronic administration [12]. As described above, Scott added a Part 3 to the Role Checklist to enable respondents to rate their perception of the quality of their performance. This addition made the Role Checklist more sensitive to change and added a component to enable the "insider view," an important aspect of the person's self-assessment of adequacy or acceptability. Part 3 brought the Role Checklist closer to meeting the criteria for measures of participation [11].

#### *1.1.2. Role Checklist Version 3: performance and satisfaction*

The Role Checklist, theoretically grounded in MOHO, was developed by Frances Oakley in 1981 to capture occupational performance by measuring role incumbency and value [8]. However, over time the concepts of MOHO have evolved. In 2002, Kielhofner introduced the dimensions of doing [7]. Scott responded to this new concept by revisiting the Role Checklist, and began the process of revising the Role Checklist (see **Figure 1**). The latest MOHO text, the 5th edition, places the Role Checklist Version 3: Participation and Satisfaction (RCv3) among measures of occupational participation [8]. This chapter describes the process of revision and establishment of the psychometric properties needed to prepare the RCv3 as a

The Role Checklist, developed in 1981, is a short, two-part assessment tool that captures a person's perceived incumbency and role value in relation to the following 10 roles: student, worker, volunteer, caregiver, home maintainer, friend, family member, religious participant, hobbyist/amateur, and participant in organizations. Each role is provided with a brief definition followed by examples. The definitions contained a criterion of at least weekly involvement as occupational therapists who employ MOHO are interested in how these roles do or do not structure the respondent's occupational participation. For each of these 10 roles, Part 1 of the assessments asks respondents to indicate whether they have previously held the role, are currently in the role, and/or expect to be in the role in the future. More specifically, Part 1 is assessing perceived incumbency, defined as the respondent's belief that he or she occupies a role [9]. Once Part 1 is completed, Part 2 asks respondents to indicate how much they value the role. To determine role value, the degree of importance the role has to the respondent, he or she must rank each of the 10 roles as "very valuable," "somewhat valuable," or "not at all valuable." The Role Checklist is available now in 20 languages [10], and available at http://www.cade.uic.edu/

The Role Checklist, as it was created in 1981, was developed around current MOHO concepts of the time. However, as MOHO has articulated the dimensions of doing, revisions were needed to respond to these changes. In a first step, Patricia Scott, in coordination with Frances Oakley, responded to both clinical experience with the instrument and the established standards in the field of measurement of participation [11]. The result was the establishment of the Role Checklist Version 2: quality of performance (RCv2:QP). This revision retains the same 10 roles as the original Role Checklist and prompts respondents to rank their satisfaction with quality of performance on a scale from "very dissatisfied" to "very satisfied." In a 2014 study, Scott and colleagues found the RCv2:QP to have high levels of test-retest reliability and consistency between paper and electronic administration [12]. As described above, Scott added a Part 3 to the Role Checklist to enable respondents to rate their perception of the quality of their performance. This addition made the Role Checklist more sensitive to change and added a component to enable the "insider view," an important aspect of the person's self-assessment of adequacy or acceptability. Part 3 brought the Role Checklist closer to meeting the criteria for measures of participation [11].

cross-culturally valid measure of participation.

moho.

**1.1. Role Checklist revisions: history and timelines**

110 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

*1.1.1. Role Checklist Version 2: quality of performance*

While creating a scoring system, Scott recognized a need for a reflection of desired participation. Scoring had been elusive in the past, in great part due to the lack of accepted standards for patterns of role participation. With the client at the focal center, and role incumbency being an internalized concept, occupational therapists do not endorse the adoption of a universal standard for desired roles. The focus on individualizing contextual performance is based on current role satisfaction and the desirability of delaying engagement (or not) in desired future roles. This effort led to the reconceptualization of Part 3 and synthesis into a one-page document. This version is named Role Checklist Version 3: Satisfaction and Performance.

This one-page assessment tool is written as follows. Each role is first defined; the definitions have remained the same for the roles of student, worker, caregiver, and home maintainer. However, the time specifications for volunteer, friend, family member, hobbyist, and participant in organizations have changed from a weekly basis to "on a regular basis." Lastly, to identify as a religious participant, involvement is no longer required to be "at least once a week," and instead has no time frame. To complete the assessment, for each role, the respondent is asked to indicate if he or she is currently performing the role. If the respondent indicates "Yes" to currently performing the given role, he or she then is prompted to indicate his or her level of satisfaction with their role performance. If the respondent indicates "No" to currently performing the given role, he or she is then asked to indicate his or her interest in role participation in the future by selecting "I would like to do this NOW," "I would like to do this IN THE FUTURE," or "I am NOT INTERESTED in doing this."

This new, revised assessment tool is no longer concerned with past role incumbency or role value. Instead, the RCv3 elicits information that allows clinicians to provide a client-centered plan of care and monitor client progress, and researches a measure to collect outcome data on an individual or population level.

#### **1.2. Connection to international audiences**

In a 2014 publication, Scott [13] presented the case for the Role Checklist Version 2: Quality of Performance as valid measure consistent with the ICF definition of participation. Her work drew the attention of International colleagues who joined Scott and formed the International Role Alliance for the study of Participation (IRAP) in October 2013.

The International Role Alliance for the Study of Participation (IRAP) maintains the mission to promote participation in society for all persons with disabling conditions. Specifically, this group seeks to establish the revised Role Checklist as a cross-culturally valid method of measuring participation, actual participation, and desired future participation, contextualized by the value and satisfaction a person associates with that participation. IRAP core members are academic clinical scholars from universities in Switzerland (German), Sweden, Japan, USA, UK, and Norway. Each has completed translations and contributed data to establish the initial psychometric properties of the Role Checklist Version 2: Quality of Performance. Initial investigations of the utility of the tool and its clinical applicability took place in Sweden and in Norway.

Among one of the first agendas of this group was to establish valid cross-cultural guidelines for translation. These guidelines would, to quote Dr. Lena Haglund from Sweden, a founding IRAP member, "place a fence around the translation process to keep the MOHO concepts in." These guidelines have been tested for feasibility and implementation. Collaborators from Iceland and China have completed valid translations of the RCv3, and Spanish and Norwegian translations are in progress. Now the translation guidelines are shown to produce culturally equivalent versions, more than a dozen collaborators are on board to complete further translations.

IRAP members work through a worldwide network of occupational therapists who provide services to persons with disabilities across the globe. This network is enabled on two fronts: first, the MOHO Clearing House, which is the source for a dozen measurements, instruments in 20 languages and second, the World Federation of Occupational Therapy with 77 member organizations, which represent over 350,000 occupational therapists internationally.

#### **2. Concepts of concern: ICF and MOHO levels of doing**

In this section, it is useful to better understand the differences between activities and participation or, as understood in MOHO, occupational participation and occupational performance [3]. In Section 1, we offered the definitions from the ICF of activities and participation. They are worth repeating here:

*Participation: "involvement in life situation" Activities which is "the execution of a task or action by an individual"*

*(WHO* [1]*, p. 10)*

Occupational therapists are inherently attuned to and concerned with the things people do and how they do them. Doing is described in MOHO at three levels: occupational skill, occupational performance, and occupational participation. Kielhofner [7] refers to this hierarchy as the "dimensions of doing." Occupational skill can be simply described as purposeful actions needed to carry out a task. They are the motor skills, process skills, and communication and interaction skills that come together to make up occupational performance [14]. Occupational performance is the act of utilizing these skills to carry out a task. These acts of occupational performance comprise occupational participation; however, there is more to participation than performance alone [15]. Kielhofner [14] explains that participation is composed of occupations that are, "part of one's sociocultural context and that are desired and/or necessary to one's well-being." They are linked to a sense of belonging, value, and meaning [15]. This is the dimension of doing in which roles reside. These levels of doing can be best understood through examples. The ability to push, grasp, and categorize would be considered occupational skill. Occupational performance would include such activities as vacuuming, scrubbing a kitchen counter, or sorting laundry. Partaking in and identifying with the role of home maintainer would be considered as occupational participation.

Occupational role participation is more than partaking in an activity [15]. Kielhofner [7] explained that it "refers to engaging in work, play, or activities of daily living that are part of one's sociocultural context and that are desired and/or necessary to one's well-being" (p. 101). Dijkers [15] notes that there are many aspects of participation, including, but not limited to frequency of activities, value and meaning, responsibility, autonomy, reciprocity, location, and the company of others. Driving a car is an activity performed by many throughout the course of a day; however, it is not always perceived the same way. A teenage boy, whom may not value his education and finds the daily commute to school quite cumbersome, may view it as nothing more than a daily task. However, later that day he may take that same route during his work hours as a pizza delivery boy. He finds the task of driving to be a necessary aspect of his valued occupation of work. Even further, the addition of friends as passengers on the way to a Friday night football game can be considered engagement in social participation. The line between participation and common performance lies within the individual's perception. Bonsaksen and colleagues analyzed over 7000 role examples and associated them with these levels of doing.

#### **3. Reliability and validity psychometrics of RCv3**

Among one of the first agendas of this group was to establish valid cross-cultural guidelines for translation. These guidelines would, to quote Dr. Lena Haglund from Sweden, a founding IRAP member, "place a fence around the translation process to keep the MOHO concepts in." These guidelines have been tested for feasibility and implementation. Collaborators from Iceland and China have completed valid translations of the RCv3, and Spanish and Norwegian translations are in progress. Now the translation guidelines are shown to produce culturally equivalent ver-

IRAP members work through a worldwide network of occupational therapists who provide services to persons with disabilities across the globe. This network is enabled on two fronts: first, the MOHO Clearing House, which is the source for a dozen measurements, instruments in 20 languages and second, the World Federation of Occupational Therapy with 77 member

In this section, it is useful to better understand the differences between activities and participation or, as understood in MOHO, occupational participation and occupational performance [3]. In Section 1, we offered the definitions from the ICF of activities and participation. They are

Occupational therapists are inherently attuned to and concerned with the things people do and how they do them. Doing is described in MOHO at three levels: occupational skill, occupational performance, and occupational participation. Kielhofner [7] refers to this hierarchy as the "dimensions of doing." Occupational skill can be simply described as purposeful actions needed to carry out a task. They are the motor skills, process skills, and communication and interaction skills that come together to make up occupational performance [14]. Occupational performance is the act of utilizing these skills to carry out a task. These acts of occupational performance comprise occupational participation; however, there is more to participation than performance alone [15]. Kielhofner [14] explains that participation is composed of occupations that are, "part of one's sociocultural context and that are desired and/or necessary to one's well-being." They are linked to a sense of belonging, value, and meaning [15]. This is the dimension of doing in which roles reside. These levels of doing can be best understood through examples. The ability to push, grasp, and categorize would be considered occupational skill. Occupational performance would include such activities as vacuuming, scrubbing a kitchen counter, or sorting laundry. Partaking in and identifying with the role of home maintainer would be considered as occupational participation. Occupational role participation is more than partaking in an activity [15]. Kielhofner [7] explained that it "refers to engaging in work, play, or activities of daily living that are part of

*(WHO* [1]*, p. 10)*

sions, more than a dozen collaborators are on board to complete further translations.

organizations, which represent over 350,000 occupational therapists internationally.

**2. Concepts of concern: ICF and MOHO levels of doing**

112 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

*Activities which is "the execution of a task or action by an individual"*

worth repeating here:

*Participation: "involvement in life situation"*

Although several studies have supported the psychometric properties of the Role Checklist, it has not yet achieved the level of psychometric evidence to be included among other MOHO assessments. **Table 1** charts the history of studies of different versions of the Role Checklist. It is



**Table 1.** Psychometric properties of the various versions of the Role Checklist.

important to note that caution must be used in the assignment of psychometric properties found for one version to another. The only consistent feature across all three versions is the 10 roles. The Role Checklist, original and versions 2 and 3, have excellent validity and cross-cultural reproducibility; however, there is still a need for feasibility, utility, and reliability testing of the RCv3.

#### **3.1. Feasibility**

In 2014, Aslasken and colleagues [16] completed a pilot study to verify subject feasibility and to illustrate how an occupational therapist used the translated RCv2: QP to direct a clinical intervention. Aslaksen reported on the feedback from four Swedish therapists and one case report from Norway. The therapists each reported that a revised tool would be helpful if it were (1) provided on a single page layout, (2) had opportunity for comments, and (3) gathered information for each role one at a time [16]. The respondent who took the RCv2: QP reported frustration with the definitions provided for each role. Despite feeling as though he identified with select roles, he did not qualify as a participant in such roles according to the provided definitions [16]. In creating the RCv3, Scott took note of these recommendations and included changes addressing several of these concerns. The new RCv3 presents on a single page and prompts answers for each role one at a time. In addition, the time specifications used to define volunteer, friend, family member, hobbyist, participant in organizations, and religious participant have changed. As Aslasken's study did, this study aims to show subject feasibility, among other psychometric properties, through employing therapist and client thought on the updates when compared to the original Role Checklist, developed in 1981 by Fran Oakley.

#### **3.2. Utility**

Utility is being the degree to which the treatment outcome is positively influenced by an assessment, in this case, the RCv3. Hayes et al. [17] provide a functional approach to evaluating an assessment's quality. The authors justify that treatment utility is not a matter of cost-benefit ratio, but instead it is the "demonstration of a particular type of benefit" ([17], p. 964). Nelson-Gray [18] provided examples of typical treatment utility questions: "(a) Does treatment selection that is based on a particular assessment result in a more successful client outcome? And (b) Does supplying outcome data to therapists result in a more successful outcome?" These are the questions Aslasken et al. [16] provides only a partial answer to—these two questions remain largely unanswered for the RCv3.

#### **3.3. Test-retest reliability**

Establishing reliability is crucial to substantiate an assessment. Kerlinger [19] supported this notion when stating, "concern for reliability comes from the necessity for dependability in measurement" (p. 442). There are three definitions of reliability [19]. The first is characterized by the question of accuracy and stability. Does this instrument truly measure the outcome measure it sets out to find? The second looks to inquire the instrument's error of measurement. This refers to its precision; how far it is from "hitting the bullseye" [20]. The third focuses on the stability, dependability, and predictability through multiple administrations. The first definition, hitting the mark, is appropriate for the RCv3. The 10 roles listed in the Role Checklist, all versions, are mutually independent, that is, no scaling is possible. For example, being in the role of a home maintainer is not necessarily associated with being a friend, any more than being a volunteer is associated with being a religious participant. Therefore, it is not surprising that the test-retest reliability performed on the 1981 version is associated with that performed in 2014 on the RCv2:QP.

#### **3.4. Flexible administration**

important to note that caution must be used in the assignment of psychometric properties found for one version to another. The only consistent feature across all three versions is the 10 roles. The Role Checklist, original and versions 2 and 3, have excellent validity and cross-cultural reproducibility; however, there is still a need for feasibility, utility, and reliability testing of the RCv3.

**Properties verified Title Authors Year Comments**

Scott, P.J. 2014 Same roles

Bonsaksen, T., Meidert, U., Schuman, D., Kvarsnes, H., Haglund, L., Prior, S., Forsyth, K., Yamada, T. & Scott, P.J.

Scott, PJ, Cacich D., Fulk, M., Michel, K., & Whiffen,

Meidert, U., Bonsaksen,

T., & Scott, P.

Van Antwerp, L., Haglund, L., Fenger, K., &

Scott, P.

K

are used in all versions

2015 Role examples reflect mixed classification into occupational performance and occupational participation

2016 Both

n.d. 97% of role examples classified as consistent with ICF construct of participation

2016 Translation

Scott, P., & Latham, K. n.d. Discriminates

guidelines are feasible

between persons identifying disabilityrelated limitations and those without.

assessments measure the construct of participation

outcomes following life-saving medical interventions: The Role Checklist Version 2: Quality of

Does the Role Checklist Measure Occupational Participation?

Validity of the Role Checklist version 2 with the OCAIRS in Post Liver transplant patients

According to the ICF With the Modified Role Checklist

revised Role Checklist

**Table 1.** Psychometric properties of the various versions of the Role Checklist.

The Role Checklist Version 3.

*Construct validity with ICF* Measuring participation

*Concurrent validity* Establishing Concurrent

*Content validity* Measuring Participation

**Role Checklist Version 3: Performance and Satisfaction** *Cross-cultural validity* Translation Guidelines for the

*Discriminate validity* Measurement of Participation:

*Construct validity with MOHO levels of doing*

Performance

114 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

In 2014, Aslasken and colleagues [16] completed a pilot study to verify subject feasibility and to illustrate how an occupational therapist used the translated RCv2: QP to direct a clinical intervention. Aslaksen reported on the feedback from four Swedish therapists and one case

**3.1. Feasibility**

Previous studies have found that assessments administered electronically are consistent with paper and pencil administrations [21]. Using electronic means to administer the assessment allows for flexibility versus being limited to paper and pencil format. Because technology is advancing and becoming more prevalent in our society, clients benefit from having the option of taking an assessment in an electronic format. The RCv3 can be administered as a self-report, completed on a variety of electronic devices such as a smartphone, a tablet, or a laptop, or as an interview with the answers being submitted by the therapist. Studies have shown that clients often feel more at ease when taking surveys online versus on paper due to feeling less concerned with societal norms and how others might perceive them especially when it comes to personal and sensitive topics such as role incumbency and satisfaction [21, 22]. Additionally, using electronic means to gather data eliminates human error when transferring data into a database for analysis and is time and cost-effective [22, 23].

Although using electronic means to implement an assessment has many benefits, there are some shortcomings as well. Based on a study conducted by Gwaltney et al. [21], there are two reasons why administering an assessment electronically may not be equivalent to paper and pencil administration. First, the assessment tool presents itself different on paper versus electronically. Aspects such as letter size, spacing, or how many items per screen can vary between the two and ultimately alter the way a client would respond. Second, some clients may not feel comfortable using a computer or other electronic devise such as an iPad or a smartphone. This is especially true for the older population in which paper and pencil are most familiar. For these reasons, it is important to have an administrator around to address confusion or questions the client might have, as well as aid clients who may have a cognitive impairment, low vision, physical challenges, or lack of experience using technology.

#### **3.5. Summary**

As seen in **Table 1**, the RCv3 has established validity and cross-cultural standards; however, there is currently an obvious need for feasibility, utility, and replication of reliability. Establishing test-retest reliability for the RCV3 will improve the psychometrics that assessment tools needed to be considered a valid standardized instrument for occupational therapists to confidently use in treatment planning, goal progression, and outcome measurement. Verifying the RCv3 as a psychometric tool with feasibility and treatment utility through therapist perceptions, as well as replicating reliability will validate revisions to the assessment tool.

#### **4. Use as a population-based measure**

Thus far, we have addressed the use of the RCv3 as a client-centered measure of participation theoretically grounded in MOHO. It also has implications for a population-based population measure of interest to policy makers, as well as health and disability scholars.

In the 2011 World Report on Disability, the World Health Organization claims that improvement within a person's social participation may be made when the health-care professional addresses barriers, which hinder their everyday activities (WHO [24], p. 4). These barriers must be identified through reliable measures, which measure participation. The CRPD, Convention on the Rights of Person's with Disabilities, specifies that there is a need and an obligation for development of assessments, which promote participation (WHO [24], p. 11). Recommendation 8 describes the need to develop methodologies for data collection on persons with disabilities, which are tested cross-culturally and applied consistently.

#### **5. Chapter summary**

allows for flexibility versus being limited to paper and pencil format. Because technology is advancing and becoming more prevalent in our society, clients benefit from having the option of taking an assessment in an electronic format. The RCv3 can be administered as a self-report, completed on a variety of electronic devices such as a smartphone, a tablet, or a laptop, or as an interview with the answers being submitted by the therapist. Studies have shown that clients often feel more at ease when taking surveys online versus on paper due to feeling less concerned with societal norms and how others might perceive them especially when it comes to personal and sensitive topics such as role incumbency and satisfaction [21, 22]. Additionally, using electronic means to gather data eliminates human error when transferring data into a

Although using electronic means to implement an assessment has many benefits, there are some shortcomings as well. Based on a study conducted by Gwaltney et al. [21], there are two reasons why administering an assessment electronically may not be equivalent to paper and pencil administration. First, the assessment tool presents itself different on paper versus electronically. Aspects such as letter size, spacing, or how many items per screen can vary between the two and ultimately alter the way a client would respond. Second, some clients may not feel comfortable using a computer or other electronic devise such as an iPad or a smartphone. This is especially true for the older population in which paper and pencil are most familiar. For these reasons, it is important to have an administrator around to address confusion or questions the client might have, as well as aid clients who may have a cognitive

impairment, low vision, physical challenges, or lack of experience using technology.

replicating reliability will validate revisions to the assessment tool.

**4. Use as a population-based measure**

As seen in **Table 1**, the RCv3 has established validity and cross-cultural standards; however, there is currently an obvious need for feasibility, utility, and replication of reliability. Establishing test-retest reliability for the RCV3 will improve the psychometrics that assessment tools needed to be considered a valid standardized instrument for occupational therapists to confidently use in treatment planning, goal progression, and outcome measurement. Verifying the RCv3 as a psychometric tool with feasibility and treatment utility through therapist perceptions, as well as

Thus far, we have addressed the use of the RCv3 as a client-centered measure of participation theoretically grounded in MOHO. It also has implications for a population-based population

In the 2011 World Report on Disability, the World Health Organization claims that improvement within a person's social participation may be made when the health-care professional addresses barriers, which hinder their everyday activities (WHO [24], p. 4). These barriers must be identified through reliable measures, which measure participation. The CRPD, Convention on the Rights of Person's with Disabilities, specifies that there is a need and an

measure of interest to policy makers, as well as health and disability scholars.

database for analysis and is time and cost-effective [22, 23].

116 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**3.5. Summary**

There are currently no general appropriate assessments, which may be reliably scored among health-care professionals on a multidisciplinary team, are cross-culturally consistent, and are both cost-effective and efficient. We have presented the Role Checklist Version 3: Quality and Performance as a way to fill this void. In this chapter, we have defined participation as defined by international standards, the ICF, and theoretically according to the most widely used model in occupational therapy, MOHO. We have substantiated conceptual consistency with the ICF participation domains. In addition, cross-cultural translational guidelines have been developed and internationally established as both feasible and valid [25]. Therefore, the revised Role Checklist that meets criteria for a balanced measure of participation [26] is conceptually consistent with the ICF [13], has cross-culturally valid translation guidelines [25], construct validity as a MOHO-based measure of participation [27] and concurrent validity with an established measure of participation [12].

#### **Author details**

Patricia J. Scott\*, Kelsey McKinney, Jeff Perron, Emily Ruff and Jessica Smiley

\*Address all correspondence to: scottp@iu.edu

Indiana University, Indianapolis, IN, USA

#### **References**


[21] Gwaltney CJ, Shields AL, Shiffman S. Equivalence of electronic and paper-and-pencil administration of patient-reported outcome measures: A meta-analytic review. Value in Health. 2008;**11**(2):322-333. DOI: http://dx.doi.org/10.1111/j.1524-4733.2007.00231.x

[6] Lee SW, Taylor R, Kielhofner G. Choice, knowledge, and utilization of a practice theory: A national study of occupational therapists who use the Model of Human Occupation.

[7] Kielhofner G. Model of Human Occupation: Theory and Application. 3rd ed. Baltimore:

[8] Taylor R, editor. Kielhofner's Model of Human Occupation: Theory and Application. 5th

[9] Oakley F, Kielhofner G, Barris R, Reichler R. The Role Checklist: Development and empirical assessment of reliability. Occupational Therapy Journal of Research.

[10] Hemphill-Pearson B, editor. Assessments in Occupational Therapy Mental Health: An

[11] Brown M, Dijkers MPJM, Gordon WA, Ashman T, Charatz H, Cheng Z. Participation objective, participation subjective: A measure of participation combining outsider and insider perspectives. The Journal of Head Trauma Rehabilitation. 2004;**19**(6):459-481 [12] Scott PJ, McFadden R, Yates K, Baker S, McSoley S. The Role Checklist V2: QP: Establishment of reliability and validation of electronic administration. British Journal

[13] Scott PJ. Measuring participation outcomes following life-saving medical interventions: The Role Checklist Version 2: Quality of performance. Disability and Rehabilitation.

[14] Kielhofner G. Model of Human Occupation: Theory and Application. 4th ed. Baltimore:

[15] Dijkers MP. Issues in the conceptualization and measurement of participation: An overview. Archives of Physical Medicine and Rehabilitation. 2010;**91**(Suppl 9):S5–S16. DOI:

[16] Aslaksen M, Scott P, Haglund L, Ellingham B, Bonsaksen T. The Role Checklist Version 2: Quality of performance in the occupational therapy process in a mental health setting.

[17] Hayes SC, Nelson RO, Jarrett RB. The treatment utility of assessment: A functional approach to evaluating assessment quality. American Psychologist. 1987;**42**(11):963 [18] Nelson-Gray RO. Treatment utility of psychological assessment. Psychological

[19] Kerlinger FN. Foundations of Behavioral Research (New York: Holt, Rinehart, and Winston, 1964). Health Behavior and Health Education: Theory, Research and Practice.

[20] Riegelman RK. Studying a Study and Testing a Test: How to Read the Medical Evidence.

Occupational Therapy in Health Care. 2009;**23**(1):60-71

118 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

ed. Philadelphia: Wolters Kluwer Health. New Jersey; 2017

Integrative Approach. 2nd ed. Slack INC; 2008

of Occupational Therapy. 2014;**77**(2):96-102

Lippincott Williams & Wilkins; 2008

Lippincott Williams & Wilkins; 2002

1986;**6**(3):158-170

2014;**36**(13):1108-1112

10.1016/j.apmr.2009.10.036

Ergoterapeuten. 2014;**4**:38-45

Assessment. 2003;**15**(4):521

4th ed. San Francisco: Jossey Bass; 2008. pp. 26-27

Baltimore: Lippincott Williams & Wilkins; 2005


#### **Chapter 7**

### **Arthritis/Rheumatoid Arthritis**

Zeynep Bahadır Ağce, Esma Özkan and Barkın Köse

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68477

#### **Abstract**

Rheumatoid arthritis is a progressive, chronic, and degenerative disease that adversely affects the quality of life of individuals. Depending on the individual's symptoms of rheumatoid arthritis, basic and instrumental daily life activities are restricted, and par‐ ticipation of life is adversely affected. Occupational therapy interventions for rheumatoid arthritis rehabilitation include self‐management programs (e.g., arthritis self‐manage‐ ment program, bone up on arthritis, self‐management arthritis treatment physical activ‐ ity), splinting techniques for rheumatoid arthritis, and vocational rehabilitation. In this chapter, updated information about these approaches is brought together and presented to the reader.

**Keywords:** coping with rheumatoid arthritis, health education, joint protection, energy conservation, occupational therapy, rheumatoid arthritis

#### **1. Introduction**

Arthritis is a very common health problem which is cause activity of daily living (ADL)– related and instrumental activity of daily living (IADL)–related functional disability, restriction of work and social participation, and fulfilling their life roles [1–6]. Arthritis is characterized by inflammation, autoimmune cell activation, and tissue destruction in the joints [7–9]. The patients typically complain about joint pain, stiffness, generalized fatigue, and reduced quality of life [2, 9–12]. Symptoms are seen in exacerbations and remissions [9]. Arthritis has many different types, such as rheumatoid arthritis (RA), psoriatic arthritis, sys‐ temic lupus erythematosus, ankylosing spondylitis, reactive arthritis, and juvenile idiopathic arthritis [8].

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This chapter focuses on the rheumatoid arthritis and influences person's life. Rheumatoid arthri‐ tis (RA) prevalence ranges from 0.3 to 1% of the adult population, and female‐to‐male preva‐ lence ratio was 4:1 [10, 13, 14]. It is related to low‐ and middle‐income countries [10, 15, 16].

Rheumatoid arthritis affects people's life balance and their ability to perform work, leisure, self‐care, and rest and sleep decreased [17–19]. In addition, they lose values of activity for their life so feel anxious and depressed and influence their health related quality of life [20–22].

Occupational therapist works with not only pain or symptoms management in rheumatoid arthritis but also the prevention of functional limitations and adaptation to lifestyle changes improve emotional state and social participation to maintain independence in daily living activities [11, 19, 23]. Occupational therapy (OT) interventions especially focus on improving occupational performance which is negatively affected by rheumatoid arthritis. For this rea‐ son, occupational therapists use some approaches for improving occupational performance such as using behavioral change approach, energy conservation approach, relax renovation and pain control, fatigue management, maintain ındependence, adaptive device, and home adaptations in rheumatoid arthritis [9, 24].

#### **2. Prevalence and incidence**

Arthritis includes approximately over 150 diseases and syndromes, and arthritis is the com‐ mon problem and reason of substantial pain, limitation of activity, work, and social participa‐ tion [2, 25, 26]. Rheumatoid arthritis is the most common variety among arthritis types [27]. Rheumatoid arthritis is typically diagnosed in adults between the ages 30 and 50, though it can develop at any age [28]. It is related to low‐ and middle‐income countries, and one study showed high education level is influenced by positive feel pain and functional capacity [15, 25, 29]. At least 50% of the patients who live in developed countries have lost their ability to work in 10 years [25]. Family history is an important risk to occurrence of RA, the risk rate of twins increased approximately three to five [27]. The incidence of rheumatoid arthritis is thought to be influenced by geographical conditions, the prevalence of rheumatoid arthritis according to studies conducted in various nations is: in Turkey 0.57%, in Italy 0.48%, in France 0.29%,in Lithuania 0.50%, in Serbia 0.35%, in Argentina 0.329%, in Sweden 0.41%, in the USA 0.5–1.0% of general population [14, 30–33]. According to the 2010 classification criteria, coun‐ tries' incidence rates are different from each other, for instance, the rate in Catalonia 0.20/1000 person/years, in Argentina 18.5/100,000 person/years, in Sweden 41/100,000 person/years, in Italy 68/100,000 person/years, in the UK 79/10,000 person/years, and in the USA 41/100,000 person/years [14, 30–32, 34].

#### **3. Pathology**

Rheumatoid arthritis is a chronic progressive disease that affects joints and systems [35]. Due to the presence of autoantibodies [seropositivity] in rheumatoid arthritis, which is an autoimmune disease, many symptoms have occurred, such as joints and bone destruction and mortality [27, 36, 37]. Although the pathophysiology of rheumatoid arthritis is not clearly explained, it is known that genetic and environmental factors affect the development of the illness [27, 35, 37]. Environmental effects such as recurrent exposure to exogenous, endog‐ enous, commensal viral, bacterial, silica, alcohol, or smoking are factors that support the development of rheumatoid arthritis [27, 35, 38]. T cells, B cells, and pro‐inflammatory cyto‐ kines have a key role in the development of the disease [35, 39]. The presence of HLA‐DRB1, particularly HLA‐DRB1, is associated with disease progression by affecting peptides [27]. Genetic factors affecting the development of rheumatoid arthritis have been associated with anti‐citrullinated protein antibody (ACPA) positive [40]. When ACPA is positive, the risk of developing rheumatoid arthritis is increased [37]. The presence of ACPA was detected 10 years before the diagnosis of rheumatoid arthritis, and it indicated that there is an increase in ACPA, such as serum cytokine concentrations, especially before the onset of joint involve‐ ment [27]. In a study conducted on twins, it was reported that the stochastic factors, lifestyle and environmental effects, may be more effective than genetic factors in ACPA positivity. It is stated that there is a significant relationship between ACPA positivity and smoking in the study of smokers who have the DRB1 allele gene [41]. When rheumatoid arthritis is treated effectively, there is a decrease in RF and ACPA [27].

#### **4. Diagnosis and special tests**

This chapter focuses on the rheumatoid arthritis and influences person's life. Rheumatoid arthri‐ tis (RA) prevalence ranges from 0.3 to 1% of the adult population, and female‐to‐male preva‐ lence ratio was 4:1 [10, 13, 14]. It is related to low‐ and middle‐income countries [10, 15, 16].

Rheumatoid arthritis affects people's life balance and their ability to perform work, leisure, self‐care, and rest and sleep decreased [17–19]. In addition, they lose values of activity for their life so feel anxious and depressed and influence their health related quality of life [20–22].

Occupational therapist works with not only pain or symptoms management in rheumatoid arthritis but also the prevention of functional limitations and adaptation to lifestyle changes improve emotional state and social participation to maintain independence in daily living activities [11, 19, 23]. Occupational therapy (OT) interventions especially focus on improving occupational performance which is negatively affected by rheumatoid arthritis. For this rea‐ son, occupational therapists use some approaches for improving occupational performance such as using behavioral change approach, energy conservation approach, relax renovation and pain control, fatigue management, maintain ındependence, adaptive device, and home

Arthritis includes approximately over 150 diseases and syndromes, and arthritis is the com‐ mon problem and reason of substantial pain, limitation of activity, work, and social participa‐ tion [2, 25, 26]. Rheumatoid arthritis is the most common variety among arthritis types [27]. Rheumatoid arthritis is typically diagnosed in adults between the ages 30 and 50, though it can develop at any age [28]. It is related to low‐ and middle‐income countries, and one study showed high education level is influenced by positive feel pain and functional capacity [15, 25, 29]. At least 50% of the patients who live in developed countries have lost their ability to work in 10 years [25]. Family history is an important risk to occurrence of RA, the risk rate of twins increased approximately three to five [27]. The incidence of rheumatoid arthritis is thought to be influenced by geographical conditions, the prevalence of rheumatoid arthritis according to studies conducted in various nations is: in Turkey 0.57%, in Italy 0.48%, in France 0.29%,in Lithuania 0.50%, in Serbia 0.35%, in Argentina 0.329%, in Sweden 0.41%, in the USA 0.5–1.0% of general population [14, 30–33]. According to the 2010 classification criteria, coun‐ tries' incidence rates are different from each other, for instance, the rate in Catalonia 0.20/1000 person/years, in Argentina 18.5/100,000 person/years, in Sweden 41/100,000 person/years, in Italy 68/100,000 person/years, in the UK 79/10,000 person/years, and in the USA 41/100,000

Rheumatoid arthritis is a chronic progressive disease that affects joints and systems [35]. Due to the presence of autoantibodies [seropositivity] in rheumatoid arthritis, which is an autoimmune disease, many symptoms have occurred, such as joints and bone destruction

adaptations in rheumatoid arthritis [9, 24].

122 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**2. Prevalence and incidence**

person/years [14, 30–32, 34].

**3. Pathology**

Diagnostic tests play an important role in the diagnosis of RA, but diagnosis is based on clini‐ cal findings [28]. For the diagnosis of rheumatoid arthritis, especially autoantibodies, such as RF and anti‐citrullinated protein antibody (ACPA) (tested as anti‐cyclic citrullinated peptide (anti‐CCP)), have been used for many years [42]. RF is frequently used in the diagnosis and follow‐up of rheumatoid arthritis but is not a distinctive diagnostic parameter because it is also detected in other rheumatic diseases [28, 43]. Rheumatoid arthritis causes destruction in joints and causes disability, so early diagnosis is very important [43, 44]. Anti‐cyclic citrulli‐ nated peptide/protein (anti‐CCP) is especially used for early diagnosis [44]. The most widely used and most reliable test, anti‐ccp2, was accepted as the gold standard in ACPAs in 2010 [42]. But ACPA is not positive for every rheumatoid arthritis patient [43]. Individuals with ACPA positive are 90% estimated to be diagnosed with rheumatoid arthritis within 3 years, while 30% of those with ACPA positive [45]. As a result of a joint study by American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) for rheuma‐ toid arthritis diagnostic criteria, ACPA has been included in the current 2010 rheumatoid arthritis diagnostic criteria (**Table 1**) [42].

#### **5. Living with rheumatoid arthritis**

In rheumatoid arthritis, loss of function is seen in daily life due to symptoms such as degener‐ ation, pain, swelling in joints, morning impairment, and fatigue based on joint inflammation [46]. In addition, especially effects on hand joints of rheumatoid arthritis also influence inde‐ pendence by causing problems in the individual's daily life activities [47, 48]. Gradually,


**Table 1.** The 2010 American College of Rheumatology/European League against rheumatism classification criteria for rheumatoid arthritis [42].

changes in the health of individuals lead to limitations in their ability to participate in every‐ day life, such as individual roles, work, school, self‐care, leisure time activities, home work, and family functioning, so the quality of life of an individual is reduced [6, 32, 48–51]. The daily life of women on rheumatoid arthritis is more affected than men because of the com‐ plex roles such as motherhood, spouse, and nursing [52, 53]. It is a very difficult process to live with a chronic disease like rheumatoid arthritis [54]. After the diagnosis, the individual learns to live with rheumatoid arthritis in three stages, namely "becoming aware," "learning to live with," and finally "mastery." The first stage involves the initiation of medical treatment for the twinges problem. In the second stage, as physical life and emotional manifestations emerge, there is living with the experience of coping with multiple physical and emotional symptoms in daily life. Finally, it increases the quality of life of individuals by learning how to set goals and expectations, how to use energy, how to maintain the relationship between family and society, and how to manage the medical routine with doctors [53]. İndividuals' disease experience is different from others, and individual responses are influenced by the individual's spiritual characteristics, his/her view of the disease, biological, social, and envi‐ ronmental factors [49, 53, 55]. The person not only that burden from clinical symptoms, but also the physical weakness effected her/his life, so it is important that the individual main‐ tains his/her independence in social and recreational areas [46, 53]. For this reason, although the individual has effective treatment, the level of pain, fatigue, and functionality may be low [55]. Individuals may lose physical well‐being, independence, privacy, autonomy, control of cynicism, restriction of social roles, loss of opportunity to plan for the future, and decrease in family and friends relations [54]. Maintaining independence in the lives of individuals with rheumatoid arthritis is important for quality of life and well‐being [48].

#### **6. Occupational therapy evaluation**

In progress of time, rheumatoid arthritis leads to a decline in well‐being and quality of life, depending on the individual's functional capacity and decreased mobility, decreased productiv‐ ity, and difficulties in daily life performance [6, 51, 56, 57]. For this reason, it is very important to implement the evaluation with an interdisciplinary approach [58]. As stated in the "International Classification of Functioning, Disability And Health" (ICF), the body structure and functions of the individual, as well as the level of activity and life participation and the personal and envi‐ ronmental factors affecting it, must be approached with a holistic perspective [59]. Rheumatoid arthritis focuses on evaluating the individual's disease management, compliance, self‐efficacy, comprehension, and range of motion; due to pain and fatigue effect, the individual's functional ability to be restricted and participation in social life is affected [11, 59, 60]. Symptoms of individ‐ uals with rheumatoid arthritis may be fluctuating, so how the individual occupational perfor‐ mance affected by symptoms such as morning stiffness, pain and fatigue, and how to deal with it and the use of assistive devices should be evaluated [26]. In addition, how rheumatoid arthritis affects the individual's life and treatment goals and expectations should also be assessed [60].

#### **6.1. Client history**

changes in the health of individuals lead to limitations in their ability to participate in every‐ day life, such as individual roles, work, school, self‐care, leisure time activities, home work, and family functioning, so the quality of life of an individual is reduced [6, 32, 48–51]. The daily life of women on rheumatoid arthritis is more affected than men because of the com‐ plex roles such as motherhood, spouse, and nursing [52, 53]. It is a very difficult process to live with a chronic disease like rheumatoid arthritis [54]. After the diagnosis, the individual learns to live with rheumatoid arthritis in three stages, namely "becoming aware," "learning to live with," and finally "mastery." The first stage involves the initiation of medical treatment

**Table 1.** The 2010 American College of Rheumatology/European League against rheumatism classification criteria for

**Score**

Target population (who should be tested?): patients who

a–d;

RA)

**A. Joint involvement**

**classification)**

**D. Duration of symptoms**

rheumatoid arthritis [42].

1. Have at least 1 joint with definite clinical synovitis (swelling) 2. With the synovitis not better explained by another diseas

124 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Classification criteria for RA (score‐based algorithm: add score of categories

A score of ≥6/10 is needed for classification of a patient as having definite

**B. Serology (at least one test result is needed for classification)**

**C. Acute‐phase reactants (at least one test result is needed for** 

1 large joint 0 2–10 large joints 1 1–3 small joints (with or without involvement of large joints) 2 4–10 small joints (with or without involvement of large joints) 3 >10 joints (at least one small joint) 5

Negative RF and negative ACPA 0 Low‐positive RF or low‐positive ACPA 2 High‐positive RF or high‐positive ACPA 3

Normal CRP and normal ESR 0 Abnormal CRP or abnormal ESR 1

<6 weeks 0 ≥6 weeks 1

> In the past medical history of the individual, age, gender, date of diagnosis, medication and adherence, current clinical symptoms, second complications, deformities due to rheumatoid arthritis, and previous treatments should be questioned. In the assessment, personal factors such as the individual's point of view of the illness, his/her values, his/her knowledge of the illness, self‐efficacy, problem‐solving skills, spiritual activities, his/her feelings should be taken into consideration. In addition, the individual's personal, environmental, and social experiences, current activity level, activities restricted by rheumatoid arthritis, difficulties in work, leisure activities, family, and friends relations should be questioned [6, 9, 17, 46, 49, 55].

#### **6.2. Occupational profile**

Occupation is defined as everything that a person does in his life, such as physical, men‐ tal, social, and rest occupations, and occupations for productivity, leisure, and self‐care [61]. Everybody's priority and meaningful occupations are different from others. For this reason, it is important to determine the occupation and occupational profile of the individuals who are affected by the clinical symptoms of rheumatoid arthritis [9, 53]. The individual's abil‐ ity to cope with stress, where he lived or worked, family and socio cultural expectations, community resources, and transport opportunities affect his occupational performance [9, 62]. In‐depth interviews with open‐ended questions provide information on individual roles, meaningful activities, occupational activity level, priorities, occupational profile, activ‐ ity‐rest balance, individual's stress perception, social stress, relationship with health profes‐ sionals, comorbidity, and physical fitness [6, 55]. Another effective method for determining the occupational profile of an individual is the typical day assessment. Typical day assess‐ ments can provide important information about how a person lives a day, such as habits and routines, sleeping, diet, exercise habits, and activity rest periods [6, 55].

#### **6.3. Occupational performance**

Occupational therapists work to improve the occupational performance of individuals who are affected by the person, environment and occupations from themselves [59]. Occupational performance can be evaluated by interviewing and observing the Canadian Occupational Performance Measure (COPM) [6, 63]. COPM is revealed by the occupational performance and satisfaction of the individual in self‐care, leisure, and productivity activities [26, 64–66]. Individual self‐efficacy, stress, sleep posture, use of assistive technology, and exercise habits should be considered because they may affect symptoms of rheumatoid arthritis [26]. In addi‐ tion, the person‐centered approach should be used to understand the individual experiences in daily life due to rheumatoid arthritis [17, 63]. Activity requirements such as work‐house ergonomic conditions, tools and equipment should be assessed while assessing the factors that limit the individual's activities [6, 26]. It should not be forgotten that during the evalua‐ tion of the activity, the symptoms that the individual struggles with may change day by day or day to day [23]. For instance, which activity increased the fatigue or pain, or when it is more intense, the way the individual follows in the fight with it should be evaluated [67–70].

#### **6.4. Evaluation of body structure**

Rheumatoid arthritis is characterized by swelling in the joints, tenderness on palpation, morn‐ ing stiffness, decreased range of motion, and weakening in the muscles due to them [71–73]. Therefore, the presence of posture, atrophy, swelling, scar tissue, skin changes, and deformity should be observed with the inspection [74, 75]. The increased inflammation symptom can be detected such as tenderness and swelling of the joint with palpation in rheumatoid arthritis [9, 76]. Goniometer is used to determine whether there are any limitations by evaluating passive and active ranges of motion [75]. Hand joints are particularly affected by rheumatoid arthritis, so manual muscle testing can be used to assess muscle strength; in addition, power grip, pinch grip, and tripod grip strength can be evaluated for both hands using Jamar Dynamometer [77]. The use of manual muscle testing is indicated in the general muscle strength instead of the iso‐ kinetic devices because they may provoke inflammation [9]. Surrounding measurement or water immersion methods can be used to assess swelling around the joint [77].

#### **7. Patient education**

**6.2. Occupational profile**

126 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**6.3. Occupational performance**

**6.4. Evaluation of body structure**

Occupation is defined as everything that a person does in his life, such as physical, men‐ tal, social, and rest occupations, and occupations for productivity, leisure, and self‐care [61]. Everybody's priority and meaningful occupations are different from others. For this reason, it is important to determine the occupation and occupational profile of the individuals who are affected by the clinical symptoms of rheumatoid arthritis [9, 53]. The individual's abil‐ ity to cope with stress, where he lived or worked, family and socio cultural expectations, community resources, and transport opportunities affect his occupational performance [9, 62]. In‐depth interviews with open‐ended questions provide information on individual roles, meaningful activities, occupational activity level, priorities, occupational profile, activ‐ ity‐rest balance, individual's stress perception, social stress, relationship with health profes‐ sionals, comorbidity, and physical fitness [6, 55]. Another effective method for determining the occupational profile of an individual is the typical day assessment. Typical day assess‐ ments can provide important information about how a person lives a day, such as habits and

Occupational therapists work to improve the occupational performance of individuals who are affected by the person, environment and occupations from themselves [59]. Occupational performance can be evaluated by interviewing and observing the Canadian Occupational Performance Measure (COPM) [6, 63]. COPM is revealed by the occupational performance and satisfaction of the individual in self‐care, leisure, and productivity activities [26, 64–66]. Individual self‐efficacy, stress, sleep posture, use of assistive technology, and exercise habits should be considered because they may affect symptoms of rheumatoid arthritis [26]. In addi‐ tion, the person‐centered approach should be used to understand the individual experiences in daily life due to rheumatoid arthritis [17, 63]. Activity requirements such as work‐house ergonomic conditions, tools and equipment should be assessed while assessing the factors that limit the individual's activities [6, 26]. It should not be forgotten that during the evalua‐ tion of the activity, the symptoms that the individual struggles with may change day by day or day to day [23]. For instance, which activity increased the fatigue or pain, or when it is more intense, the way the individual follows in the fight with it should be evaluated [67–70].

Rheumatoid arthritis is characterized by swelling in the joints, tenderness on palpation, morn‐ ing stiffness, decreased range of motion, and weakening in the muscles due to them [71–73]. Therefore, the presence of posture, atrophy, swelling, scar tissue, skin changes, and deformity should be observed with the inspection [74, 75]. The increased inflammation symptom can be detected such as tenderness and swelling of the joint with palpation in rheumatoid arthritis [9, 76]. Goniometer is used to determine whether there are any limitations by evaluating passive and active ranges of motion [75]. Hand joints are particularly affected by rheumatoid arthritis, so manual muscle testing can be used to assess muscle strength; in addition, power grip, pinch grip, and tripod grip strength can be evaluated for both hands using Jamar Dynamometer [77].

routines, sleeping, diet, exercise habits, and activity rest periods [6, 55].

Development of early and progressive treatment for rheumatoid arthritis (RA) made inter‐ ventions to occupational therapy, physiotherapy, and patient education be done earlier [78].

The multidisciplinary teamwork consisting of rheumatologists, occupational therapists, phys‐ iotherapists, surgeons, and other contributing professionals is rather important for obtain‐ ing positive results in RA. Occupational therapy is defined as a treatment method that aims to treat and compensate the limited functions of the patients. Occupational therapy helps patients manage their daily life activities and improves their self‐care skills [79].

In rheumatoid arthritis, personalized treatment programs consisting of arthritis education (individual or group), ADL education, joint protection, fatigue management and exercise (especially for the hands and arms), splinting (for the wrist/hand, foot, and neck), assisting devices, work and free time counsel, sexual advice, pain relaxation, and stress management and self‐management education as required are developed by occupational therapists [3].

OT involves both therapeutic and educational interventions and aims to increase the perfor‐ mance of daily life duties, to facilitate successful organization of the lifestyle, and to prevent function loss. Therapists also aim to improve psychological organization of living with arthri‐ tis by helping individuals have the sense of controlling the symptoms more by means of using self‐management methods and developing self‐efficiencies of the individuals [79–81].

For individuals with RA, a preventive approach is adopted in order to maintain optimum par‐ ticipation to normal activities, to minimize dysfunction, to protect and help improve health by means of providing knowledge about the disease and facilitating positive behavior regarding effective learning strategies in improving self‐management skills [81].

Patient education can be defined as planned, organized learning experiences that are devel‐ oped in order to enable and support individuals to organize their health and well‐being and to manage living with their condition. Education of the patient is proposed as an inseparable part of the management in RA because the individual gets prepared for self‐management activities with patient education [82, 83].

A comprehensive review of studies on patient education in patients with arthritis showed a positive change in more than one factor in 77–87% of studies [84]. Another comprehensive review examined the effectiveness of patient education interventions on health status (dis‐ ease activity, patient global assessment, joint counts, pain, functional disability, and psycho‐ logical well‐being) in patients with RA. At the end of the study was found a small beneficial effect of patient education at first follow‐up for psychological status, joint counts functional disability, depression, and patient global assessment [85]. A meta‐analysis of psychoeduca‐ tional interventions in arthritis showed that the intervention groups experienced 22% greater advancement in depression score, 16% advancement in pain over control groups, and an 8% greater advancement in disability [86].

Patient education programs are developed based on psycho‐behavioristic theories and holistic approaches in order for the patients to assume their self‐care and to acquire problem‐solving skills. The attitudes that reduced the risks regarding health were examined, and the fact that educational approaches aimed at individuals required behavioral change was emphasized by the World Health Organization [9]. In patient education programs, health belief model, social cognitive theory, and transtheoretical model are widely used [80, 87].

#### **7.1. Models of health behavior**

#### *7.1.1. Health belief model*

Health belief model is structured in order to clarify which beliefs are to be targeted in the com‐ municational interventions that result in positive health behaviors. According to the health belief model, probability of a person changing his/her behavior in order to prevent the disease depends on the person's realization of the facts that he/she can also catch the disease (per‐ ceived sensitivity), the consequences of the disease may be serious (perceived seriousness), cautious behavior will prevent the disease effectively (perceived benefit) and that the benefit of reducing the dangers/risks is greater than the damage of getting into the act. The basic struc‐ tures and application proposals for the health belief model are briefly given in **Table 2** [88, 89].


**Table 2.** Basic structures of the health belief model and application proposals [89].

Other variable factors in the application of the health belief model (age, gender, ethnic back‐ ground, personal characteristics, socioeconomic condition, and educational status) influence the individual's perception of sensitivity, seriousness, benefit, and prevention and thus his/her behaviors [90].

#### *7.1.2. Social cognitive theory*

advancement in depression score, 16% advancement in pain over control groups, and an 8%

Patient education programs are developed based on psycho‐behavioristic theories and holistic approaches in order for the patients to assume their self‐care and to acquire problem‐solving skills. The attitudes that reduced the risks regarding health were examined, and the fact that educational approaches aimed at individuals required behavioral change was emphasized by the World Health Organization [9]. In patient education programs, health belief model, social

Health belief model is structured in order to clarify which beliefs are to be targeted in the com‐ municational interventions that result in positive health behaviors. According to the health belief model, probability of a person changing his/her behavior in order to prevent the disease depends on the person's realization of the facts that he/she can also catch the disease (per‐ ceived sensitivity), the consequences of the disease may be serious (perceived seriousness), cautious behavior will prevent the disease effectively (perceived benefit) and that the benefit of reducing the dangers/risks is greater than the damage of getting into the act. The basic struc‐ tures and application proposals for the health belief model are briefly given in **Table 2** [88, 89].

behavior.

real risk.

Set goals gradually. Give verbal support.

Reduce the anxiety.

Show sample for desired actions.

Define the population at risk and the level of risk.

Indicate the consequences of the risks and conditions.

the expected positive effects of these behaviors will be.

misinformation, giving courage, and helping.

Personalize the risks based on an individual's characteristics or

Synchronize the perceived sensitivity of the individual with the

Clarify when, where, and how a person should behave, and what

Reduce the perceived barrier by giving assurance, correcting

Provide information regarding how behavioral change could be made, increase awareness and use appropriate reminding systems.

Provide education and guidance during the recommended action.

cognitive theory, and transtheoretical model are widely used [80, 87].

**Basic structures Application proposals**

**Table 2.** Basic structures of the health belief model and application proposals [89].

Perceived sensitivity expresses the person's belief regarding the possibility of catching the disease.

Perceived seriousness is defined as the belief about how serious a situation and its sequels are.

Perceived benefit expresses the belief regarding the effectiveness of a recommended action to reduce the risk or seriousness of a disease.

Perceived barrier is defined as the belief about the moral and material cost of the proposed action.

Action hints indicate the strategies based upon

Self‐efficacy reflects the confidence of the individual in his/her skill of getting into action.

increasing the state of readiness.

greater advancement in disability [86].

128 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**7.1. Models of health behavior**

*7.1.1. Health belief model*

Social cognitive theory adopted concepts from sociology and political sciences in order to understand the functions and capacity of a group. The theory also integrated concepts of humanistic psychology by means of analyzing the processes that formed the basis of self‐will, self‐sacrifice, and moral behavior. Moreover, it highlights the fact that perceived targets, per‐ ceived environmental barriers and promoters, outcome expectations, and self‐efficacy influ‐ ence the organization of human behavior, motivation, and well‐being. Perceived self‐efficacy is the most important key consideration in this causative structure with the effect of other deter‐ miners. According to the social cognitive theory, social structure is also effective on health as much as personal determiners [91, 92].

Social cognitive theory added new concepts to the list of behaviors regarding health that are excluded from health belief model. First, it highlighted the motivational role of support and role of observational learning through modeling (imitating) others' behavior [93].

Second significant contribution is the definition of the concept of self‐efficacy (efficacy expec‐ tations), which is distinct from the concept of outcome expectations. Outcome expectations are known as predictions of the individual regarding specific actions that would bring ulti‐ mate results, and it is quite similar to the concept of perceived benefit in the health belief model. Efficacy expectations are defined as the belief that the actions required to bring results can be managed successfully. Both efficacy and outcome expectations are required for the behavior (**Figure 1**) [94].

**Figure 1.** The effect of self‐efficacy on behavior [95].

In the figure mentioned above, Bandura demonstrates this relation [95]. For instance, a woman with RA (person) wants to lose weight (behavior) to be healthier (outcome). For the woman to achieve this, she has to believe in the fact that both losing weight is beneficial for her health (outcome expectation) and that she has the ability to lose weight (efficacy expectation).

#### *7.1.3. Transtheoretical model*

The model consists of stages of pre‐contemplation, contemplation, preparation, action, maintenance, and termination. At the pre‐contemplation stage, individuals are either very little aware or not aware at all of the problems; thus, they are unwilling to make a change in these problems. Behavioral change within the next 6 months is out of question for the individuals at this stage. Contemplation stage is when both the problem and change are evaluated and addressed. Individuals at this stage are more open to feedback and informa‐ tion regarding their behaviors, and they think of changing their behaviors within the next 6 months. In the preparation stage, individuals are usually determined to change their behaviors within the next 30 days. These people have tried changing in the past and have put some effort in getting prepared for the change. Stage of action is when behavioral change or the change occurs and at this stage some explicit changes have occurred in the last 6 months in the lifestyles of the individuals. Maintenance stage is when the unlimited period begins as the first 6 months of the change begin as well. Changes have already turned into habits and recurrence risk of the behavior is decreased. In the termination stage, individuals do not have the desire to return to unhealthy behaviors, and the efficacy level is 100% [96, 97].

Stages of change clarify the time of changes in individuals' intention, attitude, and behavior. The process of change, on the other hand, helps to understand which experiences individuals use in order to change their problematic behaviors. Ten variables consisting of five cognitive and five behavioral variables were found to facilitate change. The cognitive ones are emo‐ tions, values, and factors regarding awareness of the individuals, while behavioral processes indicate which behaviors individuals do choose on the path to change. Processes guide the studies on change, significantly [97, 98].

During the practice of TTM applications, it should be taken into account that not all the indi‐ viduals in the study group are ready for the change, and even if they are thought to be ready, not everyone is at the same stage; thus, personalized interventions are required. At the first two stages, providing more information regarding change and how it is to be made and giv‐ ing motivational support are very important. At the third and fourth stages, suggestions aim‐ ing at providing support about their self‐efficacy may be made and discussed about, and motivational prizes may be benefitted from. At the fifth stage, determination of the conditions in order to prevent recurrence and planning of the required steps in order to sustain the change in the long term are necessary [98].

#### **7.2. Self‐management**

In the last 20 years, self‐management interventions in chronic diseases have gained sig‐ nificance. Self‐management education programs highlight the role of patient education in protective and therapeutical health‐care activities and consist of organized learning experiences usually designed to facilitate the adoption of health‐promoting behaviors. Self‐management interventions often involve various skills regarding the disease, includ‐ ing problem solving, decision‐making, and relations with health professionals [99, 100]. Self‐management interventions are person‐centered, and they focus on encouraging active participation of the individuals in order for them to develop their well‐being and to manage the symptoms [101].

Self‐management training programs include three main topics: information sharing, behav‐ ioral change (skills development), and psychosocial counseling. Information about the diagnosis and symptoms of the disease is provided, and training is provided to develop self‐ management skills to manage these symptoms. The individuals are expected to participate actively in these trainings. Self‐management skills are taught through observation and role‐ play within educational groups. Considering the individual needs, individuals are trained about joint protection, fatigue management, exercise, pain‐related factors, and sleep adjust‐ ment [102, 103]. Psychosocial counseling can be provided to help individuals feel stronger about their self‐efficacy and help them cope with arthritis to enable them to acquire a func‐ tional and socially active lifestyle [101].

The first step needs evaluation of self‐management programs in RA. The first assessment is conducted via face‐to‐face interview. The interview is very important for recognizing the strong aspects of the individual and the aspects to be supported. A needs evaluation pro‐ vides information about individual's notice, abilities, obstacles, strong sides, and motivation for self‐management. It should also be addressed in demographic and environmental factors that may be effective in the behavioral change of the individual during evaluation interview. Arthritis patient education programs aim to teach the individual how to organize daily activi‐ ties that are affected by the symptoms of the disease after the initial assessment interview with the patient. In other words, the patient is taught how to approach situations related to arthritis and how to arrange each individual needs [104, 105].

#### *7.2.1. Self‐management intervention programs for arthritis*

#### *7.2.1.1. Arthritis self‐management program*

little aware or not aware at all of the problems; thus, they are unwilling to make a change in these problems. Behavioral change within the next 6 months is out of question for the individuals at this stage. Contemplation stage is when both the problem and change are evaluated and addressed. Individuals at this stage are more open to feedback and informa‐ tion regarding their behaviors, and they think of changing their behaviors within the next 6 months. In the preparation stage, individuals are usually determined to change their behaviors within the next 30 days. These people have tried changing in the past and have put some effort in getting prepared for the change. Stage of action is when behavioral change or the change occurs and at this stage some explicit changes have occurred in the last 6 months in the lifestyles of the individuals. Maintenance stage is when the unlimited period begins as the first 6 months of the change begin as well. Changes have already turned into habits and recurrence risk of the behavior is decreased. In the termination stage, individuals do not have the desire to return to unhealthy behaviors, and the efficacy

130 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Stages of change clarify the time of changes in individuals' intention, attitude, and behavior. The process of change, on the other hand, helps to understand which experiences individuals use in order to change their problematic behaviors. Ten variables consisting of five cognitive and five behavioral variables were found to facilitate change. The cognitive ones are emo‐ tions, values, and factors regarding awareness of the individuals, while behavioral processes indicate which behaviors individuals do choose on the path to change. Processes guide the

During the practice of TTM applications, it should be taken into account that not all the indi‐ viduals in the study group are ready for the change, and even if they are thought to be ready, not everyone is at the same stage; thus, personalized interventions are required. At the first two stages, providing more information regarding change and how it is to be made and giv‐ ing motivational support are very important. At the third and fourth stages, suggestions aim‐ ing at providing support about their self‐efficacy may be made and discussed about, and motivational prizes may be benefitted from. At the fifth stage, determination of the conditions in order to prevent recurrence and planning of the required steps in order to sustain the

In the last 20 years, self‐management interventions in chronic diseases have gained sig‐ nificance. Self‐management education programs highlight the role of patient education in protective and therapeutical health‐care activities and consist of organized learning experiences usually designed to facilitate the adoption of health‐promoting behaviors. Self‐management interventions often involve various skills regarding the disease, includ‐ ing problem solving, decision‐making, and relations with health professionals [99, 100]. Self‐management interventions are person‐centered, and they focus on encouraging active participation of the individuals in order for them to develop their well‐being and to manage

level is 100% [96, 97].

studies on change, significantly [97, 98].

change in the long term are necessary [98].

**7.2. Self‐management**

the symptoms [101].

Although there are many different models, perhaps the most well‐known program is the arthritis self‐management program (ASMP) developed by Lorig and his colleagues. Arthritis self‐management program (ASMP), also known as the arthritis self‐help course (ASHC), is the arthritis education program. First developed by Kate Lorig, DrPH, at Stanford University, arthritis foundation adopted the program in 1981. The ASMP is a 6‐week series of classes for 2–2.5 h per session (total 12 h). Standardized course materials have been developed to assess pain, fear, depression, and disability in arthritic individuals. It focuses on what people need to know about arthritis concerns and aims to learn problem‐solving skills so that individuals can adapt to fluctuations in disease activity and disorder levels [106].

Problem‐solving, decision‐making, communication with providers, exercise, relaxation, and energy‐saving techniques are utilized in training how to deal with illnesses during the program. Self‐efficacy strategies (goal setting/contract, role modeling, peer support and persuasion, rein‐ terpretation of symptoms), experiential training methods (problem‐solving discussions, brain‐ storming, demonstration, and feedback), behavioral change techniques (behavior shaping, repetitive implementation and feedback, self‐monitoring/diaries, environmental sign), and social support strategies (important other people's involvement, time sharing, and feedback for group sharing) are used during the program [107, 108].

#### *7.2.1.2. Bone up on arthritis*

The bone up on arthritis (BUOA) program is a home‐based self‐management education program. It consists of six 2‐h lessons on audiocassettes, supplemented by illustrated print materials. The program, the contents of which are similar to the arthritis self‐management program, was adopted by the arthritis foundation in 1989. The BUOA concept is based on basic disease information, communication, disease management skills, and problem‐solv‐ ing strategies. Coping with depression, sleep regulation and pain management techniques, relaxation techniques, and exercise are taught. Self‐efficacy strategies and behavioral strate‐ gies (promoting the repeated application of self‐care behaviors, problem‐solving), similar to ASMP training, are used in the training process [109].

#### *7.2.1.3. Self‐management arthritis treatment*

Self‐management arthritis treatment (SMART)] program was developed by Healthtrac, Inc. and is also known as the arthritis home health program. Course materials including self‐man‐ agement plan, self‐care books, relaxation audiotapes, and an exercise videotape are uploaded to attendees' personal computers. The letter created in the computer environment is transmit‐ ted via e‐mail and communication is provided in this way. The program is intended to teach individuals improve in order to use self‐care activities and problem‐solving skills, and enhance their self‐efficacy, and to use health‐care services to reduce side effects of medication [109].

#### *7.2.1.4. Physical activity*

Physical activity is a core self‐management activity for people with arthritis. The recommenda‐ tion for early treatment of arthritis recommends a professional‐directed therapeutic exercise for arthritic individuals. In 2002, the American Rheumatism Academy (ARA) recommended physi‐ cal activity involving individuals exercising aerobic activity and lower extremities for 2–3 days per week for 30–60 min [34, 110]. People with arthritis can exercise (PACE) program developed by the arthritis foundation in 1987 and revised in 1999, is a group exercise program, preferably 1–3 times a week. It is applied in two levels according to the skills of the individuals. The advanced level includes more aerobic activities. The trainer selects 72 exercises that are appropriate to the needs of the group. The program includes endurance exercises and relaxation techniques [109].

#### **8. Joint protection and energy conservation**

When the changes that patients with rheumatoid arthritis experienced during the course of the disease are examined, permanent and progressive changes have a direct impact on main‐ taining joint independence in daily life, such as joint limitations, edema, general or regional pain complaints, and fatigue. From this point of view, ergotherapists use joint and energy conservation techniques in the treatment process in order to ensure the independence of the individual in daily life, to protect the joints in order for the activities to be performed by the individual, and to perform the activity in the most effective manner [39, 79, 111].

Why should we protect the joints?

#### **8.1. In inflammatory arthritis, the aims of joint protection are to:**


#### **8.2. What can be done in this situation?**

*7.2.1.2. Bone up on arthritis*

*7.2.1.4. Physical activity*

ASMP training, are used in the training process [109].

132 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**8. Joint protection and energy conservation**

Why should we protect the joints?

*7.2.1.3. Self‐management arthritis treatment*

The bone up on arthritis (BUOA) program is a home‐based self‐management education program. It consists of six 2‐h lessons on audiocassettes, supplemented by illustrated print materials. The program, the contents of which are similar to the arthritis self‐management program, was adopted by the arthritis foundation in 1989. The BUOA concept is based on basic disease information, communication, disease management skills, and problem‐solv‐ ing strategies. Coping with depression, sleep regulation and pain management techniques, relaxation techniques, and exercise are taught. Self‐efficacy strategies and behavioral strate‐ gies (promoting the repeated application of self‐care behaviors, problem‐solving), similar to

Self‐management arthritis treatment (SMART)] program was developed by Healthtrac, Inc. and is also known as the arthritis home health program. Course materials including self‐man‐ agement plan, self‐care books, relaxation audiotapes, and an exercise videotape are uploaded to attendees' personal computers. The letter created in the computer environment is transmit‐ ted via e‐mail and communication is provided in this way. The program is intended to teach individuals improve in order to use self‐care activities and problem‐solving skills, and enhance their self‐efficacy, and to use health‐care services to reduce side effects of medication [109].

Physical activity is a core self‐management activity for people with arthritis. The recommenda‐ tion for early treatment of arthritis recommends a professional‐directed therapeutic exercise for arthritic individuals. In 2002, the American Rheumatism Academy (ARA) recommended physi‐ cal activity involving individuals exercising aerobic activity and lower extremities for 2–3 days per week for 30–60 min [34, 110]. People with arthritis can exercise (PACE) program developed by the arthritis foundation in 1987 and revised in 1999, is a group exercise program, preferably 1–3 times a week. It is applied in two levels according to the skills of the individuals. The advanced level includes more aerobic activities. The trainer selects 72 exercises that are appropriate to the needs of the group. The program includes endurance exercises and relaxation techniques [109].

When the changes that patients with rheumatoid arthritis experienced during the course of the disease are examined, permanent and progressive changes have a direct impact on main‐ taining joint independence in daily life, such as joint limitations, edema, general or regional pain complaints, and fatigue. From this point of view, ergotherapists use joint and energy conservation techniques in the treatment process in order to ensure the independence of the individual in daily life, to protect the joints in order for the activities to be performed by the

individual, and to perform the activity in the most effective manner [39, 79, 111].


#### **9. Joint protection and energy conservation principles**

Different authors have identified a variety of principles. A consensus was published by the College of Occupational Therapy specialist section in rheumatology [19].

#### **9.1. Joint protection**


#### **9.2. Energy conservation**


#### **10. Assistive technology and reorganization of living areas**

When the disease prognosis of the individual is taken carefully, it is necessary to support the individual's maximum independence in life and to be able to cope with pain and fatigue in a place where the occupational therapists should primarily emphasize (**Table 3**) [20]. At this point, it is important that the living space of the individual is arranged and a suitable auxiliary device is proposed. The term "assistive technology" has replaced the expression disability equipment to describe products and services used by people of all ages to gain increased autonomy and maximize their occupational performance [19]. Evaluation is made within the scope of the concept when a suitable auxiliary device is suggested. This assess‐ ment is effectively an interaction with each other similar to successive gear wheels. Moreover, it is impossible for this interaction process to be isolated from the living environment of the individual (**Figure 2**).

The arrangements to be made in the living environment of the individual are made by changes in the physical environment and adaptations of assistive devices. This intervention is called inclusive design. In other words, "inclusive design" is the term used to describe a design process whereby designers "address the needs of the widest possible audience by includ‐ ing the needs of groups who are currently excluded from or marginalised by mainstream design practices" [112]. The purpose here is to provide a maximum benefit by intervening in a holistic way to individuals who are not in normal life events. Given the external forces that individuals are exposed to in the home and work environment, interventions made with a holistic view are important at the point of raising quality of life and ensuring pain control. The following are a combination of living room regulations and ancillary technology recom‐ mendations applied to various problems (**Tables 4**–**6**) [19].


**Table 3.** An example of relationship between person, social environment, and technology.

**Figure 2.** The dynamic relationship between person, social environment, and technology.


**Table 4.** Personal care and hygiene.

• Avoid gripping too tightly.

**9.2. Energy conservation**

forming activities more slowly.

• Maintain muscle strength and range of movement [19].

134 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

saving gadgets, and delegating to others when necessary.

mendations applied to various problems (**Tables 4**–**6**) [19].

• Modify the environment to suit ergonomic/joint protection practices [19].

**10. Assistive technology and reorganization of living areas**

techniques.

ability.

individual (**Figure 2**).

• Avoid adopting poor body positioning, posture, and using poor moving and handling

• Pace activities by balancing rest and activity, alternating heavy and light tasks, and per‐

• Use work simplification methods, for example, planning ahead, prioritizing, using labor‐

• Avoid activities that cannot be stopped immediately if it proves to be beyond the person's

When the disease prognosis of the individual is taken carefully, it is necessary to support the individual's maximum independence in life and to be able to cope with pain and fatigue in a place where the occupational therapists should primarily emphasize (**Table 3**) [20]. At this point, it is important that the living space of the individual is arranged and a suitable auxiliary device is proposed. The term "assistive technology" has replaced the expression disability equipment to describe products and services used by people of all ages to gain increased autonomy and maximize their occupational performance [19]. Evaluation is made within the scope of the concept when a suitable auxiliary device is suggested. This assess‐ ment is effectively an interaction with each other similar to successive gear wheels. Moreover, it is impossible for this interaction process to be isolated from the living environment of the

The arrangements to be made in the living environment of the individual are made by changes in the physical environment and adaptations of assistive devices. This intervention is called inclusive design. In other words, "inclusive design" is the term used to describe a design process whereby designers "address the needs of the widest possible audience by includ‐ ing the needs of groups who are currently excluded from or marginalised by mainstream design practices" [112]. The purpose here is to provide a maximum benefit by intervening in a holistic way to individuals who are not in normal life events. Given the external forces that individuals are exposed to in the home and work environment, interventions made with a holistic view are important at the point of raising quality of life and ensuring pain control. The following are a combination of living room regulations and ancillary technology recom‐


**Table 5.** Food preparation and household tasks.


**Table 6.** Mobility and other activities.

#### **11. Splinting techniques for rheumatoid arthritis**

There are various important wrist and hand structures that may be affected by the inflamma‐ tory and degenerative process experienced by people with rheumatic conditions. Therefore, hand splints are a recommended conservative option for occupational therapists to prescribe to support vulnerable structures, reduce pain, and optimize function, and they have been used for many years [113]. Evidence continues to emerge regarding the clinical effectiveness of splints with the most robust evidence reporting their ability to reduce levels of the wrist and hand pain when worn [62].

The splints given to individuals must be made appropriately to the client. Because splinting is aimed at improving activity performance by reducing the pain and fatigue of individuals. Splints that are made of standard uniform type may damage the client [114].

There are two types of splint therapy according to the prognosis of the disease. The aim of cor‐ recting the deformities that occur when the primary disease is chronic is the deformity ortho‐ ses given to provide pain control and to increase the fatigue tolerance of the patient. These are ulnar deviation orthoses, swan necks, and ring orthoses for thumb hypertension. The second group of splints is the resting orthoses that are given to prevent pain and inflammation in the acute phase of the disease and to help the individual to rest while protecting the function. These are volar wrist orthosis, static wrist orthosis, metacarpophalangeal joint stabilization orthosis, static volar and dorsal wrist orthoses, and air pressure splint. The splints given to treat deformity should be used intensively throughout the day. Resting orthoses should be worn during the rest of the day and after exercises during the day, provided that they are removed at night [114–116].

### **12. Vocational rehabilitation**

**11. Splinting techniques for rheumatoid arthritis**

• Use of Skype with headset • Ergonomic computer keyboard • Voice‐activated computer software

and hand pain when worn [62].

Communication • Large button phones

Carrying Continuous worktops and

Lifting Consideration of weight of

Reduced reach Organization of cupboards,

units

**Table 5.** Food preparation and household tasks.

Bending Plug sockets at relevant height Grip Attention to controls on appliances

work areas

limited distances between key

136 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

household appliances, for example, irons, and products, for example, saucepans

pull out/Down shelving in

**Table 6.** Mobility and other activities.

There are various important wrist and hand structures that may be affected by the inflamma‐ tory and degenerative process experienced by people with rheumatic conditions. Therefore, hand splints are a recommended conservative option for occupational therapists to prescribe to support vulnerable structures, reduce pain, and optimize function, and they have been used for many years [113]. Evidence continues to emerge regarding the clinical effectiveness of splints with the most robust evidence reporting their ability to reduce levels of the wrist

**Activity limitation Mainstream design Assistive technology Home adaptation**

**Activity limitation Mainstream design Assistive technology Home adaptation** Standing tolerance Energy‐saving kitchen layout Perching stool It would be unusual for a

baskets

wheelchair, powered scooter or

Non‐slip grips for pens

Intercom

major kitchen adaptation to be undertaken for a person with a rheumatic condition

wheelchair

Wide range of small devices, for example, trolley, cooking

Wide range of small devices, for example, helping hand, cleaning products with extended handles

Large handled plugs

Mobility Intercom Small mobility aids manual

Steps and stairs Additional rails Stairlift, ramped access

The splints given to individuals must be made appropriately to the client. Because splinting is aimed at improving activity performance by reducing the pain and fatigue of individuals.

Splints that are made of standard uniform type may damage the client [114].

Rate of erythrocyte sedimentation, which is also known as patient activity, and sensitive joints causes structural harms such as joint destruction and deformation. Structural harms emerged in RA result in limitation of physical functions such as force, endurance, mobility, and manual skills. Work disability may develop at early stages for this reason [117, 118].

Work disability in individuals with RA depend on factors related to both work and RA; phys‐ ical effort demands at work being too high and keeping work pace under control are factors related to work. On the other hand, factors related to the disease may differ among individu‐ als. Unlike factors related to the disease, factors such as functional capacity, high age, educa‐ tional status, and stress management skill are also related with work disability [117].

One of the goals of rehabilitation in rheumatoid arthritis is ensuring return to work. It may require job modification, vocational training, and vocational rehabilitation in order to achieve this goal. Vocational rehabilitation helps an individual with a health problem for continuing to work, returning to work, or getting a new job. Occupational therapists play an important role in individuals' continuation to work and getting a new job by means of increasing the capacity of the individual with RA. Moreover, occupational therapists aim to maximize the level of individual‐environment occupation harmony and to develop work performance [26].

In vocational rehabilitation, the occupational therapy process is based on interview, observa‐ tion, and individual evaluations made through standardized procedures. A comprehensive starter interview that gathers detailed information regarding the individual's medical record, performance level of daily life activities and work activities, and work background is held. Furthermore, participation of the individual to the daily life activities, leisure activities, and productive activities is evaluated. Positive factors supporting individual's participation and negativities preventing him/her from participating are determined. This process is important in order to rely on the strengths of the individual during the intervention. Moreover, during the evaluation, person's roles, abilities, interests, and needs regarding work performance and work task demands are determined. In occupational therapy evaluations, functional capacity analysis to determine the suitability of the individual and the work that he/she desires to do; work analysis to detect the task demands expected from the individual in the corresponding work; and work place analysis including ergonomic assessment and assessment of the equip‐ ment, work routine, and accessibility in order to determine the factors related to the work place, are considerably important [26, 119, 120].

After the interviews and evaluations, short‐ and long‐term intervention plans are formed. These formed plans should be suitable to the roles, habits, functional capacity, life choices, and the living environment of the individual. The interventions should be aimed at bringing edu‐ cational performance skill and developing daily life skills, preparation to work skills and work performance. In vocational rehabilitation, education about occupational therapy, RA, and medication involves education on employee rights, employer rights, ergonomic recommenda‐ tions, prevention of injury in order to reduce disability regarding injuries, stress management, sleep posture and hygiene, choice of shoe, and splinting. Moreover, occupational activity training in order to develop producer behaviors, employee roles, and skills; work modifica‐ tions and adaptations in order to develop the work performance, and personalized programs on transition to work are also quiet significant in occupational therapy interventions [26, 120].

#### **Author details**

Zeynep Bahadır Ağce<sup>1</sup> \*, Esma Özkan<sup>2</sup> and Barkın Köse<sup>2</sup>

\*Address all correspondence to: fztzeynepbahadir@gmail.com

1 Faculty of Health Sciences, Occupational Therapy Department, Üsküdar University, Turkey

2 Faculty of Health Sciences, Occupational Therapy Department, Hacettepe University, Turkey

#### **References**


[5] Theis KA, Furner SE. Shut‐in? Impact of chronic conditions on community participation restriction among older adults. Journal of Aging Research. 2011;**2011**

work analysis to detect the task demands expected from the individual in the corresponding work; and work place analysis including ergonomic assessment and assessment of the equip‐ ment, work routine, and accessibility in order to determine the factors related to the work

After the interviews and evaluations, short‐ and long‐term intervention plans are formed. These formed plans should be suitable to the roles, habits, functional capacity, life choices, and the living environment of the individual. The interventions should be aimed at bringing edu‐ cational performance skill and developing daily life skills, preparation to work skills and work performance. In vocational rehabilitation, education about occupational therapy, RA, and medication involves education on employee rights, employer rights, ergonomic recommenda‐ tions, prevention of injury in order to reduce disability regarding injuries, stress management, sleep posture and hygiene, choice of shoe, and splinting. Moreover, occupational activity training in order to develop producer behaviors, employee roles, and skills; work modifica‐ tions and adaptations in order to develop the work performance, and personalized programs on transition to work are also quiet significant in occupational therapy interventions [26, 120].

and Barkın Köse<sup>2</sup>

1 Faculty of Health Sciences, Occupational Therapy Department, Üsküdar University, Turkey 2 Faculty of Health Sciences, Occupational Therapy Department, Hacettepe University,

[1] Loyola‐Sanchez A, Richardson J, Pelaez‐Ballestas I, Alvarez‐Nemegyei J, Lavis JN, Wilson MG, et al. The impact of arthritis on the physical function of a rural Maya‐Yucateco com‐ munity and factors associated with its prevalence: A cross sectional, community‐based

[2] Hootman JM, Helmick CG, Barbour KE, Theis KA, Boring MA. Updated projected prev‐ alence of self‐reported doctor‐diagnosed arthritis and arthritis‐attributable activity limi‐

[3] Mann WC, Hurren D, Tomita M. Assistive devices used by home‐based elderly persons with arthritis. American Journal of Occupational Therapy. 1995;**49**(8):810‐820

[4] Griffith LE, Raina P, Levasseur M, Sohel N, Payette H, Tuokko H, et al. Functional dis‐ ability and social participation restriction associated with chronic conditions in middle‐ aged and older adults. Journal of Epidemiology and Community Health. 2016;**71**. DOI:

tation among US adults, 2015‐2040. Arthritis & Rheumatology. 2016

place, are considerably important [26, 119, 120].

138 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

\*, Esma Özkan<sup>2</sup>

study. Clinical Rheumatology. 2015:1‐10

10.1136/jech‐2016‐207982

\*Address all correspondence to: fztzeynepbahadir@gmail.com

**Author details**

Turkey

**References**

Zeynep Bahadır Ağce<sup>1</sup>


[33] Zlatkovic‐Svenda M, Saraux A, Tuncer T, Dadoniene J, Miltiniene D, Gilgil E, et al. FRI0558 rheumatoid arthritis prevalence in Europe, a eular‐endorsed survey. Annals of the Rheumatic Diseases. 2016;**75**(Suppl 2):643

[20] Poole JL, Cordova JS, Sibbitt WL, Skipper B. Quality of life in American Indian women with arthritis or diabetes. American Journal of Occupational Therapy. 2010;**64**(3):496‐505

[21] Matcham F, Rayner L, Steer S, Hotopf M. The prevalence of depression in rheumatoid arthritis: a systematic review and meta‐analysis. Rheumatology. 2013;**52**(12):2136‐2148

[22] Klaassen K, Nyklíček I, Traa S, de Nijs R. Distressed personality is associated with lower psychological well‐being and life satisfaction, but not disability or disease activity in

[23] de Almeida PHTQ, Pontes TB, Matheus JPC, Muniz LF, da Mota LMH. Occupational therapy in rheumatoid arthritis: What rheumatologists need to know?. Revista Brasileira

[24] Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L. The person‐environment‐occu‐ pation model: A transactive approach to occupational performance. Canadian Journal of

[25] WHO. Chronic Diseases and Health Promotion World Health Organization: WHO: World Health Organization: WHO; 2016 [Available from: http://www.who.int/chp/

[26] Macedo AM, Oakley SP, Panayi GS, Kirkham BW. Functional and work outcomes improve in patients with rheumatoid arthritis who receive targeted, comprehensive

[28] Ağıllı M, Ekinci Ş, Aydın FN, Şener İ, Parlak A, Yaman H. Anti‐siklik Sitrüllinlenmiş Peptid/Protein (Anti‐CCP) ve Romatoid Artrit Tanısındaki Değeri. TAF Preventive

[29] Jiang X, Sandberg ME, Saevarsdottir S, Klareskog L, Alfredsson L, Bengtsson C. Higher education is associated with a better rheumatoid arthritis outcome concerning for pain and function but not disease activity: Results from the EIRA cohort and Swedish rheu‐

[30] Rossini M, Rossi E, Bernardi D, Viapiana O, Gatti D, Idolazzi L, et al. Prevalence and inci‐ dence of rheumatoid arthritis in Italy. Rheumatology International. 2014;**34**(5):659‐664

[31] Eriksson JK, Neovius M, Ernestam S, Lindblad S, Simard JF, Askling J. Incidence of rheu‐ matoid arthritis in Sweden: A nationwide population‐based assessment of incidence, its determinants, and treatment penetration. Arthritis Care & Research. 2013;**65**(6):870‐878

[32] Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disabil‐ ity of common conditions requiring rehabilitation in the United States: Stroke, spi‐ nal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Archives of Physical Medicine and Rehabilitation.

occupational therapy. Arthritis Care & Research. 2009;**61**(11):1522‐1530

[27] Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. The Lancet. 2016;**388**

matology register. Arthritis Research & Therapy. 2015;**17**(1):1

rheumatoid arthritis patients. Clinical Rheumatology. 2012;**31**(4):661‐667

de Reumatologia (English Edition). 2015;**55**(3):272‐280

140 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Occupational Therapy. 1996;**63**(1):9‐23

topics/rheumatic/en/

Medicine Bulletin. 2014;**13**(1)

2014;**95**(5):986‐995. e1


[57] Nordgren B, Fridén C, Jansson E, Österlund T, Grooten WJ, Opava CH, et al. Criterion validation of two submaximal aerobic fitness tests, the self‐monitoring Fox‐walk test and the Åstrand cycle test in people with rheumatoid arthritis. BMC Musculoskeletal Disorders. 2014;**15**(1):1

[45] van der Helm‐vanMil AH, le Cessie S, van Dongen H, Breedveld FC, Toes RE, Huizinga TW. A prediction rule for disease outcome in patients with Recent‐onset undifferenti‐ ated arthritis: How to guide individual treatment decisions. Arthritis & Rheumatism.

[46] Dür M, Coenen M, Stoffer MA, Fialka‐Moser V, Kautzky‐Willer A, Kjeken I, et al. Do patient‐reported outcome measures cover personal factors important to people with rheumatoid arthritis? A mixed methods design using the International Classification of Functioning, Disability and Health as frame of reference. Health and Quality of Life

[47] Manning VL, Hurley MV, Scott DL, Coker B, Choy E, Bearne LM. Education, self‐man‐ agement, and upper extremity exercise training in people with rheumatoid arthritis: A

[48] Dellhag B, Bjelle A. A five‐year followup of hand function and activities of daily living in

[49] Keefe FJ, Affleck G, Lefebvre J, Underwood L, Caldwell DS, Drew J, et al. Living with rheumatoid arthritis: The role of daily spirituality and daily religious and spiritual cop‐

[50] Hammond A, Tyson S, Prior Y, Hawkins R, Tennant A, Nordenskiold U, et al. Linguistic validation and cultural adaptation of an English version of the Evaluation of Daily Activity Questionnaire in rheumatoid arthritis. Health and Quality of Life Outcomes.

[51] Suurmeijer TP, Waltz M, Moum T, Guillemin F, Van Sonderen F, Briançon S, et al. Quality of life profiles in the first years of rheumatoid arthritis: results from the EURIDISS longi‐

[52] Lapsley H, March L, Tribe K, Cross M, Courtenay B, Brooks P. Living with rheuma‐ toid arthritis: Expenditures, health status, and social impact on patients. Annals of the

[53] Shaul MP. From early twinges to mastery: The process of adjustment in living with rheu‐

[54] Ziarko M, Mojs E, Kaczmarek Ł, Warchol‐Biedermann K, Malak R, Lisinski P, et al. Do urban and rural residents living in Poland differ in their ways of coping with chronic diseases? European Review for Medical and Pharmacological Sciences.

[55] Walter MJ, van't Spijker A, Pasma A, Hazes JM, Luime JJ. Focus group interviews reveal reasons for differences in the perception of disease activity in rheumatoid arthritis.

[56] Janssens X, Decuman S, De Keyser F, group BRADAs. Assessment of activity limita‐ tions with the health assessment questionnaire predicts the need for support measures in patients with rheumatoid arthritis: A multicenter observational study. PloS One.

tudinal study. Arthritis Care & Research. 2001;**45**(2):111‐121

matoid arthritis. Arthritis & Rheumatism. 1995;**8**(4):290‐297

randomized controlled trial. Arthritis Care & Research. 2014;**66**(2):217‐227

rheumatoid arthritis patients. Arthritis Care and Research. 1999;**12**:33‐41

2007;**56**(2):433‐440

Outcomes. 2015;**13**(1):1

2014;**12**(1):1

ing. The Journal of Pain. 2001;**2**(2):101‐110

142 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Rheumatic Diseases. 2002;**61**(9):818‐821

2015;**19**(22):4227‐4234

2014;**9**(9):e106749

Quality of Life Research. 2016:**1‐8**


[84] Hirano PC, Laurent DD, Lorig K. Arthritis patient education studies, 1987‐1991: A review of the literature. Patient Education and Counseling. 1994;**24**(1):9‐54

[70] Matcham F, Ali S, Hotopf M, Chalder T. 087. Psychological correlates and predictors of fatigue in rheumatoid arthritis: A systematic review. Rheumatology. 2015;**54**(suppl

[71] Grassi W, De Angelis R, Lamanna G, Cervini C. The clinical features of rheumatoid

[72] Shankar V, Sharma P, Mittal R, Mittal S, Kumar U, Gamanagatti S. Effectiveness of arthroscopic elbow synovectomy in rheumatoid arthritis patients: Long‐term follow‐up of clinical and functional outcomes. Journal of Clinical Orthopaedics and Trauma. 2016;**7**

[73] Häkkinen A, Sokka T, Kotaniemi A, Hannonen P. A randomized two‐year study of the effects of dynamic strength training on muscle strength, disease activity, func‐ tional capacity, and bone mineral density in early rheumatoid arthritis. Arthritis &

[74] Steinbrocker O, Traeger CH, Batterman RC. Therapeutic criteria in rheumatoid arthritis.

[75] Clarkson HM. Musculoskeletal Assessment: Joint Range of Motion and Manual Muscle

[76] Hwang YS, Moon KP, Kim KT, Kim JW, Park WS. Total knee arthroplasty for severe flexion contracture in rheumatoid arthritis knees. Knee Surgery & Related Research.

[77] Fraser A, Vallow J, Preston A, Cooper R. Predicting'normal'grip strength for rheumatoid

[78] Ekelman BA, Hooker L, Davis A, Klan J, Newburn D, Detwiler K, et al. Occupational therapy interventions for adults with rheumatoid arthritis: An appraisal of the evidence.

[79] Rapolienė J, Kriščiūnas A. The effectiveness of occupational therapy in restoring the functional state of hands in rheumatoid arthritis patients. Medicina. 2006;**42**(10):823‐828

[80] Hammond A, Young A, Kidao R. A randomised controlled trial of occupational ther‐ apy for people with early rheumatoid arthritis. Annals of the Rheumatic Diseases.

[81] Hammond A. The Elizabeth Casson Memorial Lecture 2014: Changing ways; changing

[82] Ndosi M, Johnson D, Young T, Hardware B, Hill J, Hale C, et al. Effects of needs‐based patient education on self‐efficacy and health outcomes in people with rheumatoid arthri‐ tis: A multicentre, single blind, randomised controlled trial. Annals of the Rheumatic

[83] Hill J, Bird H, Johnson S. Effect of patient education on adherence to drug treatment for rheumatoid arthritis: A randomised controlled trial. Annals of the Rheumatic Diseases.

times. British Journal of Occupational Therapy. 2014;**77**(8):392‐399

Journal of the American Medical Association. 1949;**140**(8):659‐662

arthritis. European Journal of Radiology. 1998;**27**:S18‐S24

144 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Rheumatism. 2001;**44**(3):515‐522

2016;**28**(4):325

2004;**63**(1):23‐30

2001;**60**(9):869‐875

Strength. Lippincott Williams & Wilkins; 2000

arthritis patients. Rheumatology. 1999;**38**(6):521‐528

Occupational therapy in health care. 2014;**28**(4):347‐361

Diseases. 2015;**75**:10.1136/annrheumdis‐2014‐207171

1):i84–i.


[116] Taşkıran ÖÖ. Romatoid El. Journal of Physical Medicine & Rehabilitation Sciences/ Fiziksel Tup ve Rehabilitasyon Bilimleri Dergisi. 2011;**14**

[101] Iversen MD, Hammond A, Betteridge N. Self‐management of rheumatic dis‐ eases: State of the art and future perspectives. Annals of the Rheumatic Diseases.

[102] Hammond A, Badcock L. Improving education about arthritis. Rheumatology.

[103] Hammond A, Bryan J, Hardy A. Effects of a modular behavioural arthritis education programme: A pragmatic parallel‐group randomized controlled trial. Rheumatology.

[104] Schwarze M, Kirchhof R, Schuler M, Musekamp G, Nolte S, Jordan J, et al. Ein blick

[105] Riemsma RP, Kirwan JR, Taal E, Rasker J. Patient education for adults with rheumatoid

[106] Lorig K, Holman H. Arthritis self‐management studies: A twelve‐year review. Health

[107] Lorig K, González VM, Laurent DD, Morgan L, Laris B. Arthritis self‐management pro‐ gram variations: Three studies. Arthritis & Rheumatology. 1998;**11**(6):448‐454

[108] Lorig K, Ritter PL, Plant K. A disease‐specific self‐help program compared with a generalized chronic disease self‐help program for arthritis patients. Arthritis Care &

[109] Brady TJ, Kruger J, Helmick CG, Callahan LF, Boutaugh ML. Intervention programs for arthritis and other rheumatic diseases. Health Education & Behavior. 2003;**30**(1):44‐63

[110] Bartlett SJ. Clinical care in the rheumatic diseases: Association of Rheumatology Health

[111] Tonga E, Uysal SA, Karayazgan S, Hayran M, Düger T. Development and reliability of a Turkish version of the short form‐joint protection behavior assessment (JPBA‐S).

[112] Yang C‐W, Yen Z‐S, McGowan JE, Chen HC, Chiang W‐C, Mancini ME, et al. A system‐ atic review of retention of adult advanced life support knowledge and skills in health‐

[113] Williams A, Lee P, Kerr A. Scottish intercollegiate guidelines network (SIGN) guide‐ lines on tonsillectomy: A three cycle audit of clinical record keeping and adherence to national guidelines. The Journal of Laryngology & Otology. 2002;**116**(06):453‐454 [114] Kaya T. İnflamatuvar Romatizmal Hastalıkların Ortezle Tedavisi. Turkish Journal of

[115] Günendi Z, Göğüş F, Keleş Z, Durukan T. Romatoid Artritli Hastaların El‐El Bileği İstirahat Splinti Kullanımına Uyumu. Turkiye Klinikleri Journal of Medical Sciences.

down under. Zeitschrift für Rheumatologie. 2008;**67**(3):189‐198

arthritis. The Cochrane Database of Systematic Reviews. 2003;**2**

2010;**69**:annrheumdis129270

146 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

2008;**47**(11):1712‐1718

Education Quarterly. 1993;**20**(1):17‐28

Journal of Hand Therapy. 2016;**29**(3):275‐280

care providers. Resuscitation. 2012;**83**(9):1055‐1060

Research. 2005;**53**(6):950‐957

Professionals; 2006

Rheumatology. 2009;**24**(1)

2010;**30**(1):213‐217

2002;**41**:87


### **Assistive Technology in Occupational Therapy**

Gokcen Akyurek, Sinem Kars, Zeynep Celik, Ceren Koc and Özge Buket Cesim

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68471

#### **Abstract**

In this chapter, occupational therapists from leading specialists exploring ways they can collaborate with assistive technology (AT) users to help them get the most out of these devices. By gratefully acknowledging the advances in technology of the last century, people with disabilities can live independent lives, contribute to their communities, attend regular schools, and work in a career. This technological development means medically switching to a social model of technology presentation, where users are as much focused on social reintegration as their physical abilities. This change means that field workers will not be able to focus on delivering technology on their own but will have to go one step further and partner with consumers and communities to ensure that the aids are used in the best possible way.

**Keywords:** assistive technology, disabilities, performance areas, funding, disability

#### **1. Introduction: assistive technology definition**

Dictionaries provide the following definition of technology: (1) the science or study of the practical or industrial arts and (2) applied science and (3) a method, process, etc., for handling a specific technical problem. However, none of these definitions says anything about a *device*. We call an *assistive technology* for this important concept. It refers to a broad range of devices, services, strategies, and practices that are designed and applied to improve the problems of people with disabilities. One definition of an assistive technology device is used in public law of the United States as follows:

*"Any items, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized that is used to increase, maintain or improve functional capabilities of individuals with disabilities"* [1].

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This definition comprises several important details like such as commercial, modified, and customized devices. But the most important that emphasizes *functional* capabilities of *individuals* with disabilities are the main topics of occupational therapy.

Technology has an important place in our daily life. Occupational therapy uses technology to increase the occupational performance and participation of their clients. Therefore, technology is an important application of occupational therapy services.

*Assistive technology services* include evaluating the needs, selecting the appropriate device, purchasing the device, providing support to the user and other interested persons in the process of adapting to the device, and training staff.

Occupational therapists use some evaluation methods like activity analysis in the therapy process in order to meet the activity demands of each client in context. They consider the tools used to meet their occupational demands and consider about the skills and abilities of the clients with which tools they use. These tools can be an assistive technology as a definition, if they increase, maintain, or improve someone's functional capabilities. If these tools typically used to improve the performance of the activity do not match the skills and abilities of the client, the therapist adapts or changes them, as he or she will use them. Therefore, providing assistive technology devices and services is an important element of occupational therapy intervention to support individuals, improve their performance, and increase their participation for their activities [2].

#### **2. A historical perspective on assistive technology devices and services**

Although industry of assistive technology is very demanding, important developments in this topic began to appear about 30 years ago. If you want to look at its root, it is needed to go old times. Let us imagine we are at the Stone Age; a friend broke his foot in the hunt. However, there was no plaster at that time; therefore, his foot is left to self-healing process. When he began to heal, he started to limp. However, he had to provide food to his clan. So that, he used a stick that would help him walk. In this way, the first assistive technology tool has come up. At that time, a special tool is named as high technology. As time passes, it is decided that assistive technologies respond to other needs also.

After the stick, it is discovered that empty animal horn can be used for loading to voice. Thus, it can be supported to fade hearing. As another example, the wheel that provides the transportation is an invention that is reinvented many times over the years. This device is the most important component of the current wheelchair. The most important thing in these devices at the past is that they were functioning extensively in terms of form or style. The stick that is used as a walking tool is similar with the todays' crutches and canes. The animal horn is only functionally related with the current hearing aids as well. The major point that will carry us to the next step in assistive technology is the similarity between the examples from the past and todays' assistive technology.

#### **2.1. Evolution of the latest assistive technology**

This definition comprises several important details like such as commercial, modified, and customized devices. But the most important that emphasizes *functional* capabilities of *indi-*

Technology has an important place in our daily life. Occupational therapy uses technology to increase the occupational performance and participation of their clients. Therefore, technol-

*Assistive technology services* include evaluating the needs, selecting the appropriate device, purchasing the device, providing support to the user and other interested persons in the pro-

Occupational therapists use some evaluation methods like activity analysis in the therapy process in order to meet the activity demands of each client in context. They consider the tools used to meet their occupational demands and consider about the skills and abilities of the clients with which tools they use. These tools can be an assistive technology as a definition, if they increase, maintain, or improve someone's functional capabilities. If these tools typically used to improve the performance of the activity do not match the skills and abilities of the client, the therapist adapts or changes them, as he or she will use them. Therefore, providing assistive technology devices and services is an important element of occupational therapy intervention to support individuals, improve their performance, and increase their participa-

**2. A historical perspective on assistive technology devices and services**

Although industry of assistive technology is very demanding, important developments in this topic began to appear about 30 years ago. If you want to look at its root, it is needed to go old times. Let us imagine we are at the Stone Age; a friend broke his foot in the hunt. However, there was no plaster at that time; therefore, his foot is left to self-healing process. When he began to heal, he started to limp. However, he had to provide food to his clan. So that, he used a stick that would help him walk. In this way, the first assistive technology tool has come up. At that time, a special tool is named as high technology. As time passes, it is

After the stick, it is discovered that empty animal horn can be used for loading to voice. Thus, it can be supported to fade hearing. As another example, the wheel that provides the transportation is an invention that is reinvented many times over the years. This device is the most important component of the current wheelchair. The most important thing in these devices at the past is that they were functioning extensively in terms of form or style. The stick that is used as a walking tool is similar with the todays' crutches and canes. The animal horn is only functionally related with the current hearing aids as well. The major point that will carry us to the next step in assistive technology is the similarity between the examples from the past

*viduals* with disabilities are the main topics of occupational therapy.

150 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

ogy is an important application of occupational therapy services.

decided that assistive technologies respond to other needs also.

cess of adapting to the device, and training staff.

tion for their activities [2].

and todays' assistive technology.

Assistive technology always is shaped according to the materials of the time. All the time, the functionality is more important than other features. Therefore, for many years, some applications have been modified little. The stick is an example; although its structure remains same, the material is modified. For sure, the other developments are only feasible as long as technologies are evolved. Over the years, some events that have happened have ensured these developments. For example, the Civil War in the United States especially provided the improvements in lower limb prostheses. In order to create a better fit and to be more functional outcome, sockets were enhanced. A socket developed by Parmelee in 1863 featured the first suction attachment of lower limb prosthesis [3]. Still, this kind of socket is used to prevent alignment problems and the risk of breakage at the joint. Though, there is a little similarity between the materials used in the past and today. As the current prosthesis consists of metal and plastic, Parmelee's component consists of wood and leather.

The miniature electronic circuits that were replaced with animal horn have been reached approximately in the last 35 years. Although this hearing aid was patented in the 1890s, throughout the years its actual function has not been changed. The only thing changed is its structure (fit in to the ear, amplify a wider range of sounds, and more effective). In the last 100 years, much progress has been made in comparison with the improvements made after 1890 with the horn hearing aid produced.

The development in electronics is the reason of gain today. In some conditions, the current assistive technology applications were not possible up to 15 years ago, and especially developments of the computers provide this situation. The biggest development is the existence of the microprocessor electronic circuit named as chip that reduces complicacy in computer design and structure. It is provided that room-sized devices are reduced by microprocessor up to affordable sizes that everyone can get. Moreover, microprocessors have become useful in our life such as microwave ovens and household appliances, not only in computer technology. These chips make possible developments in assistive technology such as synthesized speech, robotic aids, and computer graphics.

The recent improvements in assistive technology devices and the industrial developments in assistive technology have been affected by federal legislation in the United States, and the summary of this legislation is shown below.

#### *2.1.1. Recent major US federal legislation affecting assistive technologies*


This legislation basically mandates the facilitate access to or the use of assistive technologies by providing structure to society by prohibiting discrimination and provides services that may include assistive technologies, in relation to assistive technology.

#### **2.2. Developments in Turkey**

In our country, the statistical institution of Turkey in 2002 carried out the first comprehensive research on the people with disabilities. The second research was done in 2010 and the results were analyzed. It has been found that the analysis results in basically five categories (physical, visual, hearing, speech, and mental) of disabilities and about 9 million of the total population.

Disability is not only the person who is experiencing this problem; it is a question that affects his/her family and the surrounding environment economically, socially, and psychologically; and each group with disabilities has different needs.

While it is a disadvantage for some to be advanced and expensive, for some, simple and inexpensive technological tools can reshape their way of life. On this account, their lives can be made more livable and sustainable. Thanks to today's advanced information and communication technologies, approximately one in every eight people in the community is able to survive on better terms, becoming both necessary and feasible for them and for the general health of the community.

In addition, many legal regulations introduce responsibilities for people with disabilities. The Constitution obliges the right to work, education and social security and similar rights of all members of the society directly and indirectly in the 17-I, 42-I, 49-I, 50-I and 50-II, and 61-I materials. The regulation of 61-I, "The state takes measures to protect the people with disabilities and their adaptation to the society's life" is the responsibility of the state to take measures to protect the people with disabilities and to ensure their adaptation to society. On the other hand, Article 5 of the Electronic Communication Law No. 5809 states that "The special needs of people with disabilities, elderly and other people in need of social protection, including the use of technological innovations, are taken into account." In addition, Article 5 of the Consumer Rights Regulation in the Electronic Communications Sector stipulates, "Visually impaired persons have the right to demand subscription contracts and invoices so that they can benefit from them." Again, in our Institutional 2010–2012 Strategic Plan, it was aimed to raise awareness among entrepreneurs in related fields, including how to make access to electronic communication services easier for people with disabilities, such as accessing products and services accessible to other consumers.

#### **3. Ethics and standards of practice**

"The study of standards of conduct and moral judgment… and the system or code of morals of a particular… profession" is ethics definition [4]. When applied to a field of professional endeavor such as assistive technology delivery or a profession such as occupational therapy or rehabilitation engineering, the ethical conduct of practitioners is embodied both in code (or canons) of ethics and in standards of practice. Each assistive technology practitioner (ATP) must comply with the code of ethics for his or her discipline (e.g., rehabilitation engineering, occupational or physical therapy, speech-language pathology, or vocational rehabilitation counseling). The professional association serving a discipline generally develops the code of ethics for it. As discussed, ATPs have responsibilities in assistive technology service delivery that are not specified by their individual discipline's code of ethics. For this reason, it is important to have a code of ethics that addresses the specific issues related to the application of assistive technologies. Standards of practice differ from codes of ethics in that they describe more specifically what is and is not considered to be good practice in a given discipline [5].

• American with Disabilities Act (ADA) of 1990

152 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

and each group with disabilities has different needs.

**3. Ethics and standards of practice**

• Early and Periodic Screening, Diagnosis, and Treatment Program

may include assistive technologies, in relation to assistive technology.

This legislation basically mandates the facilitate access to or the use of assistive technologies by providing structure to society by prohibiting discrimination and provides services that

In our country, the statistical institution of Turkey in 2002 carried out the first comprehensive research on the people with disabilities. The second research was done in 2010 and the results were analyzed. It has been found that the analysis results in basically five categories (physical, visual, hearing, speech, and mental) of disabilities and about 9 million of the total population. Disability is not only the person who is experiencing this problem; it is a question that affects his/her family and the surrounding environment economically, socially, and psychologically;

While it is a disadvantage for some to be advanced and expensive, for some, simple and inexpensive technological tools can reshape their way of life. On this account, their lives can be made more livable and sustainable. Thanks to today's advanced information and communication technologies, approximately one in every eight people in the community is able to survive on better terms, becoming both necessary and feasible for them and for the general health of the community.

In addition, many legal regulations introduce responsibilities for people with disabilities. The Constitution obliges the right to work, education and social security and similar rights of all members of the society directly and indirectly in the 17-I, 42-I, 49-I, 50-I and 50-II, and 61-I materials. The regulation of 61-I, "The state takes measures to protect the people with disabilities and their adaptation to the society's life" is the responsibility of the state to take measures to protect the people with disabilities and to ensure their adaptation to society. On the other hand, Article 5 of the Electronic Communication Law No. 5809 states that "The special needs of people with disabilities, elderly and other people in need of social protection, including the use of technological innovations, are taken into account." In addition, Article 5 of the Consumer Rights Regulation in the Electronic Communications Sector stipulates, "Visually impaired persons have the right to demand subscription contracts and invoices so that they can benefit from them." Again, in our Institutional 2010–2012 Strategic Plan, it was aimed to raise awareness among entrepreneurs in related fields, including how to make access to electronic communication services easier for people with disabilities, such as accessing products and services accessible to other consumers.

"The study of standards of conduct and moral judgment… and the system or code of morals of a particular… profession" is ethics definition [4]. When applied to a field of professional

• Medicaid

• Medicare

**2.2. Developments in Turkey**

A standard is a document. Professional practitioner can find everything in this document about providing requirements, specifications, guidelines, or characteristics that can be used consistently to ensure that materials, products, processes, and services are fit for their purpose. ISO standards are an important tool, because they give information about the specifications and guidelines on how to design products and services that are accessible to everybody, to manufacturers, service providers, designers, and policy makers. There are quite a few alternative methods for grouping assistive technology. The most well-known and official classification of assistive technology is the International Classification of ISO 9999 or its European Standard CEN 29999. ISO 9999:2011 establishes a classification of assistive products, especially produced or generally available, for persons with disability. Assistive products used by a person with disability, but which require the assistance of another person for their operation, are included in the classification. The following items are specifically excluded from ISO 9999:2011: items used for the installation of assistive products; solutions obtained by combinations of assistive products that are individually classified in ISO 9999:2011; medicines; assistive products and instruments used exclusively by healthcare professionals; nontechnical solutions, such as personal assistance, guide dogs, or lipreading; implanted devices; and financial support.

There are a number of different usability standards (Bevan 2001ab; Earthy, 2001); some of them are ISO 9241 series, ISO/IEC 9126 ISO 20282 Ease of Operation of Everyday Products, ISO 9241, ISO 14915, IEC TR 61997, ISO CD 9241-151, ISO 13406, ISO 13407, ISO 16982, and ISO WD 20282. These usability standards are about different issues such as a definition of usability; product quality, which defines usability in terms of understandability, learnability, operability, and attractiveness; the usability of the user interface of everyday products; ergonomic requirements for office work with visual display terminals; software ergonomics for multimedia user interfaces; and guidelines for the user interfaces in multimedia equipment for general purpose use [6–9].

#### **3.1. Code of ethics for assistive technologies: the RESNA Code of Ethics**

RESNA is an interdisciplinary professional association whose activities focus on assistive technologies. Its members come from many disciplines and a variety of settings, and their activities involve the full scope of assistive technology applications. In 1991 the RESNA Board of Directors adopted the code of ethics shown in **Figure 1**. This code is similar to those of other


**Figure 1.** RESNA code of ethics [9].

disciplines involved in rehabilitation and is based on several of them. However, it includes issues related to the provision of technology. It is presented as a reminder of the obligations that a practitioner in the assistive technology industry has to his or her consumers, others who work with and care for them, the general public, and the profession as a whole [10, 11].


**Table 1.** Techno-ethical considerations within the four-level model prepared by Peterson and Murray.

#### **3.2. Standards of practice**

disciplines involved in rehabilitation and is based on several of them. However, it includes issues related to the provision of technology. It is presented as a reminder of the obligations that a practitioner in the assistive technology industry has to his or her consumers, others who work with and care for them, the general public, and the profession as a whole [10, 11].

*context*Client-practitioner • Educating consumers of AT services

available

device

fidelity

service training • Justice, fidelity

• Justice, fidelity

• Legal issues

• Clinical assessment matching consumer to

• Beneficence, non-maleficence, autonomy,

• Resource allocation, preservice and in-

• Efficient and effective service provision

• Periodic review and assessment

• Reciprocal advocacy, justice

**Ethical levels Techno-ethical considerations**

154 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

*context*Practitioner-practitioner • Information dissemination

*context*Institution-member • Adequate AT service provision

**Table 1.** Techno-ethical considerations within the four-level model prepared by Peterson and Murray.

*context*Legislative-constituent • Adequacy of resources

**Figure 1.** RESNA code of ethics [9].

*Level 1*: clinical/AT services*Operational* 

*Level 2*: clinical/interdisciplinary*Operational* 

*Level 3*: institutional/agency*Operational* 

*Level 4*: social resourcesPublic policy*Operational* 

Because each assistive technology practitioner belongs to his or her own discipline, it is important that the standards are often the basis for professional certification programs. RESNA has developed the standards of practice accessed from http://www.resna.org/sites/default/files/ legacy/certification/Standards\_of\_Practice\_final\_10\_10\_08.pdf for assistive technology practitioners and suppliers.

A hierarchical model of ethical practice that could be applied in education, supervision, and research is proposed by Tarvydas and Cottone [11]. Peterson and Murray defined that given the ubiquity of AT and its seemingly unlimited applications, a similar approach can be used to discuss ethical considerations with AT and its related applications; critical techno-ethical considerations related to each level are discussed and summarized in **Table 1** [12].

#### **4. Assistive technology's effects on occupational performance areas: selfcare, productivity, play, and leisure**

The role of assistive technology with disabilities is not to compensate or to adapt for missing or delaying functions; it is also used to support for everyday living in targeted performance areas [13]. The role of assistive technology in performance areas defines the occupational therapy practice framework appropriately. It includes the analysis of the performance skills and patterns of the person and the activity demands of the occupation the person is attempting to perform [14].

Occupational performance areas occurred from routines, tasks, and subtasks performed by people fulfill the requirements of occupational performance roles. These include self-care (activities of daily living, ADLs), school/productivity, and leisure/play activities. Assistive technology assists a person that has functional limitations secondary to some pathology; they may not have the cognitive, motor, or psychological skills necessary to engage in meaningful activity. To assist means to help, aid, or support, not restoration of these activities. This supports an impaired function of the user without being expected to change the native functioning of the person. For example, a wheelchair replaces the function of walking or canes support independent walking but do not improve strength or not change the ability to walk without them [13].

#### **4.1. Technology for daily living or self-care**

The ADLs comprise typical tasks required for self-care and self-maintenance, such as hygiene, bathing, feeding, dressing, medication routine, socialization, and communication. Impaired occupational performance may trigger a process that frequently influences people's biopsychosocial context, impaired self-esteem, and the sense of independence. Technological support for everyday living is all pervasive. It is also about adaptive strategies and personal assistance services. Without some combination of this supportive service, a person with a disability may not be able to get out of the house and into bed, eat dinner, take a bath, or put on clothes. The supporting services used may vary according to the needs, time, and circumstances of the person. In that way, this technology is the most challenging of all technological interventions [15, 16].

An individual's need of experience and practice with the devices that may become a part of his or her ongoing support system is frequently ignored. Professional rehabilitation intervention is often not continuing after rehabilitation process in the hospital is finished, usually because of the lack of funding. The distance of rural areas to an occupational service may be another complication. Individuals and families should be informed about the benefits and availability of professional services. Ideally, the process of technology teaching to client should be a part of the first rehabilitation in the hospital. The independent living skills training programs designed for people with disabilities and geriatrics for their social integration are important exceptions. These programs that focus on human-environment interactions should be widespread [16].

The everyday technology usefulness is not limited to any particular group of people. Everyone can use it and easy to understand design is important (**Picture 1**). Because everyone who is in contact with a person with a disability sooner or later touches his or her tool that he or she is using to live, caregivers, assistants, classmates and coworkers, and the everyday contacts should think before choosing the equipment. Another important thing about selection of equipment is that the device is perfectly fit for the person, but it causes stigmatization which creates an obstacle for interpersonal interaction for the people who use it. So everyday technology that works for everyone should be evaluated by occupational therapist in every aspect [17].

A careful match between the abilities and activities of people with disabilities for sensory perception, cognitive processing, and motor capabilities of assistive technologies ensures effective interventions [13].

A person can have different roles simultaneously, and the roles we hold during our lifetime can change such as being a student, parents, a son, a sibling, an employee, a friend, and a

**Picture 1.** Assistive technology for daily living activities.

homemaker. The life role of the individual influences the activities performed by the individual. As a part of our everyday lives, activities can be learned and are governed by the society and culture in which we live. The activities performed by an individual are determined by the roles of the individual. At the most basic level of daily living activity is the use of the upper extremities, especially fingers and hands for manipulation [18].

Daily living technology includes technological support systems in the following areas: shelter such as access and environmental control; interpersonal relationships such as communicating; personal care such as eating, hygiene, dressing, and health management; home management such as food preparation and cleaning; and functional tasks such as lifting, reaching, holding, and transferring [18].

Low technology for daily living:

General-purpose aids: mouth sticks, head pointers, and reaches

Special purpose aids:

circumstances of the person. In that way, this technology is the most challenging of all tech-

An individual's need of experience and practice with the devices that may become a part of his or her ongoing support system is frequently ignored. Professional rehabilitation intervention is often not continuing after rehabilitation process in the hospital is finished, usually because of the lack of funding. The distance of rural areas to an occupational service may be another complication. Individuals and families should be informed about the benefits and availability of professional services. Ideally, the process of technology teaching to client should be a part of the first rehabilitation in the hospital. The independent living skills training programs designed for people with disabilities and geriatrics for their social integration are important exceptions. These programs that focus on human-environment interactions

The everyday technology usefulness is not limited to any particular group of people. Everyone can use it and easy to understand design is important (**Picture 1**). Because everyone who is in contact with a person with a disability sooner or later touches his or her tool that he or she is using to live, caregivers, assistants, classmates and coworkers, and the everyday contacts should think before choosing the equipment. Another important thing about selection of equipment is that the device is perfectly fit for the person, but it causes stigmatization which creates an obstacle for interpersonal interaction for the people who use it. So everyday technology that works for everyone should be evaluated by occupational therapist in every aspect [17]. A careful match between the abilities and activities of people with disabilities for sensory perception, cognitive processing, and motor capabilities of assistive technologies ensures effec-

A person can have different roles simultaneously, and the roles we hold during our lifetime can change such as being a student, parents, a son, a sibling, an employee, a friend, and a

nological interventions [15, 16].

156 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

should be widespread [16].

tive interventions [13].

**Picture 1.** Assistive technology for daily living activities.

Self-care: a variety of utensils with modified handles, modified plates, and removable rims that are attached to any plate. Zipper pulls, single-handed buttoning, quad grip handles, long handled shoe horn, manual razors, long handled sponges, curved handled brushes, and key holders

Work and school: book holders and mouth stick

Play and leisure: modified shutter release, modified grip scissors, or garden tools

Special purpose electromechanical aids: electrically powered feeders, page-turners, environmental control units, and trainable or programmable devices

Robotic aids: robotic arms, desktop vocational assistant robot, mobile assistive robots, and mobile vocational assistant robot

#### **4.2. Technology for mobility**

Mobility is fundamental of every person's quality of life and is necessary for participation in each of the performance areas: self-care, work or school, and play or leisure. The ambulation can be replaced by low-tech aids such as canes, walker, crutches, wheelchair, or systems of various types. Increased mobility can achieve goals such as independence, functionality, positive self-imagination, social interaction, and health care [19, 20].

Disorders that affect the musculoskeletal and neurological systems such as ankylosing spondylitis, osteogenesis imperfecta, osteoporosis, Paget's disease and cerebral palsy, traumatic brain injury, cerebral vascular accident, Guillain-Barre syndrome, Huntington's chorea, muscular dystrophy, Parkinson's disease, polio myelitis, spinal cord injury, stroke, spina bifida, and multiple sclerosis result in mobility disorders [19] (**Table 2**).

The degree of limitation in mobility are full ambulatory, marginal ambulatory can walk short distances; may need wheelchair at times; marginal manual wheelchair users (part of time


**Table 2.** Conditions that require consideration of seating and positioning.

manual, part of time powered wheelchair users); totally mobility impaired users (dependent mobility base) [19] (**Pictures 2** and **3**).

Factors to consider when selecting a wheelchair:


These factors need to be evaluated for wheeled mobility. The selection of a wheelchair is a process of matching characteristics to the person's needs and skills [19].

**Picture 2.** Mobility device for participation of people with disabilities.

**Picture 3.** Client's needs for mobility.

#### **4.3. Sensory aids**

manual, part of time powered wheelchair users); totally mobility impaired users (dependent

**2.** Client's needs: activities, contexts of use, preferences, transportation, reliability, and

**3.** Physical and sensory skills: range of motion, motor control, strength, vision, and perception

These factors need to be evaluated for wheeled mobility. The selection of a wheelchair is a

mobility base) [19] (**Pictures 2** and **3**).

durability

Factors to consider when selecting a wheelchair:

**4.** Functional skills: transfers and ability to propel [19]

**1.** Client's profile: disability, date of onset, size, and weight (**Table 2**)

**Medical condition Characteristics of conditions Seating needs**

movements, abnormal patterns

movement, hypermobility

Spina bifida Decreased or absent sensation Reduce high risk for pressure

below level of injury, decreased or

Poliomyelitis syndrome Fixed or flexible If fixed, support; if flexible, correct

have cognitive component

strength, incontinence

central nervous system damage, may

decreased stability

to distal

remissions

absent sensation

fractures

Correct deformities, improve alignment, decrease tone

Provide support for upright positioning, promote development of

Provide stability but allow controlled

Provide stable seating base, allow person to find balance point

Prepare for flexibility of system to

concerns, allow for typically good upper extremity and head control

Allow for functional improvement, flexible to changing needs

Provide comfort and visual

orientation

Reduce high risk for pressure concerns, allow for trunk movements

muscle control

follow needs

used for function

Provide protection

mobility for function

Cerebral palsy (spastic type) Fixed deformity, decreased

Cerebral palsy hypotonus Subluxations, decreased active

158 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Athetoid tone Excessive active movement,

Multiple sclerosis Series of exacerbations and

Muscular dystrophies (Duchenne) Loss of muscular control proximal

Spinal cord injuries Partial or complete loss of function

Osteogenesis imperfecta Limited functional range, multiple

Traumatic brain injury Severity dependent on the extent of

Geriatrics Decreased bone mass, decreased

**Table 2.** Conditions that require consideration of seating and positioning.

process of matching characteristics to the person's needs and skills [19].

When a person has a sensory impairment such as seeing and hearing, assistive technology can provide assistance with information entry. In the case of the sensory aid, the human technology interface is a user screen, which depicts the sensory information for the human user. The processed information is presented to the user so that the alternative pathway can also be processed. For the visual pathway, this is a visible display such as a video monitor; for the auditory pathway, it is an audio display such as a speaker; and for the tactile pathway, it is a vibrating pin or electrode array through which pressure or touch data are provided to the user [21].

*Hearing impairment* is unique among disabilities and does not prevent an individual from performing an activity of daily living nor limit his or her ability to function effectively at a vocation. It is important to evaluate and use appropriate assistive technology for deafness or hearing impairment, because communicating with others affects social development or makes his or her life more difficult [22].

Assistive device for people with hearing impairment and deafness can generally be classified as either alerting devices or communicating devices. An alerting device often communicates some information to the individual, and a communicating device may well need to alert the individual that information is being communicated [23].

Alerting device may use sound, light, vibration, or any combination of these three to provide the alert. The modality selected for a given situation depends on the disability and preferences of the individual who will use the device, as well as on the environmental conditions. If the person's hearing impairment is not great, an amplified sound is impractical or ineffective; a light or vibration alerting device may be necessary. Because a vibration device needs to be contact with the body, a light-based device is preferable for a stationary device in an environment where the hearing impaired individual needs to move around.

Many assistive communication devices consist of a receiver and a transmitter. The person with the hearing impairment wears the receiver. The transmitter either is worn by the speaker or is stationary within a given environment. Three primary methods of transmission are used for these devices: infrared, radio frequency modulation, and inductive coupling.

Devices for daily living activities: these devices are helpful in using the telephone, listening television, and performing other daily living activities. A variety of sound within a home indicate things that require attention; among these sounds are doorbells, smoke alarms, alarm clocks, baby crying, and telephone ringing. Alerting systems similar to those that inform individuals who are hearing impaired or deaf of the ringing of a telephone are available for other sounds. Vibrating and flashing alarm clocks can be used to awaken an individual who cannot hear a standard alarm clock in their whole life.

The technologies produced for blind or low vision are mainly designed to provide access to information or provide safe travel. Determining the time on a watch, identifying money, reading today's mail, reviewing text on a computer screen, differentiating between black and white chess pieces, or preparing dinner without being burned access to information may mean accessing information. The information may be transmitted in tactile form, as synthetic or digitized speech, or through the use of some sort of visual enhancement such as optical or electronic magnification. People who are visually impaired typically have sufficient residual vision to permit them to perform most of their daily activities with the assistance of optical aids.

For people with low vision, increased illumination is frequently essential to their use of residual vision. Small tensor lamps placed near printed text can improve reading. Large bright light illuminates large areas; environmental adaptation or optical filters can help to provide the desired visual contrast. They can read books and magazines using computer technology. It is the most important tool for education, employment, and recreation for people with low vision. Use of Braille notetakers and Braille printers in lessons and exams is important for blind students and their teachers.

#### **4.4. School and work aids**

Assistive technologies can prove major benefits for children in education settings through all education life. Postural control or mobility systems allow children for maximal participation in classroom activities. For the use of computer and other electronic devices, special purpose interface can be effective for speaking and writing. There are some manipulatives in education that can be used to independently manipulate real objects. However policy and rules make opportunities or barriers for reaching these technologies; these are the potentials for achieving a positive educational effect.

Assistive device for people with hearing impairment and deafness can generally be classified as either alerting devices or communicating devices. An alerting device often communicates some information to the individual, and a communicating device may well need to alert the

Alerting device may use sound, light, vibration, or any combination of these three to provide the alert. The modality selected for a given situation depends on the disability and preferences of the individual who will use the device, as well as on the environmental conditions. If the person's hearing impairment is not great, an amplified sound is impractical or ineffective; a light or vibration alerting device may be necessary. Because a vibration device needs to be contact with the body, a light-based device is preferable for a stationary device in an environ-

Many assistive communication devices consist of a receiver and a transmitter. The person with the hearing impairment wears the receiver. The transmitter either is worn by the speaker or is stationary within a given environment. Three primary methods of transmission are used

Devices for daily living activities: these devices are helpful in using the telephone, listening television, and performing other daily living activities. A variety of sound within a home indicate things that require attention; among these sounds are doorbells, smoke alarms, alarm clocks, baby crying, and telephone ringing. Alerting systems similar to those that inform individuals who are hearing impaired or deaf of the ringing of a telephone are available for other sounds. Vibrating and flashing alarm clocks can be used to awaken an individual who cannot

The technologies produced for blind or low vision are mainly designed to provide access to information or provide safe travel. Determining the time on a watch, identifying money, reading today's mail, reviewing text on a computer screen, differentiating between black and white chess pieces, or preparing dinner without being burned access to information may mean accessing information. The information may be transmitted in tactile form, as synthetic or digitized speech, or through the use of some sort of visual enhancement such as optical or electronic magnification. People who are visually impaired typically have sufficient residual vision to permit them to perform most of their daily activities with the assistance of optical aids.

For people with low vision, increased illumination is frequently essential to their use of residual vision. Small tensor lamps placed near printed text can improve reading. Large bright light illuminates large areas; environmental adaptation or optical filters can help to provide the desired visual contrast. They can read books and magazines using computer technology. It is the most important tool for education, employment, and recreation for people with low vision. Use of Braille notetakers and Braille printers in lessons and exams is important for

Assistive technologies can prove major benefits for children in education settings through all education life. Postural control or mobility systems allow children for maximal participation

for these devices: infrared, radio frequency modulation, and inductive coupling.

individual that information is being communicated [23].

160 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

hear a standard alarm clock in their whole life.

blind students and their teachers.

**4.4. School and work aids**

ment where the hearing impaired individual needs to move around.

In order to discuss assistive technology for classroom, we need to understand educational activities first. And secondly necessary appropriate access between occupational therapist and school staffs for all these sources can be used affectively. Reading, writing, math, music, and art, all, require motor, sensory, and cognitive skills.

*Reading* primarily associated with as motor skills is positioning the material, turning pages, picking up a book, and opening it. If reading material is electronic, tasks include using mouse and keyboard, searching a word, and printing a part of or all text. For sensory tasks we use visual system such as visual field, visual acuity, and oculomotor function. For cognitive tasks, we use word identification, spelling, and comprehension.

*Writing* can be divided into three groups such as note taking, massaging, and formal writing. There are many alternative methods for writing by hand. Computer-aided writing can do word processing, recognize the screen, and edit and translate the task. Despite all these aids, writing needs more motor control such as pencil grip or producing the letters; sensory skills such as visual, auditory, and tactile monitoring; and cognitive skills such as thinking and reasoning. Thus occupational therapist must need to understand which process, hand use, or electronic alternatives are more affective for client in the education setting.

*Music* instruction involves basic rhythm and group participation. They need to learn instrument and listen to voice. *Art* activities need to fine motor skills and understand, imagine, and create shapes and colors.

*Work* is one of the three basic performance areas that many individuals participate daily. However in the community setting, there is barrier to participate in the work activities; it is an important life role to survive in life. There are two types of individuals that need to use assistive technology for access to employment. One is with typical disability such as spinal cord injury, arthritis, cerebral palsy, and visual impairment. Second population is at high risk for injury or has been injured while working. Disabilities most commonly seen in the second population are musculoskeletal disorders such as back pain, carpal tunnel syndrome, and tendonitis and shoulder injuries.

In order to discuss assistive technology applications in the work setting, we must define the activities that are performed in the workplace. There are three major activities that we use in the job: communication, manipulation, and mobility.

*Communication* includes all various information handling activities which include writing, reading, interacting with others, and using telephone. *Manipulation* also includes a number of different tasks such as filing, sorting, assembling, lifting, and moving objects such as books, documents, and equipment and using office machines such as copiers. Paperless office becomes much easier of this activity output. *Mobility* characteristics involve personal movement to and from the work site and within the workplace. For many individuals, getting to work is the single largest barrier. For wheelchair users, accessible public transportation means booking pickup times with range of an hour or more and paying additional fees. Due to the special tax reduction policy, the modified private transportation means may be more advantageous for individuals with disabilities. Work environment can be a challenge for person with disabilities. Activities include entering and exiting the building safely, opening and closing doors, climbing the stairs, sitting and standing, postural control, pressure management, operating device, and manipulating objects at the same time. All these activities need motor, sensory, and cognitive skills [23].

#### **4.5. Recreation or leisure and play**

*Recreation*, *leisure*, *or play* is the last of the three basic performance areas that many individuals participate. It is essential to consider individual interests, goals, skills, and functional abilities in identifying appropriate and satisfying leisure pursuits. The identification of *recreational* interests should focus initially on the features of different types of activity, rather than the naming of specific hobbies or sports. Characteristics of activities may be competitive such as amputee football, creative such as art craft, individual or group, organized or unstructured, physically active or sedentary. One's activity needs to match with individual's ability and desire. A person's motor, sensory, and cognitive functions must be assessed adequately. Then assistive device must be selected for those people. Adaptation can be made to ensure satisfactory participation. Assistive devices for recreation can be categorized as personal, activity-specific, or environmental technologies. Personal technology is an equipment that they wear to participate in a desired activity such as racing wheelchair, dynamic prosthesis; activity-specific technologies enable them to perform specific types of activities such as hand bike, monoski, and tennis grips. Environmental technologies most often function to provide the daily living needs of people such as shelter, food, and water. Additionally environmental technologies also include maps, signs, and other means used to communicate accessible information for each environment [24].

Nowadays, it is common to consider *play* a child's work. For children with physical conditions that limited their opportunities to explore play materials and their play possibilities, the purpose of intervention and assistive technology must bring the opportunities to them not to direct their play but to make intrinsically motivated activities and play pleasurably as possible.

There are two important areas for play: environment (indoor and outdoor) and toys. Every child's bedroom and play areas have the same four things: walls, floors, ceiling, and openings such as windows and doors. There are many ways to match an individual child's developmental needs with the home's physical environment. Most of the following ideas are simple, inexpensive, or free and are just a starting point to stimulate thinking. It is important to keep in mind the child's developmental changes, the family's life style, and the child's siblings and friends. There are many ways to use assistive technology to make an outdoor play area fun for children with a disability. For them there are some important challenges such as safety, gates, water play, ground, trees, and commercial play structures [25].

#### **5. Interaction of setting and context and assistive technology**

In the models used before the 1950s, only the disability was focused. Later, with the developing models, it was observed that the person with a disability has environmental factors as obstacles that hinder the person from doing the activity, and the awareness in this subject has increased. It has been seen that the lives of people with disabilities are greatly facilitated by person-environment harmony. In relation to this, there are many approaches that define and regulate the environment. These models include:


movement to and from the work site and within the workplace. For many individuals, getting to work is the single largest barrier. For wheelchair users, accessible public transportation means booking pickup times with range of an hour or more and paying additional fees. Due to the special tax reduction policy, the modified private transportation means may be more advantageous for individuals with disabilities. Work environment can be a challenge for person with disabilities. Activities include entering and exiting the building safely, opening and closing doors, climbing the stairs, sitting and standing, postural control, pressure management, operating device, and manipulating objects at the same time. All these activities need

*Recreation*, *leisure*, *or play* is the last of the three basic performance areas that many individuals participate. It is essential to consider individual interests, goals, skills, and functional abilities in identifying appropriate and satisfying leisure pursuits. The identification of *recreational* interests should focus initially on the features of different types of activity, rather than the naming of specific hobbies or sports. Characteristics of activities may be competitive such as amputee football, creative such as art craft, individual or group, organized or unstructured, physically active or sedentary. One's activity needs to match with individual's ability and desire. A person's motor, sensory, and cognitive functions must be assessed adequately. Then assistive device must be selected for those people. Adaptation can be made to ensure satisfactory participation. Assistive devices for recreation can be categorized as personal, activity-specific, or environmental technologies. Personal technology is an equipment that they wear to participate in a desired activity such as racing wheelchair, dynamic prosthesis; activity-specific technologies enable them to perform specific types of activities such as hand bike, monoski, and tennis grips. Environmental technologies most often function to provide the daily living needs of people such as shelter, food, and water. Additionally environmental technologies also include maps, signs, and other means used to communicate accessible information for

Nowadays, it is common to consider *play* a child's work. For children with physical conditions that limited their opportunities to explore play materials and their play possibilities, the purpose of intervention and assistive technology must bring the opportunities to them not to direct their play but to make intrinsically motivated activities and play pleasurably as

There are two important areas for play: environment (indoor and outdoor) and toys. Every child's bedroom and play areas have the same four things: walls, floors, ceiling, and openings such as windows and doors. There are many ways to match an individual child's developmental needs with the home's physical environment. Most of the following ideas are simple, inexpensive, or free and are just a starting point to stimulate thinking. It is important to keep in mind the child's developmental changes, the family's life style, and the child's siblings and friends. There are many ways to use assistive technology to make an outdoor play area fun for children with a disability. For them there are some important challenges such as safety, gates,

water play, ground, trees, and commercial play structures [25].

motor, sensory, and cognitive skills [23].

162 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**4.5. Recreation or leisure and play**

each environment [24].

possible.

Accomplishing the procedure of NARA has several loops of four steps: gathering information from users like dealing with groups and interviews, using the information to obtain requirements, producing a paper-based mock-up or low fidelity prototype that carries out the requirements, and evaluating the guidelines for accurate implementation, usability, and relevance. The new groups of assessment activities, which are advanced from procedure that is the former one, are applied to a new sample of end users.

The MPT and USERfit are also having a well-developed questionnaire structure for getting end-user data.

The HAAT and CAT models have a hierarchical structure with four components of person, activity, technology, and context at the top level (**Boxes 1** and **2**). They could be used for knowledge obtained in the format of questionnaires or interviews [27].

The CAT model consists of main categories that are similar to the HAAT model; hence, the CAT model is almost identical to the HAAT model. Both models are appropriate for applications


**Box 1.** Context in the CAT model.


**Box 2.** Context in the HAAT model.

of device design and development, guidance of the service delivery process, and outcome evaluation. However, the supporting description separates both models. The interaction that is more dynamic is hypothesized by HAAT model. The CAT model, on the other hand, presupposes more description of the individual categories.

In this part, we will observe the context closely according to the model of HAAT.

*Setting*: Setting not only is the location but also a combination of an environment, a set of governing the tasks, tasks to be done, and a level of good feeling.

The settings are listed in **Box 1** and **2**.

Many people with disabilities live in their own homes. In order for these individuals to be able to survive independently, some modifications are required within or outside the home. Group houses are houses where a large number of individuals with the same needs are present unlike individual houses. On the one hand, group houses are not enough for some requirements such as lack of privacy, degree of interaction with other consumers who can help in developing strategies of use, and the availability of organized recreational and educational activities. On the other hand, they have some principles and security system [28]. Thus, all of them should be taken into account.

The three settings that we differentiate significant to the application of assistive technologies outside the living situation are employment, school, and community. Work requires to be completed in a timely and accurate manner, and assistive technologies can influence the conclusion for a handicapped person in a vocational or educational setting. All those places that recreation, leisure, shopping, and entertainment occur are surrounded by the community setting. Why it is hard to characterize it specifically is that this setting is so different. In this setting, the variety also causes requirements being placed on the assistive technology. For instance, the use of an assistive device affects mobility of blind people in order to observe the type of terrain and existence of obstacles. In a home or employment setting that travel paths are used regularly and objects are fixed in, obtaining this orientation is relatively straightforward. However, ignorance of environment and travel is more difficult in a shopping mall, restaurant, or theater, which is an unusual place to visit for blind person. The type of setting dictates the characteristic of the assistive technology system, and a system is successful in one environment, whereas the system is not successful in another [29]. Additionally, the requirements of devices change according to terrain such as a manual wheelchair is okay around the house with hard rubber tires, but it is not for rough outdoor terrain.

#### **5.1. Social and cultural contexts**

We should deal with the social context that this performance takes place in because we deal with helping human performance in communication, manipulation, and mobility, so social context is important. Handicapped people may be stigmatized by reason of their disability; thus, using the assistive devices may cause further isolation and contribute to the labeling. For instance, a person who has hearing handicap may not want to wear a hearing aid, but the person is unlikely to have same claim not to wear glasses for reading. In the environments that the activity will be well performed, why it is crucial to conduct assessments and technology trials is that main subject in assistive technology use is likely social context.

Social and cultural contexts may be almost identical; especially, it is for people who form part of dominant cultural and social contexts except members of minority groups, including people with disabilities. Variables of interest in both the user's and wider social and cultural context include language, other cultural factors, and attitudes to people with disabilities, and attitudes to assistive technology. Why language and other cultural factors are very important is that many features of assistive technology devices that can be used are only provided in English and sometimes a small number of European languages, whereas both speech output, if any, and documentation and manuals need to be in the local language. Furthermore, the device requires designing and presenting in a way that is culturally relevant. This consists of the choice of symbols or other labels for controls that are simple in the cultural context.

#### **5.2. Physical context**

of device design and development, guidance of the service delivery process, and outcome evaluation. However, the supporting description separates both models. The interaction that is more dynamic is hypothesized by HAAT model. The CAT model, on the other hand, pre-

Group home Employment School Community

Familiar nonpeers

Strangers Alone

Sound Heat

*Setting*: Setting not only is the location but also a combination of an environment, a set of gov-

Many people with disabilities live in their own homes. In order for these individuals to be able to survive independently, some modifications are required within or outside the home. Group houses are houses where a large number of individuals with the same needs are present unlike individual houses. On the one hand, group houses are not enough for some requirements such as lack of privacy, degree of interaction with other consumers who can help in developing strategies of use, and the availability of organized recreational and educational activities. On the other hand, they have some principles and security system [28]. Thus,

The three settings that we differentiate significant to the application of assistive technologies outside the living situation are employment, school, and community. Work requires to be completed in a timely and accurate manner, and assistive technologies can influence the conclusion for a handicapped person in a vocational or educational setting. All those

In this part, we will observe the context closely according to the model of HAAT.

supposes more description of the individual categories.

Setting Individual home

164 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Social context Familiar peers

Physical context Light

The settings are listed in **Box 1** and **2**.

Context

Cultural context

**Box 2.** Context in the HAAT model.

all of them should be taken into account.

erning the tasks, tasks to be done, and a level of good feeling.

Physical context is simply environmental situation that means the system is used. Heat, sound, and light are the usual measured parameters that most directly influence the success of the assistive technologies. The temperature influences some materials. For instance, the features of gels and foams used in seat pillows can alter under hot or cold conditions. The temperature influences monitoring of liquid crystal like existing light.

In the environment of classrooms or work, the use of assistive technologies depends on existing light. In situation of bright light, some display reverse light and are better. On the other hand, others give out light and are better in low light.

Penetrability of voice recognition systems or speakers can be affected by existing sound. For instance, in a classroom, some devices that generate sound such as powered wheelchairs, computers, and printers may upset classroom attention.

The occupational therapy approaches are not considered without context. Because the occupations is affected by context is no static. The assistive technology is used in education or work that are most important occupational areas. The assistive technology is important for people with disabilities to facilitate the changing life.

#### **6. The use of assistive technology for the people with disabilities: sensory, perceptual, cognitive, and motor control and other functions**

Assistive technology is an umbrella term for assistive, adaptive, and rehabilitative devices for people with disabilities. It also includes the process of selecting, positioning, and using these devices. It is used to provide transportation to the house, to the interiors, or to the buildings. They provide access to community spaces, home, education, recreation areas, transportation, and jobs. By changing or improving the tasks that people have failed before, they are able to greatly increase their independence and contribute to health and well-being. Greatly increase their independence, and contribute to health and well-being. It can be used to protect, maintain, or increase the independence of people. Assistive technology allows people to learn, play, act, work, communicate, and participate as their peers [30, 31]. In short, it opens the gates of the world to the people.

Assistive technology can be any tool or product that enhances the individual's involvement and functions. These devices may be particularly developed for the use of a specific person or may be accessible to the whole community, developed for all, that can also be used by persons with disabilities. These tools may be products that are simple to design and use (such as clothing aids) and may also be very high-tech (bioelectrical orthoses) products. It facilitates interaction with the environment for everyone. The proper use of assistive technology reduces the help from other people to minimal level and can support people's independent living in the community. Assistive technology transport greatly enhances the quality of life for both people with and without disabilities. In addition to the people with physical, sensorial, and cognitive impairment, disadvantaged populations such as seniors and pregnant women are the most beneficiaries [31–35].

It is a common mistake to consider the assistive technology as equipment, which compensates the impaired body parts and/or functions. In the leadership of one of the mainstream occupational therapy models, Person-Environment-Occupation (PEO) model [36], an occupational therapist must remember that it is not only the personal factors that have a contribution on occupational performance but the contexts of the environment and the occupation itself. This leads us to two points: (1) expanding the assistive technology assessment and interventions, including environmental, and occupation, and (2) personal factors are not the only reason of decreased activity performance and/or participation. The first aspect is being argued in the future part of this chapter. The latter aspect, however, is the point that has to be stressed in this case. An individual who so called "healthy" may be suffering from decreased occupational performance due to either environmental or occupational factors. Although it is ideal to have a universal design in the physical environment, which is something that makes the surrounding available for the individuals in the community, the universal designed tools are not the most suitable media for everyone since they are not created for individual. And of course it has an impact on the performance of the people. Last but not least, the occupation itself can lead to the need of assistive technology. Tasks such as requiring inactivity, putting too much pressure to the human body, and forcing human body's function boundaries make the assistive technology support indispensable. Imagine an office worker, who is a 25-yearold female, consults an occupational therapy practitioner complaining about excessive fatigue and tiredness in her back during her working hours. A neurologist referred her and there was no specific problem with the medical examination. The role of occupational therapist as an assistive technology practitioner is to evaluate the both physical environment and the tasks in occupations besides the personal factors [35, 37–39].

There is something very important that needs to be underlined when talking about this subject. Assistive technology is not all about the recovery but a protection and maintenance, too. That is, assistive technology should not only be regarded as a method in the rehabilitation phase but should also take place in the previous phases of healthcare systems [31, 35, 40].

#### **6.1. Assistive technology types**

In the environment of classrooms or work, the use of assistive technologies depends on existing light. In situation of bright light, some display reverse light and are better. On the other

Penetrability of voice recognition systems or speakers can be affected by existing sound. For instance, in a classroom, some devices that generate sound such as powered wheelchairs,

The occupational therapy approaches are not considered without context. Because the occupations is affected by context is no static. The assistive technology is used in education or work that are most important occupational areas. The assistive technology is important for

Assistive technology is an umbrella term for assistive, adaptive, and rehabilitative devices for people with disabilities. It also includes the process of selecting, positioning, and using these devices. It is used to provide transportation to the house, to the interiors, or to the buildings. They provide access to community spaces, home, education, recreation areas, transportation, and jobs. By changing or improving the tasks that people have failed before, they are able to greatly increase their independence and contribute to health and well-being. Greatly increase their independence, and contribute to health and well-being. It can be used to protect, maintain, or increase the independence of people. Assistive technology allows people to learn, play, act, work, communicate, and participate as their peers [30, 31]. In short, it opens the

Assistive technology can be any tool or product that enhances the individual's involvement and functions. These devices may be particularly developed for the use of a specific person or may be accessible to the whole community, developed for all, that can also be used by persons with disabilities. These tools may be products that are simple to design and use (such as clothing aids) and may also be very high-tech (bioelectrical orthoses) products. It facilitates interaction with the environment for everyone. The proper use of assistive technology reduces the help from other people to minimal level and can support people's independent living in the community. Assistive technology transport greatly enhances the quality of life for both people with and without disabilities. In addition to the people with physical, sensorial, and cognitive impairment, disadvantaged populations such as seniors and pregnant women are

It is a common mistake to consider the assistive technology as equipment, which compensates the impaired body parts and/or functions. In the leadership of one of the mainstream occupational therapy models, Person-Environment-Occupation (PEO) model [36], an occupational therapist must remember that it is not only the personal factors that have a contribution on occupational performance but the contexts of the environment and the occupation itself. This leads us to two points: (1) expanding the assistive technology assessment and interventions,

**6. The use of assistive technology for the people with disabilities: sensory, perceptual, cognitive, and motor control and other functions**

hand, others give out light and are better in low light.

166 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

computers, and printers may upset classroom attention.

people with disabilities to facilitate the changing life.

gates of the world to the people.

the most beneficiaries [31–35].

As mentioned above, wide range of devices could be applied to improve and maintain performance and functionality. In literature, there are different ways of classification for all of these products [31, 35, 41, 42]. These could be: Low tech: communication cards made from cards High technology: special purpose computers Hardware: prostheses, mounting systems, or positioning tools Computer hardware: special keys, keyboards, and pointing devices Computer software: screen readers and communication programs

If assistive technology is available and appropriate for the people, they can benefit from living independently, enjoy self-management and decision-making skills, and be able to benefit from educational facilities, carrying on a meaningful career, being fully involved in general economic, political, social, cultural, and educational contexts.

Benefits of assistive technology in individuals can be summarized as follows [42]:


Assistive technology seems quite useful for both children and adults. However, every assistive technology tool received is unfortunately not always used for a long time. One of the main reasons of this consequence is ignoring to get the opinion of the client. And also, some machines are easy to get. This can lead to quick purchases, without having to worry much enough when making a purchase [43]. No matter how easily a device can be reached, the occupational therapist must make a detailed assessment in order to be able to combine and meet the advantages of the assistive technology to the needs of the person. Another reason is that a person thinks they can get this device easily without consulting the therapist for evaluation and application. In addition, evaluation and training are also important to make use of and benefit from the purchase of the product. And of course, a change in the priorities of the client may cause the disuse. At that point, it is important to remember an assistive technology is a tool that fills the gap among the person, environment, and occupation. Any change in them may cause a change in the need for assistive technology. For example, a child using a wheelchair, who is a student, would be in need of a ramp builder for the stairs in front of the school building until the elevator is built. When the building becomes available for that child, there will be no need for that specific tool, but rather a need auditory support for the use of the elevator.

#### **7. Service and maintenance in assistive technologies**

The steps of the service process in assistive technology (AT) are referral, need analyses, recommendations, implementation, and follow-up. In referral step, the person specifies a need about assistive technology intervention and consults a therapist or AT provider. The need analyses step is an evaluation phase of human's need, skills, and functions. In recommendation step, it is important to justify funding and make the recommendations based on the results of assessments. In implementation step, fitting and training of the AT device or system should be done. Finally, in follow-up, maintenance and repair needs of AT device or system should be considered, and the effect of AT use should be evaluated [44, 45]. If these steps of the service process in AT are not considered by the therapist or provider of AT, the barriers to use the AT device may occur [44–49]. Below, you can find barriers, which may affect the use of AT device (**Table 3**).

#### **7.1. Assistive technology assessment and intervention principles**

The first step of the AT intervention is assessment of the person. Because through results of the assessment, the person is understood and analyzed by the therapist, and then the intervention plan is conducted. For the assistive technology process, many models are developed and used [49–51]. You can find these models in the AT field below (**Table 4**).

#### **Barriers to use AT**

• Increase independence and self-care.

168 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

• Build confidence and self-confidence.

areas.

• Provide an environment free of hindrances at home, at school, at work, and in communal

Assistive technology seems quite useful for both children and adults. However, every assistive technology tool received is unfortunately not always used for a long time. One of the main reasons of this consequence is ignoring to get the opinion of the client. And also, some machines are easy to get. This can lead to quick purchases, without having to worry much enough when making a purchase [43]. No matter how easily a device can be reached, the occupational therapist must make a detailed assessment in order to be able to combine and meet the advantages of the assistive technology to the needs of the person. Another reason is that a person thinks they can get this device easily without consulting the therapist for evaluation and application. In addition, evaluation and training are also important to make use of and benefit from the purchase of the product. And of course, a change in the priorities of the client may cause the disuse. At that point, it is important to remember an assistive technology is a tool that fills the gap among the person, environment, and occupation. Any change in them may cause a change in the need for assistive technology. For example, a child using a wheelchair, who is a student, would be in need of a ramp builder for the stairs in front of the school building until the elevator is built. When the building becomes available for that child, there will be no need

for that specific tool, but rather a need auditory support for the use of the elevator.

The steps of the service process in assistive technology (AT) are referral, need analyses, recommendations, implementation, and follow-up. In referral step, the person specifies a need about assistive technology intervention and consults a therapist or AT provider. The need analyses step is an evaluation phase of human's need, skills, and functions. In recommendation step, it is important to justify funding and make the recommendations based on the results of assessments. In implementation step, fitting and training of the AT device or system should be done. Finally, in follow-up, maintenance and repair needs of AT device or system should be considered, and the effect of AT use should be evaluated [44, 45]. If these steps of the service process in AT are not considered by the therapist or provider of AT, the barriers to use the AT device may occur [44–49]. Below, you can find barriers, which may affect the use of AT device (**Table 3**).

The first step of the AT intervention is assessment of the person. Because through results of the assessment, the person is understood and analyzed by the therapist, and then the intervention plan is conducted. For the assistive technology process, many models are developed

**7. Service and maintenance in assistive technologies**

**7.1. Assistive technology assessment and intervention principles**

and used [49–51]. You can find these models in the AT field below (**Table 4**).


**Table 3.** Barriers which may affect the use of assistive technology.


**Table 4.** Models are used in assistive technology field.

According to a research study, we are focusing on environmental components especially physical environment much more in the AT studies [56]. Therefore, these models are important for focusing all parameters related to AT. Consequently, principles which are important for systematizing assessment and intervention in AT are represented below. These principles may provide significant support for the aim, selection of the models, standards, and types of assistive technology [50].


#### **7.2. The Human Activity Assistive Technology (HAAT) model**

The Human Activity Assistive Technology (HAAT) model, which is designed by Cook and Hussey in 1995, is a framework about assistive technology for people with disability. The model is created to guide assessment and clinical intervention and evaluate the outcomes. The HAAT model is a well-known model in assistive technology (AT) field [50, 57].

Some of the research studies mentioning the HAAT model suggest its extensive use in research and clinical applications [45]. According to a survey which is done to rehabilitation clinicians and by Friederich et al. [51], even though clinicians expressed that they are not using any framework for their practice, it was found that HAAT model was the only specific assistive technology model which is used [53]. Also the model is used as a reference in several research studies [56, 58–61].

#### **7.3. Components of the HAAT model**

There are four components in the model: the human, the activity, the assistive technology, and the context (**Figure 2**). There is a dynamic relation between three components, and the context has effect on these three components.

The human component contains cognitive, physical, and emotional elements. Cognitive abilities include problem solving, attention, alertness, and concentration, and they have effect on emotional abilities. Physical abilities include balance, range of motion, strength, and coordination. It is very important to know these abilities about human because they probably affect the use of assistive technology. Therefore for the effective use of assistive technology, a match between human abilities and the requirements of assistive technology is needed. Also AT may provide assistance in the area, which the person has problems such as hearing or visual. For example, in hearing problems AT can provide a device for hearing and provide the person to maintain this ability again.

The activity component contains self-care, productivity, and leisure activities. Self-care activities include dressing, eating, hygiene, mobility, and communication. Productive activities are educational and vocational activities and home management. Leisure activities include relaxation or enjoyment such as watching TV, resting, reading books, or dancing. These activities may require many abilities such as cognitive and physical. If the person has no capacity to

**Figure 2.** HAAT model [5].

• Assistive technology assessment and intervention should include all components such as

• The aim of AT should be maintaining the function which is impaired, not remediating the

• Interpreting the assessment and the outcomes of intervention is important for the selection

The Human Activity Assistive Technology (HAAT) model, which is designed by Cook and Hussey in 1995, is a framework about assistive technology for people with disability. The model is created to guide assessment and clinical intervention and evaluate the outcomes. The

Some of the research studies mentioning the HAAT model suggest its extensive use in research and clinical applications [45]. According to a survey which is done to rehabilitation clinicians and by Friederich et al. [51], even though clinicians expressed that they are not using any framework for their practice, it was found that HAAT model was the only specific assistive technology model which is used [53]. Also the model is used as a reference in several research

There are four components in the model: the human, the activity, the assistive technology, and the context (**Figure 2**). There is a dynamic relation between three components, and the

The human component contains cognitive, physical, and emotional elements. Cognitive abilities include problem solving, attention, alertness, and concentration, and they have effect on emotional abilities. Physical abilities include balance, range of motion, strength, and coordination. It is very important to know these abilities about human because they probably affect the use of assistive technology. Therefore for the effective use of assistive technology, a match between human abilities and the requirements of assistive technology is needed. Also AT may provide assistance in the area, which the person has problems such as hearing or visual. For example, in hearing problems AT can provide a device for hearing and provide the person to

The activity component contains self-care, productivity, and leisure activities. Self-care activities include dressing, eating, hygiene, mobility, and communication. Productive activities are educational and vocational activities and home management. Leisure activities include relaxation or enjoyment such as watching TV, resting, reading books, or dancing. These activities may require many abilities such as cognitive and physical. If the person has no capacity to

• Assistive technology assessment and intervention should be collaborative.

HAAT model is a well-known model in assistive technology (AT) field [50, 57].

person, activity, and environment.

of AT [44, 50].

studies [56, 58–61].

maintain this ability again.

**7.3. Components of the HAAT model**

context has effect on these three components.

function. So AT should be an enabler for the function.

170 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

• Assistive technology assessment should be perpetual.

**7.2. The Human Activity Assistive Technology (HAAT) model**

do an activity, with the use of an assistive technology system, the person may gain his/her performance on this activity again.

The context contains cultural (pattern of behaviors, values, attitudes) physical (natural and built surroundings such as home, school, workplace, or parks), institutional (religious, educational institutions), and social (family, friends, strangers). Facilitators and barriers in the environment are very important for the selection, evaluation, and use of the assistive technology system.

The assistive technology is described as extrinsic enablers because they provide the performance, which is blocked by disability. Choosing or designing an AT system should be done through considering needs, skills, and goals of the person. Therefore a detailed assessment about functions, activities, and environment is needed before determining the AT system for the person [50, 57].

#### **8. Funding assistive technology services and systems**

Most consumers have problem about evaluation, implementation, and maintenance and repair of assistive technologies because of not having the adequate financial resources available to purchase the necessary services and equipment. Funding by third-party sources is appropriate for individuals to procure assistive technology services and equipment. Funding for many assistive technology services and devices is widely available, and accessing that funding is generally a matter of following a straightforward process. As a service provider, the occupational therapist's role is assisting with the acquisition of this funding.

In most countries assistive technology services and devices are financed by numerous sources instead of by a system only dedicated to the funding of assistive technology services and equipment. For any given individual, equipment and services may be financed only by one source or a combination of sources. Funding for assistive technology is usually rendered through agencies that have been primarily developed for the provision of other types of health, education, or social services programs.

In this part funding for assistive technologies in several countries (the United States, Australia, Canada, and Turkey) is described. Funding programs in these countries are representative of those in many other countries with local modifications of elements of the programs. The various funding sources can be categorized as public and private.

#### **8.1. Public sources of funding**

#### *8.1.1. US public sources of assistive technology funding*

Public funding sources for assistive technology in the United States include federal, state, and local government agencies; several public sources of funding are listed in **Box 3** [62].



**Box 3.** The public funding sources in the United States\*.

In most countries assistive technology services and devices are financed by numerous sources instead of by a system only dedicated to the funding of assistive technology services and equipment. For any given individual, equipment and services may be financed only by one source or a combination of sources. Funding for assistive technology is usually rendered through agencies that have been primarily developed for the provision of other types of

In this part funding for assistive technologies in several countries (the United States, Australia, Canada, and Turkey) is described. Funding programs in these countries are representative of those in many other countries with local modifications of elements of the programs. The vari-

Public funding sources for assistive technology in the United States include federal, state, and

State bond issues

removal

Americans with Disabilities Act credit for small business

Credit for architectural and transportation barrier

local government agencies; several public sources of funding are listed in **Box 3** [62].

health, education, or social services programs.

172 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

*8.1.1. US public sources of assistive technology funding*

Intermediate care facilities for persons who are mentally

Individuals with Disabilities Education Act state grants

IDEA programs for infants and toddlers with disabilities

retarded

(Part B)

and their families (Part H)

**8.1. Public sources of funding**

ous funding sources can be categorized as public and private.

Public programs Low-interest loans Medicare Private foundations Medicaid Service clubs

Required and optional services Special state appropriations

Home- and community-based waivers Equipment loan program Community-supported living arrangements Corporate-sponsored loans Maternal and child health Charitable organizations

Children with special healthcare needs Medical care expense deduction

Education Employee business deductions

Maternal and child health block grant to states US TAX CODE

Special projects of regional and national significance Business deductions

State-operated programs Targeted jobs tax credit

Head start Private health insurance Vocational Rehabilitation Health insurance

Vocational education Charitable contribution deduction

Early and periodic screening, diagnosis, and treatment Employee accommodations program

#### *8.1.2. Canadian provincial and territorial sources of assistive technology funding*

In Canada the delivery of health services is the responsibility of the provinces and territories. Although there are federal programs, most of assistive technology funding is allocated and managed at the provincial/territorial level. Most of the federal programs have clauses about funding only what the provinces and territories do not fund. The Canadian federal programs that fund assistive technologies were listed in **Table 5**. Canadian public funding sources by province or territory are changed by funded assistive device, special conditions, or program features and eligibility [62].

#### *8.1.3. Australian state government funding schemes*

The funding programs that are provided through the state governments of Australia have been designed specifically to provide for people with disabilities and include assistive technology in the lists of approved items. The state programs have evolved quite independently in each Australian state or territory and therefore are not uniform. The schemes are administered through various state government departments and are funded from state/territory sources. Although all these programs have similar objectives, there is variation in the level and range of assistance that they provide to people with disabilities. These programs also vary in their level of means testing. The Australian state funding schemes are summarized in **Table 6** [62].


\*Received from Cook and Polgar [5].

**Table 5.** Canadian Federal Programs That Fund Assistive Technologies\*.


**Table 6.** Australian funding programs by state\* .

#### **8.2. Turkey state government funding**

**Program Assistive devices funded Special conditions or program** 

174 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Depends on province or

Devices necessary for return to work

A variety of mobility devices, aids to daily living items not listed on the benefit list may be considered on a case-bycase basis with written medical justification

canes, walkers; foot boards, over bed tables, raised toilet seats, bath

**Table 5.** Canadian Federal Programs That Fund Assistive Technologies\*.

territory

Veterans' affairs Aids to daily living,

\*Received from Cook and Polgar [5].

Australian Capital Territory

Scheme

**Table 6.** Australian funding programs by state\*

\*Received from Cook and Polgar [5].

benches

Aging and seniors

Workers' compensation board

Health Canada-First Nations and Inuit Health: noninsured health benefits

**features**

territory

province

**State Assistive technology funding program name Managing authority**

Queensland Medical Aids Subsidy Scheme Queensland Health

Australian Capital Territory Equipment Subsidy

.

New South Wales Program of Appliances for People with disabilities New South Wales Department

Victoria Victorian Aids and Equipment Program Department of Human Services Western Australia Community Aids and Equipment Program Disability Services Commission

South Australia Independent Living Equipment Program Disability Services South Australia Tasmania Community Equipment Scheme Department of Health and Human

Northern Territory Territory Independence and Mobility Scheme Department of Health and

Benefits related to provincial/ territorial programs

One for each province and

Device is listed by program; intended for use in a home or other ambulatory care settings; not available through any other federal, provincial territorial, or private health or social program; prescribed by health professional licensed to prescribe; provided by a recognized provider

Available devices may vary by

**Eligibility**

away from work

Workplace injuries including workrelated accidents or diseases that require medical treatment or time

Canadian resident and one of the following: (1) registered Native Canadian according to the Indian Act, (2) Inuk recognized by one of the Inuit Land Claim Organizations, or (3) infant less than 1 year of age whose parent is an eligible recipient

Group "A" clients: pension from Veterans Affairs CanadaGroup "B" clients: established eligibility for treatment of non-pensioned conditions, established health need, benefits not covered by the province

of Area Health and Community

Services

Services

Community Services

Aged Care and Rehabilitation Service

In Turkey, the assistive technology is termed as medical device which means any instrument, apparatus, appliance, software, material, or other articles, whether used alone or in combination, including the software intended by its manufacturer to be used specifically for diagnostic and/or therapeutic purposes and necessary for its proper application and intended by the manufacturer to be used for human beings for the purpose of (1) diagnosis, prevention, monitoring, treatment, or alleviation of disease; (2) diagnosis, monitoring, treatment, alleviation, or compensation for an injury or handicap; (3) investigation, replacement, or modification of the anatomy or of a physiological process; and (4) control of conception, which does not achieve its principal intended action in or on the human body by pharmacological, immunological, or metabolic means, but which may be assisted in its function by such means [63].

Health Application Notification (HAN) (Sağlık Uygulama Tebliği—SUT) is a document in which price ratio is listed. The HAN was issued within the framework of the Social Security Institution Law No. 5502, the Social Insurance and General Health Insurance Law No. 5510, and the General Health Insurance Transactions Regulation published in the Official Gazette dated August 28, 2008 and numbered 26981. The purpose of HAN is services related to health insurance, social security institution, general health insurance and establishment obligations, health services financed by the institution, methods for utilizing the road, and daily and attendant expenses, and the procedures related to the procedures are stated in the Health Services Pricing Commission [64].

#### *8.2.1. Private sources of funding*

In addition to public sources, there are private sources of funding such as self-funding, private health insurance, and others. These vary by economic condition or person. For instance, the Solidarity Association for the people with physical disabilities in Turkey provides their citizens who have physical disabilities or financial difficulties in order to facilitate their lives and to participate in life and to be liberated by making wheelchair aids with the priority needs. World Eye Foundation in Turkey provided 300 "smartphones" designed for the high school students with visually impaired to help them function independently and utilize information in their daily lives easily, support their educations and facilitate their access to information.

#### *8.2.2. Private health insurance in Turkey*

Financing of the public health insurance system in Turkey is covered by employee and employer premium. Participation in the general health insurance system, which has been implemented since January 10, 2008, is mandatory and essential. The private health insurance that "completes and supports" the general health insurance is a voluntary insurance type and secondary. In Turkey, there is no possibility of making a substitute private health insurance. For this reason, private health insurance in our country can be referred to as "voluntary health insurance" or "complementary and supportive health insurance." Health insurance is defined in article 1513 of the Turkish Commercial Code No. 6102. According to this, health insurance and insurer give a guarantee for (1) the end of the disease if necessary, including any medicinal treatment, pregnancy, and birth; (2) for costs determined for the early diagnosis of diseases, including consecutive studies, (3) in cases where it is necessary to perform medically inpatient treatment, (4) for the daily allowance for the insured's unavailability of earnings due to ill-treatment, (5) if the insured is in need of care, costs incurred due to care, or agreed daily care allowance [65].

#### **Author details**

Gokcen Akyurek\*, Sinem Kars, Zeynep Celik, Ceren Koc and Özge Buket Cesim

\*Address all correspondence to: gkcnakyrk@gmail.com

Department of Occupational Therapy, Faculty of Health Science, Hacettepe University, Ankara, Turkey

#### **References**


[10] RESNA. Standards of Practice. [Internet]. 2016. Available from: http://www.resna. org/sites/default/files/legacy/certification/Standards\_of\_Practice\_final\_10\_10\_08.pdf [Accessed: 21 February 2017]

insurance and insurer give a guarantee for (1) the end of the disease if necessary, including any medicinal treatment, pregnancy, and birth; (2) for costs determined for the early diagnosis of diseases, including consecutive studies, (3) in cases where it is necessary to perform medically inpatient treatment, (4) for the daily allowance for the insured's unavailability of earnings due to ill-treatment, (5) if the insured is in need of care, costs incurred due to care, or

Department of Occupational Therapy, Faculty of Health Science, Hacettepe University,

[1] Technology Related Assistance for Individuals with Disabilities Act of 1988, Pub. L. No.

[2] American Occupational Therapy Association. Specialized knowledge and skills in technology and environmental interventions for occupational therapy practice. American

[3] Murphy EF, Cook AM, Harvey RF. Neuromuscular prosthetics and orthotics. Englewood

[4] McKechnie JL. Webster's New Twentieth Century Dictionary of the English Language.

[5] Introduction and overview. In: Cook AM, Polgar JM, editors. Cook and Hussey's Assistive Technologies: Principles and Practice. 3rd ed. St. Louis, MO: Mosby Elsevier;

[6] Bevan N. International standards for HCI and usability. International Journal of Human-

[7] Bevan N. Quality in use: Meeting user needs for quality. Journal of Systems and Software.

[8] Earthy J. The improvement of human-centred processes—Facing the challenge and reaping the benefit of ISO 13407. International Journal of Human-Computer Studies.

[9] RESNA. Code of Ethics. [Internet]. 2016. Available from: http://www.resna.org/sites/ default/files/legacy/certification/RESNA\_Code\_of\_Ethics.pdf [Accessed: 21 February

Gokcen Akyurek\*, Sinem Kars, Zeynep Celik, Ceren Koc and Özge Buket Cesim

\*Address all correspondence to: gkcnakyrk@gmail.com

176 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Journal of Occupational Therapy. 2010;**64**:44-56

agreed daily care allowance [65].

105-394, Sec (3) (a) 3-4

Cliffs, NJ: Prentice Hall; 1982

2008. pp. 3-33

2001;**49**(1):89-96

2001;**55**:553-585

2017]

New York: Simon and Schuster; 1983

Computer Studies. 2001;**55**(4):533-552

**Author details**

Ankara, Turkey

**References**


[39] Rose DH, Hasselbring TS, Stahl S, Zabala J. Assistive technology and universal design for learning: Two sides of the same coin. Handbook of Special Education Technology Research and Practice. 2005. pp. 507-518. Whitefish Bay, WI: Knowledge by Design.

[24] Longmuir P E and Axelson P. Assistive technology for recreation. In: Galvin JC, Scherer MJ, editors. Evaluating, Selecting and Using Appropriate Assistive Technology.

[25] Greenstein DB. It' child's play. In: Galvin JC, Scherer MJ, editors. Evaluating, Selecting and Using Appropriate Assistive Technology. Gaithersburg, Md.: Aspen publishers.

[26] Hersh MA, Johnson MA. On modelling assistive technology systems part 1: Modelling

[27] Hersh MA, Johnson MA. On modelling assistive technology systems part 2: Applications of the comprehensive assistive technology model. Technology and Disability.

[28] Activity, human, and context: The human doing an activity in context. In: Cook AM, Polgar JM, editors. Cook and Hussey's Assistive Technologies: Principles and Practice.

[29] Disability and assistive technology systems. In: Hersh MA, Johnson MA, editors. Assistive Technology for Visually Impaired and Blind People. London, Guildford, UK,

[30] Bryant DP, Bryant BR. Assistive Technology for People with Disabilities. Boston: Allyn

[31] Technologies that assist people who have disabilities. In: Cook AM, Polgar JM, editors. Cook and Hussey's Assistive Technologies: Principles and Practice. 4th ed. St. Louis,

[32] Miskelly FG. Assistive technology in elderly care. Age and Ageing. 2001;**30**(6):455-458 [33] Wright VC, Chang J, Jeng G, Macaluso M, Control CfD, Prevention. Assisted reproductive technology surveillance—United States, 2005. MMWR Surveillance Summaries.

[34] Borg J, Larsson S, Östergren PO. The right to assistive technology: For whom, for what,

[35] Gitlin LN, editor. International Handbook of Occupational Therapy Interventions.

[36] Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L. The person-environment-occupation model: A transactive approach to occupational performance. Canadian Journal of

[37] Scherer MJ. Assistive Technology: Matching Device and Consumer for Successful

[38] Ivanoff SD, Iwarsson S, Sonn U. Occupational therapy research on assistive technology and physical environmental issues: A literature review. Canadian Journal of

Rehabilitation. Washington, DC, American Psychological Association; 2002

Gaithersburg, Md.: Aspen publishers. 1996. pp. 162-190

178 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

framework, Technology and Disability. 2008;**20**(3):193-215

4th ed. St. Louis, MO: Mosby Elsevier; 2015. pp. 40-67

and by whom? Disability & Society. 2011;**26**(2):151-167

Springer International Publishing; 2015, p. 165-175 11p.

1996. pp. 198-213

2008;**20**(4):251-270

Springer Verlag; 2008. pp. 1-47

MO: Mosby Elsevier; 2014. pp. 16-39

Occupational Therapy. 1996;**63**(1):9-23

Occupational Therapy. 2006;**73**(2):109-119

&Bacon/Pearson; 2011

2008;**57**(5):1-23


### **Virtual Reality and Occupational Therapy**

Orkun Tahir Aran, Sedef Şahin, Berkan Torpil,

Tarık Demirok and Hülya Kayıhan

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68799

#### **Abstract**

[54] Lenker JA, Paquet VL. A review of conceptual models for assistive technology outcomes

[55] Roelands M, Van Oost P, Depoorter A, Buysse A. A social-cognitive model to predict the use of assistive devices for mobility and self-care in elderly people. The Gerontologist.

[56] Ivanoff SD, Iwarsson S, Sonn U. Occupational therapy research on assistive technology and physical environmental issues: A literature review. Canadian Journal of

[57] Giesbrecht E. Application of the Human Activity Assistive Technology model for occupational therapy research. Australian Occupational Therapy Journal. 2013;**60**(4):230-240

[58] Wiart L, Darrah J. Changing philosophical perspectives on the management of children with physical disabilities—Their effect on the use of powered mobility. Disability and

[59] van der Woude LHV, de Groot S, Janssen TWJ. Manual wheelchairs: Research and innovation in rehabilitation, sports, daily life and health. Medical Engineering & Physics.

[60] Giesbrecht EM, Ripat JD, Quanbury AO, Cooper JE. Participation in community-based activities of daily living: Comparison of a pushrim-activated, power-assisted wheelchair and a power wheelchair. Disability and Rehabilitation Assistive Technology.

[61] Arthanat S, Nochajski SM, Lenker JA, Bauer SM, Wu YW. Measuring usability of assistive technology from a multicontextual perspective: The case of power wheelchairs. The

[62] Funding assistive technology services to the consumer. In: Cook AM, Polgar JM, editors. Cook and Hussey's Assistive Technologies: Principles and Practice. 3rd ed. St. Louis,

[63] Turkish Medicines and Medical Devices Agency (TMMDA). Available from: http:// www.titck.gov.tr/TıbbiCihaz/TıbbiCihazHakkında [Accessed: 25 February 2017]

[64] Health Application Notification (Sağlık Uygulama Tebliği-SUT). 2008. Available from: http://www.resmigazete.gov.tr/eskiler/2008/09/20080929M1-1.htm [Accessed: 25

[65] Complementary and Supportive Health Insurance Model Recommendations for Turkey. 2013. Available from: www.tsb.org.tr/Document/Yonetmelikler/TSS\_Rapor\_16.05.14.

American Journal of Occupational Therapy. 2009;**63**(6):751-764

Occupational Therapy [Revue canadienne d'ergotherapie]. 2006;**73**(2):109-119

research and practice. Assistive Technology. 2003;**15**(1):1-15

180 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

2002;**42**(1):39-50

2006;**28**(9):905-915

2009;**4**(3):198-207

February 2017]

Rehabilitation. 2002;**24**(9):492-498

MO: Mosby Elsevier; 2008. pp. 143-176

docx [Accessed: 25 February 2017]

Virtual reality is three dimensional, interactive and fun way in rehabilitation. Its first known use in rehabilitation published by Max North named as "Virtual Environments and Psychological Disorders" (1994). Virtual reality uses special programmed comput‐ ers, visual devices and artificial environments for the clients' rehabilitation. Throughout technological improvements, virtual reality devices changed from therapeutic gloves to augmented reality environments. Virtual reality was being used in different rehabilita‐ tion professions such as occupational therapy, physical therapy, psychology and so on. In spite of common virtual reality approach of different professions, each profession aims different outcomes in rehabilitation. Virtual reality in occupational therapy gen‐ erally focuses on hand and upper extremity functioning, cognitive rehabilitation, men‐ tal disorders, etc. Positive effects of virtual reality were mentioned in different studies, which are higher motivation than non‐simulated environments, active participation of the participants, supporting motor learning, fun environment and risk‐free environment. Additionally, virtual reality was told to be used as assessment. This chapter will focus on usage of virtual reality in occupational therapy, history and recent developments, types of virtual reality technologic equipment, pros and cons, usage for pediatric, adult and geriatric people and recent research and articles.

**Keywords:** virtual reality, rehabilitation, occupational therapy, ICF

#### **1. Introduction**

Enhancement of functional ability and the realization of greater participation in community life are the two major goals of rehabilitation science. Improving sensory, motor, cognitive func‐ tions and practice in everyday activities and occupations to increase participation with inten‐ sive rehabilitation may define these predefined goals [1, 2]. Intervention is based primarily on

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the different types of purposeful activities and occupations with active participation [3–5]. For many injuries and disabilities, the rehabilitation process is long, and clinicians face the chal‐ lenge of identifying a variety of appealing, meaningful and motivating intervention tasks that may be adapted and graded to facilitate this process [5].

Occupational therapy (OT), which is one of the rehabilitation professions, is a client‐centered profession that helps people who are suffering participation and occupational performance limitations. OT offers a wide range of rehabilitation strategies in different medical and social diagnosis [2]. The common point of all these strategies in rehabilitation is that OT assesses and supports enhancing functional ability and participation throughout participating in meaning‐ ful activities in a person's lifespan. To enhance participation, OT, like the rest of the health professions, uses World Health Organization's International Classification of Functioning, Disability and Health (ICF) to understand function in a biopsychosocial manner. In ICF framework, function is defined as the interactions between an individual, their health condi‐ tions and the social and personal situations in which they thrive. The complex interactions between these variables define function and disability [1].

ICF classifies health and health‐related fields in two groups. These groups are "body func‐ tions" and "body structures" and "activity and participation." Sub heading of these groups is considered as body function and structures (physical, physiological etc), activities (daily tasks) and participation (life roles) [1]. When these groups taken into account in rehabilitation, occupational therapists focus on all areas to enhance a client's activity participation, social participation, etc. However, in current literature, there are various rehabilitation approaches that are being used for this aim. Advancements in technology in the twenty‐first century cre‐ ate great opportunities for people working in different areas. In particular, in health practices like rehabilitation, technology supports therapists' to rehabilitate their clients in too many different ways like robotics, stimulation devices, assessment tools and virtual reality [6–10].

#### **2. Virtual reality**

Virtual rehabilitation is the use of VR and virtual environments (VE) within rehabilitation. VR and VE can be described as a simulation of real world environments through a computer and experienced through a "human‐machine interface" [11]. VR rehabilitation, since the 1980s, technology has become widespread with rapid developments in computer technology, and nowadays, many commercial uses have come into play with relatively affordable costs. In addition to its use in the field of health sciences, is used for industrial design, production processes and training purposes [12]. VR rehabilitation can be classified in several ways. The first is the classification method according to the specific patient population. Rehabilitation practices in this class can be classified as musculoskeletal disorders, post‐stroke and cognitive and psychological disorders. The second classification method concerns the priority of the applied rehabilitation protocol. VR practice in the rehabilitation protocol can only be used as an adjunct or as the basis of a rehabilitation program to retain the place of classical exercise or activity programs. Therapeutic approaches include education approaches through examples, video games and educational approaches or rehabilitation approaches through "exposure" used in psychological disorders. The training method with examples is frequently used in stroke rehabilitation. For example, a system that perceives the arm movements of a patient reflects arm movements on a computer screen as a motion of an object and is required to control movement of the patient. In the approach used by video games, the client tries to control the objects in the ball with a certain joint or body movement. To apply this method, patients are required to have a higher cognitive level. Finally, VR rehabilitation can be classi‐ fied according to the proximity or distance of the therapist. Therapist and client are in the same room in VR and in tele‐rehabiltation method, in tele‐rehabilitation method is participating in a remote location in the rehabilitation process of the patient therapist [3, 11, 12].

As virtual reality in its broad definition can be dated as far as the wall‐to‐wall frescoes of late Roman Republic era [12], the following text will emphasize the recent technological aspect of the phenomenon and its use in rehabilitation research, which aims to expand the read‐ er's intervention choices in occupational therapy practice. The use of computer systems has become an accepted practice in the clinical setting. VR applications are frequently used in dif‐ ferent disease groups for this purpose. VR applications are used in a variety of areas, such as neurological, orthopedic, cognitive function, sensory‐perceptual and mental health disorders in basic/instrumental daily life activities [13–16]. Following sections will include these areas.

#### **2.1. Virtual reality in pediatric rehabilitation**

the different types of purposeful activities and occupations with active participation [3–5]. For many injuries and disabilities, the rehabilitation process is long, and clinicians face the chal‐ lenge of identifying a variety of appealing, meaningful and motivating intervention tasks that

Occupational therapy (OT), which is one of the rehabilitation professions, is a client‐centered profession that helps people who are suffering participation and occupational performance limitations. OT offers a wide range of rehabilitation strategies in different medical and social diagnosis [2]. The common point of all these strategies in rehabilitation is that OT assesses and supports enhancing functional ability and participation throughout participating in meaning‐ ful activities in a person's lifespan. To enhance participation, OT, like the rest of the health professions, uses World Health Organization's International Classification of Functioning, Disability and Health (ICF) to understand function in a biopsychosocial manner. In ICF framework, function is defined as the interactions between an individual, their health condi‐ tions and the social and personal situations in which they thrive. The complex interactions

ICF classifies health and health‐related fields in two groups. These groups are "body func‐ tions" and "body structures" and "activity and participation." Sub heading of these groups is considered as body function and structures (physical, physiological etc), activities (daily tasks) and participation (life roles) [1]. When these groups taken into account in rehabilitation, occupational therapists focus on all areas to enhance a client's activity participation, social participation, etc. However, in current literature, there are various rehabilitation approaches that are being used for this aim. Advancements in technology in the twenty‐first century cre‐ ate great opportunities for people working in different areas. In particular, in health practices like rehabilitation, technology supports therapists' to rehabilitate their clients in too many different ways like robotics, stimulation devices, assessment tools and virtual reality [6–10].

Virtual rehabilitation is the use of VR and virtual environments (VE) within rehabilitation. VR and VE can be described as a simulation of real world environments through a computer and experienced through a "human‐machine interface" [11]. VR rehabilitation, since the 1980s, technology has become widespread with rapid developments in computer technology, and nowadays, many commercial uses have come into play with relatively affordable costs. In addition to its use in the field of health sciences, is used for industrial design, production processes and training purposes [12]. VR rehabilitation can be classified in several ways. The first is the classification method according to the specific patient population. Rehabilitation practices in this class can be classified as musculoskeletal disorders, post‐stroke and cognitive and psychological disorders. The second classification method concerns the priority of the applied rehabilitation protocol. VR practice in the rehabilitation protocol can only be used as an adjunct or as the basis of a rehabilitation program to retain the place of classical exercise or activity programs. Therapeutic approaches include education approaches through examples,

may be adapted and graded to facilitate this process [5].

182 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

between these variables define function and disability [1].

**2. Virtual reality**

VR is defined in pediatric rehabilitation as 'An interactive simulation allowing users to feel experiences similar to real‐life environments or objects ones with systems which consist in computer hardware and software, [17]. Virtual reality systems (VRS) are mostly used in pedi‐ atric rehabilitation program due to these properties. Pediatric rehabilitation is a concept that covers a wide range of applications and includes treatments for various diagnoses or disor‐ ders, such as children with neurological, orthopedic or developmental disabilities.

Children with neurologic or neurocognitive impairments may experience decreased func‐ tioning in multiple domains including: physical, psychosocial, cognitive or emotional. Such impairments represent significant obstacles to the child's activities of daily life [18]. Holistic approaches to the treatment of all impairments that children may encounter are implemented through a joint study of many disciplines in rehabilitation program. The use of VR by trained therapists enables to cope with these impairments [19].

Play is described as both the earliest and the most important occupation in the childhood [20, 21]. In order to be defined as play, it must contain these five essential domains: intrinsic motivation, pleasure, free choice, non‐literal and active engagement [20, 22]. A few theories have proposed the contributions of play to the developing child. Some of them thought play was a tool for intellectual growth, whereas others thought it was necessary for skills develop‐ ment [23–25]. Children with various disabilities have a more restricted play experience than healthy children [26].

VR potentially offers children with disabilities the opportunity to participate in games other‐ wise inaccessible. It provides a three‐dimensional spatial the degree of the movement between the real world and the computer. Children can also practice intensely and simultaneously receive positive visual, proprioceptive, tactile and auditory sense feedbacks in VR [11, 27]. The use of it in children with disabilities provides motor learning, postural and motor control and improves sensorial‐perceptual‐motor‐cognitive‐communication skills. So that children become more independent individuals in their daily lives [28].

#### *2.1.1. The advantages and disadvantages of VR in pediatric rehabilitation*

The virtual reality system is separated according to immersion degree and how the users inter‐ act with the system [29]. VR systems can be grouped under two main headings such as immer‐ sion VR and desktop VR. Immersion VR is a type of application that involves the use of various materials to make the virtual environment feel like it is a real. Specially, users wear a head mounted display that brings them into a 3D virtual environment. Thus, all movements are con‐ trolled by head movement. Second type of system is desktop VR. Images appear on a device such as a computer or a television [30]. The users play with the help of various tools such as keyboard, mouse, speaker, glove etc. Systems also connected to the internet (tele‐rehabilita‐ tion) have the potential to reach out to children who are in distant areas or in their home [11].

VR has many advantages for pediatric rehabilitation. Firstly, VR is a goal‐directed method so that it can be used for training and education to increase of skills like sense, perception, motor, cognitive and social in children [31]. Secondly, it was functional, motivational and fun for children [20]. Because of that, it is one of the most preferred treatment methods for thera‐ pists and children. Thirdly, VR can be used both in single and in group activity programs that may be included in more than one person. VR applications involving more than one person can be made up of their family members or peer children who can be practiced in the same ergotherapy session. It is also an advantage to promote therapy sessions. Lastly, VR game systems like Nintendo Wii, Wii sport games, Wii fit or Kinect Xbox are common, low, simple and available in both the occupational therapy departments and children's home [32].

VR also has some disadvantages. Technology is rapidly advancing, and the systems and games developed for children are changing day by day. It is not easy to follow and reach for most citi‐ zens of the country. Additionally, current virtual reality systems like Interactive Rehabilitation Exercise System (IREX) are also too expensive for the majority of the population [33].

Knowing the advantages and disadvantages of the systems is important in determining appropriate virtual reality systems for clinical use and academic research. For example, all marketed games are not appropriate for all individual, especially for children. Because of their functions, skills, needs or motivations are difference with each other. The games may increase their functional activity, but rather facilitate the appearance of some unwanted symptoms or movement patterns [20]. For this reason, be careful in the preference and use of the game, preferences should be made to the therapist control.

#### *2.1.2. Studies on VR in pediatric rehabilitation*

All studies aimed to improve function or quality of movement in upper and lower limbs in order to increase of social participation and achieve better performance in daily life activities. A great majority of the investigations on this field are children with neurological impairments such as cerebral palsy. Most of the researches showed improvement upper limb functions via VR interventions. For example, Chen et al. showed the benefit of VR use for reaching activity in four children with CP between the ages of 4 and 8. Children were treated with the Sony Eye‐Toy system for 4 weeks at 2 hours per week. The quality of reach‐ ing was shown to improve after individual training [34]. Jannink et al., in 2007, investigated to evaluate upper extremity training with a Sony Eye‐Toy. They randomly included in 12 children with CP. Upper extremity functions were evaluated with Melbourne. The results showed the Eye‐Toy to be a motivational education tool that developed upper extremity function in children with CP for 6 weeks at 30 minutes twice a week [35]. Similarly, You et al. investigated in VR‐based cortical reorganization and functional motor development with hemiparetic CP. The Bruininks‐Oseretsky Test of Motor Proficiency (BOTMP), the Modified Pediatric Motor Activity Log (PMAL) tests and functional magnetic resonance imaging (fMRI) were used pre‐/post‐measurements. Children treated with IREX for 60 minutes 5 times a week for 1 month.

the real world and the computer. Children can also practice intensely and simultaneously receive positive visual, proprioceptive, tactile and auditory sense feedbacks in VR [11, 27]. The use of it in children with disabilities provides motor learning, postural and motor control and improves sensorial‐perceptual‐motor‐cognitive‐communication skills. So that children

The virtual reality system is separated according to immersion degree and how the users inter‐ act with the system [29]. VR systems can be grouped under two main headings such as immer‐ sion VR and desktop VR. Immersion VR is a type of application that involves the use of various materials to make the virtual environment feel like it is a real. Specially, users wear a head mounted display that brings them into a 3D virtual environment. Thus, all movements are con‐ trolled by head movement. Second type of system is desktop VR. Images appear on a device such as a computer or a television [30]. The users play with the help of various tools such as keyboard, mouse, speaker, glove etc. Systems also connected to the internet (tele‐rehabilita‐ tion) have the potential to reach out to children who are in distant areas or in their home [11]. VR has many advantages for pediatric rehabilitation. Firstly, VR is a goal‐directed method so that it can be used for training and education to increase of skills like sense, perception, motor, cognitive and social in children [31]. Secondly, it was functional, motivational and fun for children [20]. Because of that, it is one of the most preferred treatment methods for thera‐ pists and children. Thirdly, VR can be used both in single and in group activity programs that may be included in more than one person. VR applications involving more than one person can be made up of their family members or peer children who can be practiced in the same ergotherapy session. It is also an advantage to promote therapy sessions. Lastly, VR game systems like Nintendo Wii, Wii sport games, Wii fit or Kinect Xbox are common, low, simple

and available in both the occupational therapy departments and children's home [32].

Exercise System (IREX) are also too expensive for the majority of the population [33].

the game, preferences should be made to the therapist control.

*2.1.2. Studies on VR in pediatric rehabilitation*

VR also has some disadvantages. Technology is rapidly advancing, and the systems and games developed for children are changing day by day. It is not easy to follow and reach for most citi‐ zens of the country. Additionally, current virtual reality systems like Interactive Rehabilitation

Knowing the advantages and disadvantages of the systems is important in determining appropriate virtual reality systems for clinical use and academic research. For example, all marketed games are not appropriate for all individual, especially for children. Because of their functions, skills, needs or motivations are difference with each other. The games may increase their functional activity, but rather facilitate the appearance of some unwanted symptoms or movement patterns [20]. For this reason, be careful in the preference and use of

All studies aimed to improve function or quality of movement in upper and lower limbs in order to increase of social participation and achieve better performance in daily life

become more independent individuals in their daily lives [28].

184 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

*2.1.1. The advantages and disadvantages of VR in pediatric rehabilitation*

According to the results, functional motor skills, amount of use in affected upper extremities and the quality of the motion, active movement, control and coordination of upper extremity motor performance were increased. Thus, it might be said that VR applications can be used to enhance motor skills [36].

Reid et al. included in 31 children aged between 8 and 12 years. They randomly divided into two: 19 study (VR) and 12 control group. Treatment for 1.5 hours per week for 8 weeks was implemented for the children. Canadian occupational performance measurement (COPM) and Quality of *Upper Extremity* Skills Test (QUEST) were used to evaluate the effect of VR treatment. All results were improved after the treatment, while there was no significant func‐ tional difference was found between the groups. According to the results, there were sig‐ nificantly increased social acceptance and motivation in the study group [37]. These results indicated an important point in rehabilitation which treatment is an extensive concept that has not only physical component but also emotional and social components.

Also, home‐based treatment approaches are important to integrate effectiveness of VR inter‐ vention in daily life. Winkels et al. included 15 children with CP [Manual ability classification system (MACS) Levels I and II] between the age of 6 and 15 in their study. The children were evaluated with the Melbourne Assessment of Upper Limb Function and ABILHAND‐Kids and had upper extremity function training using Wii games. They reported to increase in the performance of daily living activities with VR.

Activities of daily living involve in not only upper but also lower extremity. On the other hand, walking ability or strength is generally researched according to lower extremity activ‐ ity. Recent studies focused on combination with VR system and robot‐assisted gait training (RAGT), and they are emphasized the useful interventions which applies together [38, 39].

The other investigation area in disabilities with children about VR is Down syndrome and autism and attention deficit. These studies were showed to increase of sensorimotor functions and motor proficiency by using VR in these disabilities [27, 40].

As a result, these studies proved that VR systems are motivational, evidenced based and use‐ ful for children in pediatric rehabilitation interventions. It can be used for improving upper limb function and proficiency, sensorimotor and cognitive functions, activity of daily living, participation of therapy and motivation level in rehabilitation.

#### **2.2. Virtual reality rehabilitation for adult population**

VR is being used in adult rehabilitation by therapists for many years. Groups that being focused most are stroke survivors, Parkinson's disease and geriatric population who needs repetitive rehabilitation approaches with active participation. However, current approaches that were being used had some issues about repetition with fun part. VR had a new perspec‐ tive to the repetitive rehabilitation approaches after its initial use. Studies showed that VR suggests higher dosage of repetition than traditional approaches [41–43]. Initially, VR was being used with flight simulators, surgery training etc.; within the use in health practices, it spreads its use in the area of post‐traumatic stress disorder and body image disorders [3]. VR is advantaged with its goal‐oriented tasks and repetition. Repetition, task‐oriented move‐ ments and fun are needed to achieve neuromotor changes which will lead motor enhance‐ ments in client's task. The term goal oriented and repetitive tasks are in a collaboration with neuroplasticity terms which of one is the repetition of the task that is needed to be practice must be trained in rich and fun environments. VR offers a great opportunity for therapist who seeks for these terms in their approaches.

VR offers simulation systems, safe activity training etc for OT. OT comes from real‐life situa‐ tions and lives and develops itself in the community. Being this related to the life, OT needed to adapt itself with the technological developments. Nowadays, mobile phones, internet, phone applications and lots of other software and hardware are common worldwide. OT uses this to involve geriatrics, rehabilitate stroke survivors and other disability causes to rehabilitate.

Daily life activities are being studied for stroke survivors using environments such as driving rehabilitation and market simulations [44]. Akinwuntan et al. [45] used STISIM Drive System (Systems Technology Inc., United States) in their research with people with stroke which had real size computer images, visual angle of 45° and adaptations such as left‐sided accelerator and steering wheel spinner. In this study, researchers compared virtual driving rehabilitation with conventional rehabilitation which found to be no different from each other

Barcala et al. [46] used Wiifit (Nintendo, Japan) on balance training with people with stroke. The equipment that is commercially available and serves mainly for entertainment and home exercises could reproduce body movements and give auditory feedback through many display choices such as TVs or projectors. Cho et al. [47] used Interactive Rehabilitation and Exercise System (Vivid Group, Canada) for upper extremity rehabilitation of people with stroke. The system which is specifically aimed to neurorehabilitation programs included video cameras, gloves and virtual games. da Silva Cameirão et al. [48] used Rehabilitation Gaming System (Pompeu Fabra University, Spain) with people with acute stroke. The system uses a motion capturing camera in tandem with motion gloves and has activities (e.g., games) which have gradual difficulties. It aims to functional reorganization of neuronal systems through visual input of virtual extremities on screen combined with task oriented action.

Walking, balance and mobility problems of VR application are made in people with Parkinson's disease. Significant improvements are observed in the individuals in these studies [49]. In addition, studies on motor learning, retention‐transfer and cognitive functions are being stud‐ ied with VR applications in Parkinsonian individuals [50]. VR applications are utilized to improve functional balance, mobility, static‐dynamic postural control, and dual‐task reaction times [51]. VR technologies are utilized in the treatment of loss of cognitive function skills in geriatric people. In individual attention, alertness, reaction time and the short‐/long‐term memory due to the stimulation of VR applications are preferred [52, 53]. VR technology is also used in mental health treatment in geriatric people. VR technology can be used as a treatment tool for agoraphobia, social phobia, fear of death, depression, anxiety, posttraumatic stress syndrome, attention deficit, dementia and schizophrenia treatment [54]. One of VR performed on geriatric people, and the most important applications are the study of the fall and after the growing fear of falling. These studies provide postural stability, strengthening of activity muscles, ground sensing, proprioceptive and vestibular sensory training [55].

As a result, these studies proved that VR systems are motivational, evidenced based and use‐ ful for children in pediatric rehabilitation interventions. It can be used for improving upper limb function and proficiency, sensorimotor and cognitive functions, activity of daily living,

VR is being used in adult rehabilitation by therapists for many years. Groups that being focused most are stroke survivors, Parkinson's disease and geriatric population who needs repetitive rehabilitation approaches with active participation. However, current approaches that were being used had some issues about repetition with fun part. VR had a new perspec‐ tive to the repetitive rehabilitation approaches after its initial use. Studies showed that VR suggests higher dosage of repetition than traditional approaches [41–43]. Initially, VR was being used with flight simulators, surgery training etc.; within the use in health practices, it spreads its use in the area of post‐traumatic stress disorder and body image disorders [3]. VR is advantaged with its goal‐oriented tasks and repetition. Repetition, task‐oriented move‐ ments and fun are needed to achieve neuromotor changes which will lead motor enhance‐ ments in client's task. The term goal oriented and repetitive tasks are in a collaboration with neuroplasticity terms which of one is the repetition of the task that is needed to be practice must be trained in rich and fun environments. VR offers a great opportunity for therapist who

VR offers simulation systems, safe activity training etc for OT. OT comes from real‐life situa‐ tions and lives and develops itself in the community. Being this related to the life, OT needed to adapt itself with the technological developments. Nowadays, mobile phones, internet, phone applications and lots of other software and hardware are common worldwide. OT uses this to involve geriatrics, rehabilitate stroke survivors and other disability causes to rehabilitate. Daily life activities are being studied for stroke survivors using environments such as driving rehabilitation and market simulations [44]. Akinwuntan et al. [45] used STISIM Drive System (Systems Technology Inc., United States) in their research with people with stroke which had real size computer images, visual angle of 45° and adaptations such as left‐sided accelerator and steering wheel spinner. In this study, researchers compared virtual driving rehabilitation

Barcala et al. [46] used Wiifit (Nintendo, Japan) on balance training with people with stroke. The equipment that is commercially available and serves mainly for entertainment and home exercises could reproduce body movements and give auditory feedback through many display choices such as TVs or projectors. Cho et al. [47] used Interactive Rehabilitation and Exercise System (Vivid Group, Canada) for upper extremity rehabilitation of people with stroke. The system which is specifically aimed to neurorehabilitation programs included video cameras, gloves and virtual games. da Silva Cameirão et al. [48] used Rehabilitation Gaming System (Pompeu Fabra University, Spain) with people with acute stroke. The system uses a motion capturing camera in tandem with motion gloves and has activities (e.g., games) which have gradual difficulties. It aims to functional reorganization of neuronal systems through visual

with conventional rehabilitation which found to be no different from each other

input of virtual extremities on screen combined with task oriented action.

participation of therapy and motivation level in rehabilitation.

**2.2. Virtual reality rehabilitation for adult population**

186 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

seeks for these terms in their approaches.

Lee et al. [56] used K‐Pop Dance Festival (Nintendo Inc., Japan) software for Nintendo Wii platform for the rehabilitation program of participants with Parkinson's disease. The hand‐ held motion controller of the platform was strapped to the participants' hands as a compensa‐ tion strategy. The software includes songs, and the success of the activity depends on dance movements that match the songs' rhythms. The researchers found that independence in activ‐ ities of daily living and decrease in depressive symptoms were acquired by VR rehabilitation.

Pichierri et al. [57] used TX 6000 Metal DDR Platinum Pro metal dance pads (Mayflash Limited, China) in tandem with Stepmania Software, a free dance and rhythm game (https://www.step‐ mania.com). Participants were asked to match the direction of arrows on screen that appear in sync with musical rhythm by stepping on the corresponding arrows on the dance pad. By this approach, participants were asked to participate dual task activities. Researchers suggested that cognitive‐motor intervention was appropriate to use to increase strength and balance in elderly. Hoffman et al. [58] used Oculus Rift VR goggles (Facebook Inc., United States) during occupational therapy of a young burn patient. Researchers used SnowWorld (University of Washington, United States), a software developed specifically for pain management of burn patients, with Oculus Rift which showed slightly pain decrease of the client. The goggles can be worn head mounted or worn with an arm mounted apparatus. Faber et al. [59] used Cybermind Hi‐Res900ST (Jasandre Pty. Ltd, Australia), a head mounted VR goggles during the treatment of burn patients in tandem with SnowWorld software (University of Washington, United States). Researchers measured pain levels of the participants after every session of the treatment. Yoon et al. [60] used Interactive Rehabilitation and Exercise System (Vivid Group, Canada) along with traditional occupational therapy in their research on patients with brain tumor. Researchers used Birds and Balls, Conveyor, Drums, Juggler, Coconuts, and Soccer VR programs of the system. Jahn et al. [61] used Nintendo Wii (Nintendo, Japan) in their research with inpatient adults with cancer. Participants were able to choose either Wii Sports, Family Trainer, Sports Island or Family Ski and Snowboard programs for each single session. Rohani et al. [62] used Kinect (Microsoft, United States) along with a virtual classroom software. The classroom software had two different tasks, and children were asked to accomplish the tasks, while distractions were presented (e.g., a construction worker entering the classroom).

#### **3. Discussion**

VR in rehabilitation is a common approach in current rehabilitation era. The repetition enhancement, moving client away from one's diagnosis/disability, enabling and active par‐ ticipation in rehabilitation, enriched environments and making rehabilitation fun are the greatest motives to use VR for rehabilitation. Lots of studies showed the benefits of using VR in different rehabilitation settings. A therapist with VR access may feel confident to use VR.

Both pediatrics and adult population had fun with their VR rehabilitation, which removes the boring role of rehabilitation. In particular, in pediatrics, using VR opens a wide per‐ spective for the therapists. However, technological improvements must consider rehabilita‐ tion‐based games or applications to achieve fully adaptable and client‐special rehabilitation patterns. Commercially, sold games and applications still have low awareness of disability. Additionally, new coded software are needed to be adaptable for each participant and one's current motor/cognitive/social status related to the disability. Also game types that may used for VR may be gender depended as the children or older participants may not be willing to participate VR session.

As the technology improves, more opportunities are likely to occur; as rehabilitation special‐ ists, we must keep our contact with these developments and develop ourselves according to our client's needs.

#### **Author details**

Orkun Tahir Aran\*, Sedef Şahin, Berkan Torpil, Tarık Demirok and Hülya Kayıhan

\*Address all correspondence to: orkunaran@gmail.com

Faculty of Health Sciences, Occupational Therapy, Hacettepe University, Ankara, Turkey

#### **References**


[5] Weiss PL, Rand D, Katz N, Kizony R. Video capture virtual reality as a flexible and effec‐ tive rehabilitation tool. Journal of Neuroengineering and Rehabilitation. 2004;**1**(1):12

**3. Discussion**

participate VR session.

our client's needs.

**Author details**

**References**

VR in rehabilitation is a common approach in current rehabilitation era. The repetition enhancement, moving client away from one's diagnosis/disability, enabling and active par‐ ticipation in rehabilitation, enriched environments and making rehabilitation fun are the greatest motives to use VR for rehabilitation. Lots of studies showed the benefits of using VR in different rehabilitation settings. A therapist with VR access may feel confident to use VR. Both pediatrics and adult population had fun with their VR rehabilitation, which removes the boring role of rehabilitation. In particular, in pediatrics, using VR opens a wide per‐ spective for the therapists. However, technological improvements must consider rehabilita‐ tion‐based games or applications to achieve fully adaptable and client‐special rehabilitation patterns. Commercially, sold games and applications still have low awareness of disability. Additionally, new coded software are needed to be adaptable for each participant and one's current motor/cognitive/social status related to the disability. Also game types that may used for VR may be gender depended as the children or older participants may not be willing to

As the technology improves, more opportunities are likely to occur; as rehabilitation special‐ ists, we must keep our contact with these developments and develop ourselves according to

Orkun Tahir Aran\*, Sedef Şahin, Berkan Torpil, Tarık Demirok and Hülya Kayıhan

Faculty of Health Sciences, Occupational Therapy, Hacettepe University, Ankara, Turkey

[1] Organization WH. International Classification of Functioning, Disability and Health:

[2] Roley SS, Barrows CJ, Susan Brownrigg OTR L, Sava DI, Vibeke Talley OTR L, Kristi Voelkerding B. Occupational therapy practice framework: Domain and process 2nd edi‐

[3] Schultheis MT, Rizzo AA. The application of virtual reality technology in rehabilitation.

[4] Trombly CA. Occupation: Purposefulness and meaningfulness as therapeutic mecha‐

tion. The American Journal of Occupational Therapy. 2008;**62**(6):625

nisms. American Journal of Occupational Therapy. 1995;**49**(10):960‐972

\*Address all correspondence to: orkunaran@gmail.com

188 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

ICF: World Health Organization; 2001

Rehabilitation Psychology. 2001;**46**(3):296


[34] Chen Y‐P, Kang L‐J, Chuang T‐Y, Doong J‐L, Lee S‐J, Tsai M‐W. Use of virtual real‐ ity to improve upper‐extremity control in children with cerebral palsy: A single‐subject design. Physical Therapy. 2007;**87**(11):1441

[19] Chen Y‐P, Lee S‐Y, Howard AM. Effect of virtual reality on upper extremity func‐ tion in children with cerebral palsy: A meta‐analysis. Pediatric Physical Therapy.

[20] Harris K, Reid D. The influence of virtual reality play on children's motivation. Canadian

[21] Kielhofner G. Model of Human Occupation: Theory and Application. Lippincott Williams

[22] Rubin KH, Fein GG, Vandenberg B. Play. Handbook of Child Psychology. 1983;**4**:693‐774 [23] Bjorklund DF, Brown RD. Physical play and cognitive development: Integrating activ‐

[24] Eppright TD, Sanfacon JA, Beck NC, Bradley JS: Sport psychiatry in childhood and ado‐ lescence: An overview. Child Psychiatry and Human Development. 1997;**28**(2):71‐88 [25] Piaget J. Play, Dreams and Imitation in Childhood. Routledge; Abbington, Oxon; 2013 [26] Howard L. A comparison of leisure‐time activities between able‐bodied children and children with physical disabilities. The British Journal of Occupational Therapy.

[27] Wuang Y‐P, Chiang C‐S, Su C‐Y, Wang C‐C. Effectiveness of virtual reality using Wii gaming technology in children with Down syndrome. Research in Developmental

[28] Gunel MK, Kara OK, Ozal C, Turker D. (2014). Virtual Reality in Rehabilitation of Children with Cerebral Palsy, Cerebral Palsy ‐ Challenges for the Future, Associate Prof. Emira Švraka (Ed.), InTech, p 273‐301; DOI: 10.5772/57486. Available from: https://www.intechopen.com/books/cerebral‐palsy‐challenges‐for‐the‐future/

[29] Sandlund M, McDonough S, Häger‐Ross C. Interactive computer play in rehabilitation of children with sensorimotor disorders: A systematic review. Developmental Medicine

[30] Wilson PN, Foreman N, Stanton D. Virtual reality, disability and rehabilitation. Disability

[31] Gabyzon ME, Engel‐Yeger B, Tresser S, Springer S. Using a virtual reality game to assess goal‐directed hand movements in children: A pilot feasibility study. Technology and

[32] Galvin J, Levac D. Facilitating clinical decision‐making about the use of virtual reality within paediatric motor rehabilitation: Describing and classifying virtual reality sys‐

[33] Reid DT. Benefits of a virtual play rehabilitation environment for children with cerebral palsy on perceptions of self‐efficacy: A pilot study. Pediatric Rehabilitation. 2002;**5**(3):

virtual‐reality‐in‐rehabilitation‐of‐children‐with‐cerebral‐palsy

tems. Developmental Neurorehabilitation. 2011;**14**(2):112‐122

ity, cognition, and education. Child Development. 1998;**69**(3):604‐606

Journal of Occupational Therapy. 2005;**72**(1):21‐29

190 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

2014;**26**(3):289‐300

1996;**59**(12):570‐574

Disabilities. 2011;**32**(1):312‐321

and Child Neurology. 2009;**51**(3):173‐179

and Rehabilitation. 1997;**19**(6):213‐220

Health Care. 2016;**24**(1):11‐19

141‐148

& Wilkins, Baltimore; 2008


trol during occupational therapy in pediatric burn patients. Cyberpsychology, Behavior, and Social Networking. 2014;**17**(6):397‐401

[59] Faber AW, Patterson DR, Bremer M. Repeated use of immersive virtual reality therapy to control pain during wound dressing changes in pediatric and adult burn patients. Journal of Burn Care and Research: Official Publication of the American Burn Association. 2013;**34**(5):563

[47] Cho K, Yu J, Jung J. Effects of virtual reality‐based rehabilitation on upper extremity function and visual perception in stroke patients: A randomized control trial. Journal of

[48] da Silva Cameirão M, Bermúdez i Badia S, Duarte E, Verschure PF. Virtual reality based rehabilitation speeds up functional recovery of the upper extremities after stroke: A ran‐ domized controlled pilot study in the acute phase of stroke using the rehabilitation gam‐

[49] Mirelman A, Maidan I, Herman T, Deutsch JE, Giladi N, Hausdorff JM. Virtual reality for gait training: Can it induce motor learning to enhance complex walking and reduce fall risk in patients with Parkinson's disease? The Journals of Gerontology Series A.

[50] dos Santos Mendes FA, Pompeu JE, Lobo AM, da Silva KG, de Paula Oliveira T, Zomignani AP. Motor learning, retention and transfer after virtual‐reality‐based train‐ ing in Parkinson's disease‐effect of motor and cognitive demands of games: A longitudi‐

[51] Bisson E, Contant B, Sveistrup H, Lajoie Y. Functional balance and dual‐task reac‐ tion times in older adults are improved by virtual reality and biofeedback training.

[52] Cherniack EP. Not just fun and games: Applications of virtual reality in the identification and rehabilitation of cognitive disorders of the elderly. Disability and Rehabilitation:

[53] Optale G, Urgesi C, Busato V, Marin S, Piron L, Priftis K. Controlling memory impair‐ ment in elderly adults using virtual reality memory training: a randomized controlled

[54] Gregg L, Tarrier N. Virtual reality in mental health. Social Psychiatry and Psychiatric

[55] Suárez H, Suárez A, Lavinsky L. Postural adaptation in elderly patients with instabil‐ ity and risk of falling after balance training using a virtual‐reality system. International

[56] Lee N‐Y, Lee D‐K, Song H‐S. Effect of virtual reality dance exercise on the balance, activities of daily living, and depressive disorder status of Parkinson's disease patients.

[57] Pichierri G, Coppe A, Lorenzetti S, Murer K, de Bruin ED. The effect of a cognitive‐ motor intervention on voluntary step execution under single and dual task conditions in older adults: A randomized controlled pilot study. Clinical Interventions in Aging.

[58] Hoffman HG, Meyer III WJ, Ramirez M, Roberts L, Seibel EJ, Atzori B. Feasibility of articulated arm mounted Oculus Rift Virtual Reality goggles for adjunctive pain con‐

pilot study. Neurorehabilitation and Neural Repair. 2010;**24**(4):348‐357

ing system. Restorative Neurology and Neuroscience. 2011;**29**(5):287‐298

Biological Sciences and Medical Sciences. 2011;66(2);234‐240.

nal, controlled clinical study. Physiotherapy. 2012;**98**(3):217‐223

Cyberpsychology and Behavior. 2007;**10**(1):16‐23

Journal of Physical Therapy Science. 2015;**27**(1):145‐147

Assistive Technology. 2011;**6**(4):283‐289

Epidemiology. 2007;**42**(5):343‐354

Tinnitus Journal. 2006;**12**(1):41

2012;**7**:175‐184

Physical Therapy Science. 2012;**24**(11):1205‐1208

192 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation


### **Occupational Therapy for Elderly People**

Onur Altuntaş, Berkan Torpil and Mine Uyanik

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69472

#### **Abstract**

The population of the elderly is raising in the improved countries with the death age becoming later in life due to the improvement of contemporary therapy approaches and socio‐economic and cultural levels. Most older people with major disability of recent onset have the potential to benefit from geriatric rehabilitation. Rehabilitation for older people should have specific goals. Rehabilitation of elderly people involves an active process, delivered through a coordinated multidisciplinary team approach, aiming to improve function and enable subjects to live their lives to the whole potential. The major goal of rehabilitation programs for older people is to assist them to manage personal activities of daily living without the assistance of another person. Occupational therapy facilitates optimal occupational performance and community participation across the full spectrum of ability. In this chapter, there is information on the principles of occupa‐ tional rehabilitation for elderly people and evaluation and different therapy approaches in occupational therapy.

**Keywords:** elderly, rehabilitation, falls, cognition, home visit

#### **1. Introduction**

Aging is a physiologically inevitable process with chronological, social and psychological dimensions. Due to the physiological and physical changes that occur in the elderly in this process, some activities of the individuals are restricted or prevented from realizing these activities. These changes cause individuals to feel unhappy and especially affect the quality of life in terms of their health [1, 2].

In the old age period, the negativity of individual characteristics (poor socio‐economic situation, low education level, gender, etc.), functional disorder, decrease in level of daily living activity,

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

decrease in mobility, falling anxiety due to movement and vision problems, sleep problems, cog‐ nitive changes, other conditions and situations that cause disability lead to decrease in quality of life and social participation [3, 4].

The quality of life for the elderly in occupational therapy and social participation of examin‐ ing the factors influencing factors within the framework of a holistic approach to people and the environment are examined [5]. Aging is defined as a part of life in which progressive physiological changes are accompanied by an increase in the prevalence of acute and chronic diseases. Decreased functioning of an organism, as well as the wasting of organs, tissues, and cells, reduces the ability of elderly people to adapt to environmental factors [6]. The reduction of the biological and physiological capacity of the individual is an inevitable part of aging. Aging is a process that negatively affects many living systems. Physiological and anatomical changes in the aging process also lead to functional disorders in the individual [7]. In this sense, quality of life is consisted of such as physical and financial well‐being of individuals, social participation, participation in leisure time activities, psychological and emotional sta‐ tus, and family and social environment [8].

Today, we need to better understand the importance of physical functions in order to remem‐ ber that elderly individuals are a productive part of society, to minimize the incompetence, limitations, discomforts that occur with aging, and to continue their lives independently. Physical functions can be explained by environmental factors, force, balance, other physi‐ ological and psychological ways [9, 10]. In the process of aging, such as the many changes in the human body, balance is also affected. In addition to being associated with inadequacy in geriatric age groups, these changes are also a cause of the increase in the rate of falls in older ages. Approximately one‐third of geriatric individuals have a story of falling at least once every year, half of the individuals over 80 years of age [11, 12].

#### **2. Home rehabilitation and housing regulations for geriatric people**

World Health Organization, home accidents, in the house and/or in the garden, in the garage, etc., are defined as any kind of accident that occurs in the parts connected to the house. Accidents usually seen at home: falling, boiling, burning, poisoning, cuts, electric shocks and drowning. In home accidents, children, elderly people, and physical, mental and social dis‐ abilities constitute the three most important risk groups. The elderly are most often affected by house accidents such as falling, burning and poisoning [13, 14]. Falling in geriatric indi‐ viduals is an important factor that causes injuries and deaths. Due to falls, mobility problems and dependence in daily life activities are emerging. The incidence of falls increases with age, and 2–15% of falls result in fatal or life‐threatening injuries such as fractures, head trauma or severe soft tissue trauma. Reductions in age‐related physiological capacities increase the sever‐ ity and severity of damage due to excess disease [15, 16]. These negative occurrences in geriat‐ ric individuals can cause falls. Falls of the most common places are the homes of individuals experiencing. Many accidents at home cause falling. Many of the falls are preventable with many causes [17, 18]. The falls are divided into individual and environmental factors. Various physical and cognitive deficits such as dizziness, chronic illnesses, visual problems, sensory perception problems, neurological problems, psychiatric problems in the individual constitute individual factors. Environmental factors constitute the external environment in which the individual is home and interacting. In the home environment, Wet floor, Doorknob, Bathroom, Toilet, Kitchen, Carpet, Slippery floor, Inadequate lighting, The presence of an unbalanced object (TV cable, internet, electric cable) can cause many factors to fall. On the outside, the height of the cobblestone, unstable paving stones, rugged and/or icy roads is causing the fac‐ tors to fall. Unsuitable shoes are other factors that may cause misuse of the substance, such as alcohol‐drug intake [9, 19].

Home rehabilitation is important for eliminating the limitations of daily life activities that occur in geriatric individuals. Occupational therapist aims to provide active participation not only at home or in individual physical arrangements but also in each direction of the individual [20]. Geriatric individuals are subjected to home visits, home arrangements, caregiver training, and assistive technology design, especially due to hip fracture, amputa‐ tion, various neurological diseases and various home accidents [21–24]. An interdisciplinary approach is important in home rehabilitation. House arrangements in home rehabilitation are important. It is aimed that the geriatric individual will have the independence of his/her life in‐house arrangements. Home arrangements not only involve physical changes but also caregiver education, daily basic/instrumental life skills training, assistive technology use, and cognitive rehabilitation education. House arrangements include streets, streets, apart‐ ment entrances, staircases, elevators, home entrances and house parts.

Some of the considerations in‐house arrangements can be summarized as follows [25]:


#### **On the stairs:**

decrease in mobility, falling anxiety due to movement and vision problems, sleep problems, cog‐ nitive changes, other conditions and situations that cause disability lead to decrease in quality of

The quality of life for the elderly in occupational therapy and social participation of examin‐ ing the factors influencing factors within the framework of a holistic approach to people and the environment are examined [5]. Aging is defined as a part of life in which progressive physiological changes are accompanied by an increase in the prevalence of acute and chronic diseases. Decreased functioning of an organism, as well as the wasting of organs, tissues, and cells, reduces the ability of elderly people to adapt to environmental factors [6]. The reduction of the biological and physiological capacity of the individual is an inevitable part of aging. Aging is a process that negatively affects many living systems. Physiological and anatomical changes in the aging process also lead to functional disorders in the individual [7]. In this sense, quality of life is consisted of such as physical and financial well‐being of individuals, social participation, participation in leisure time activities, psychological and emotional sta‐

Today, we need to better understand the importance of physical functions in order to remem‐ ber that elderly individuals are a productive part of society, to minimize the incompetence, limitations, discomforts that occur with aging, and to continue their lives independently. Physical functions can be explained by environmental factors, force, balance, other physi‐ ological and psychological ways [9, 10]. In the process of aging, such as the many changes in the human body, balance is also affected. In addition to being associated with inadequacy in geriatric age groups, these changes are also a cause of the increase in the rate of falls in older ages. Approximately one‐third of geriatric individuals have a story of falling at least once

**2. Home rehabilitation and housing regulations for geriatric people**

World Health Organization, home accidents, in the house and/or in the garden, in the garage, etc., are defined as any kind of accident that occurs in the parts connected to the house. Accidents usually seen at home: falling, boiling, burning, poisoning, cuts, electric shocks and drowning. In home accidents, children, elderly people, and physical, mental and social dis‐ abilities constitute the three most important risk groups. The elderly are most often affected by house accidents such as falling, burning and poisoning [13, 14]. Falling in geriatric indi‐ viduals is an important factor that causes injuries and deaths. Due to falls, mobility problems and dependence in daily life activities are emerging. The incidence of falls increases with age, and 2–15% of falls result in fatal or life‐threatening injuries such as fractures, head trauma or severe soft tissue trauma. Reductions in age‐related physiological capacities increase the sever‐ ity and severity of damage due to excess disease [15, 16]. These negative occurrences in geriat‐ ric individuals can cause falls. Falls of the most common places are the homes of individuals experiencing. Many accidents at home cause falling. Many of the falls are preventable with many causes [17, 18]. The falls are divided into individual and environmental factors. Various

life and social participation [3, 4].

196 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

tus, and family and social environment [8].

every year, half of the individuals over 80 years of age [11, 12].


#### **Bedroom:**


#### **Living room:**


#### **Kitchen:**


#### **Bathroom and toilet:**


#### **Also:**


• Telephone, night lamp or switch must be in close proximity and prominence to reach the

• The individual should have adequate space, the room should be simple, not to interfere

• The individual's clothing and personal care materials should be within easy reach.

• There should not be any twisted carpet/rugs/mats or cables that cause it to get stuck.

• Countertop, cabinets, tables and chairs must be the person to the appropriate height.

• The buttons of the technological tools used must be clear and safety protection.

• Furniture materials such as chairs and tables should have a suitable ergonomic structure.

• Hold bars should be found. Diameters should be 4–5 cm. Height must be 90–100 cm or

• It must be placed in the appropriate manner to the needs of the individual firm grip bars

• Important materials such as drugs, telephone, alarm, etc. should be marked in distinct

• Explanatory text should be written to prevent the use of the wrong drug and special iden‐

elderly.

**Living room:**

**Kitchen:**

with the passage of goods.

• The floor should not be wet.

• The hob must be gas safety.

**Bathroom and toilet:**

trochanter major.

in the bathroom.

**Also:**

shapes.

• Fire and gas alarms must be present.

• Slippers should be slip resistant.

• Electrical cables should be close to the stove and sink.

198 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

• Bathtubs or high shower cabs should be avoided.

• The cables must be unplugged after using electrical equipment.

• Special technological tools must be available in emergencies.

• You must write emergency numbers on the phone.

tification boxes should be used if necessary.

• The floor must be made of non‐slip materials.

• All rooms should have adequate lighting.

• It should be explained that the bed should not be smoking. Smoking ashtrays must be deep.

#### **3. Occupational therapy as a teamwork in care and rehabilitation services of elderly people**

Care and rehabilitation are two important issues that need to be addressed together. Rehabilitation aims to improve the quality of life by ensuring that elderly people cope with the difficulties caused by the chronic diseases they encounter in daily life. For successful rehabilitation, however, not focusing on physical function, it is necessary to determine that social and psychological problems from a broad perspective and appropriate approaches are needed.

Geriatric rehabilitation is the work of professional disciplines together for the improvement of physical and emotional capacities and the development of quality of life due to the chronic problems of the elderly. The decrease in the musculoskeletal system, cardiovascular system and neuromuscular response times with age affects the physical capacities of individuals nega‐ tively. The declining level of physical activity due to these adverse effects affects the roles of elderly individuals in society and in the family in a negative way. In addition to general sys‐ temic problems with age, falling fear, lack of motivation, and depression trigger the inactivity of the elderly. The physiotherapist and the occupational therapist are involved in the multidis‐ ciplinary team in the process of bringing the active role to the elderly individual. The physio‐ therapist plays a role in planning the personalized exercise program considering the general health level and physical activity level of the elderly as well as achieving appropriate ergonomic approaches by determining the limitations of the elderly at home and social environment. It is inevitable to increase the level of physical activity in order to enable older individuals to reac‐ tivate in society. Gaining exercise habits for elderly people helps to maintain functional perfor‐ mance levels and thus to maintain daily living activity levels. It is known that older people with physical activity habits have longer and better general health status than inactive individuals. Small gains at the functional level can cause significant changes at the functional level. Studies have proven that strengthening exercises, balance and coordination exercises and gait training increase the level of functional performance, quality of life and general health.

As a result of treatment of the elderly with acute illnesses in Geriatric Assessment and Treatment Units (GATU), the mortality rates were found to be quite low compared to general hospital clinics. Detailed evaluation of interdisciplinary and all related diseases, early mobi‐ lization/rehabilitation and discharge planning is carried out in GATU. In the rehabilitation of elderly patients, it is stated that a successful discharge is achieved by evaluating home vis‐ its, determining safety recommendations and helping vehicle requirements, especially when planning for discharge in hip replacement, amputation or stroke rehabilitation. The majority of elderly people have difficulty with functional activities, and elderly people are not aware that they can help themselves [26–30].

Today, home care services are carried out with the interdisciplinary team approach with the participation of different professions such as physicians, nurses, occupational thera‐ pists, physiotherapists, dietitians, psychologists, pharmacists, social work specialists, den‐ tists and home economists. In countries where home care services are carried out, it is worth noting that the group that makes the most use of these services is the elderly. The home care model, which allows the elderly to present their health services at home, aims to increase the health and functionality of the elderly. It is also expected that the aging population will contribute to the economy by reducing hospital expenses. "Home health care programs" have been developed for the care of the elderly who have multiple prob‐ lems and are therefore at high risk for disability. Models that offer flexible services to each elderly patient are planned as a complementary model to the hospital. In these models, it is aimed to prevent cognitive and functional impairment considering the care of elderly patients. Encouraging and motivating elderly individuals to exercise in the framework of home care model also affect the development of meaningful activity trainings for them‐ selves in the long term in the development of physical and psychosocial health and well‐ being. According to the regulation, home care is the provision of health care and follow‐up services by the health team to meet the medical needs, including rehabilitation, occupa‐ tional therapy, physiotherapy and psychological treatment, in the environment where the physician suggests.

Examination, analysis, treatment, medical care, follow‐up and rehabilitation services include social and psychological counseling services at home and in the family environ‐ ment for the individuals who need to provide health services at home depending on their socioeconomic status. Within the team, occupational therapy service is applied as mobility, self‐care and home improvement in many areas of assistive devices and home modifica‐ tions to provide independence and security for the elderly. These practices can be based on the results of occupational performance assessments, using activities and organizing programs to help develop a healthy lifestyle, especially helping and giving advice to care‐ givers in physical activities, adapting the environment to day‐to‐day work and activities, and using assistive devices. According to the evaluation results, problems are encountered especially such as daily life teaching activities, transfer techniques, self‐care, dressing, eating, kitchen security, organizational skills, writing, reminders, hiking, education etc. We also provide advice and trainings in the areas of leisure and productive activities that will improve performance and satisfaction. Teaching assistive device training and energy conservation techniques can provide to greater independence and security in household management, mobility and self‐care areas to make things easier and to protect from second‐ ary injuries. Home modifications are an important and widely used approach in the world for occupational therapy applications as a result of person‐environment‐occupation interac‐ tion especially for the elderly with activity performance problems in the home settlements. Recreational activity training in occupational therapy programs includes sensory stimula‐ tion, short question‐and‐answer games and puzzle activities, real orientation (exercise and movement, music, singing), painting and handicrafts, bingo, chess, table games, puzzles, music dance, expressive activities (drama), and person‐centered education. In this training program, the person is given the ability to determine his/her own future, the authority to implement the decisions, and the whole family is taken into the therapeutic program. The task of occupational therapy is to help improve the role performance of the elderly. The necessary compensation or new role finding for elderly people is essential in the future in order to increase the quality of life of these individuals. Through the "Reorganization of Life Style" programs, elderly people reorganize their roles and activities by entering into meaningful activities within health and daily routines. The elderly changes pre‐cognitively in itself with the acquired experiences, then cognitively re‐senses itself by reflecting it to itself. When choosing an assistive device for a person, many factors such as suitability to that person's individual needs should be considered. In patients with chronic arthritis, tools for reaching, magnifiers, holding bars, jar openers and hearing aids are used. In gen‐ eral, there is a high satisfaction with the use of assistive devices. Most of the devices are chosen for their participation in leisure activities and to be more active. The occupational therapy approach, a new area for elderly assistive devices, needs to be more informed about the prognosis [31–34].

#### **4. Cognitive rehabilitation**

Today, home care services are carried out with the interdisciplinary team approach with the participation of different professions such as physicians, nurses, occupational thera‐ pists, physiotherapists, dietitians, psychologists, pharmacists, social work specialists, den‐ tists and home economists. In countries where home care services are carried out, it is worth noting that the group that makes the most use of these services is the elderly. The home care model, which allows the elderly to present their health services at home, aims to increase the health and functionality of the elderly. It is also expected that the aging population will contribute to the economy by reducing hospital expenses. "Home health care programs" have been developed for the care of the elderly who have multiple prob‐ lems and are therefore at high risk for disability. Models that offer flexible services to each elderly patient are planned as a complementary model to the hospital. In these models, it is aimed to prevent cognitive and functional impairment considering the care of elderly patients. Encouraging and motivating elderly individuals to exercise in the framework of home care model also affect the development of meaningful activity trainings for them‐ selves in the long term in the development of physical and psychosocial health and well‐ being. According to the regulation, home care is the provision of health care and follow‐up services by the health team to meet the medical needs, including rehabilitation, occupa‐ tional therapy, physiotherapy and psychological treatment, in the environment where the

200 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Examination, analysis, treatment, medical care, follow‐up and rehabilitation services include social and psychological counseling services at home and in the family environ‐ ment for the individuals who need to provide health services at home depending on their socioeconomic status. Within the team, occupational therapy service is applied as mobility, self‐care and home improvement in many areas of assistive devices and home modifica‐ tions to provide independence and security for the elderly. These practices can be based on the results of occupational performance assessments, using activities and organizing programs to help develop a healthy lifestyle, especially helping and giving advice to care‐ givers in physical activities, adapting the environment to day‐to‐day work and activities, and using assistive devices. According to the evaluation results, problems are encountered especially such as daily life teaching activities, transfer techniques, self‐care, dressing, eating, kitchen security, organizational skills, writing, reminders, hiking, education etc. We also provide advice and trainings in the areas of leisure and productive activities that will improve performance and satisfaction. Teaching assistive device training and energy conservation techniques can provide to greater independence and security in household management, mobility and self‐care areas to make things easier and to protect from second‐ ary injuries. Home modifications are an important and widely used approach in the world for occupational therapy applications as a result of person‐environment‐occupation interac‐ tion especially for the elderly with activity performance problems in the home settlements. Recreational activity training in occupational therapy programs includes sensory stimula‐ tion, short question‐and‐answer games and puzzle activities, real orientation (exercise and movement, music, singing), painting and handicrafts, bingo, chess, table games, puzzles, music dance, expressive activities (drama), and person‐centered education. In this training

physician suggests.

As people age, changes in the brain can affect memory and cognition. The scope of these changes varies from person to person. It is important not to assume that an old person does not ignore changes in memory or personality, or that it is only a normal part of aging [35].

Cognitive skill is the process of using the information of the central nervous system. Cognitive disorders are difficulties in retrieving, evaluating, organizing, and interpreting information that develops due to brain impairment, which alters the answers generated by the person in his/her daily life [36]. Cognitive function refers to an individual's perceptions, memory, think‐ ing, reasoning, and awareness. Along with physical decline, the decline in cognitive function is a hallmark of aging and is predictive of mortality [37]. Independence in the later stages of life is determined by both physical and cognitive abilities [38]. Among older adults, there is a range of skills ranging from normal cognitive function to broad cognitive functioning. Adequate cognitive functioning is required to perform simple activities of daily living such as eating and bathing and more complex tasks such as managing money, paying bills and taking medications. Cognitive function also affects an individual's ability to work and plays a role in retirement planning and decisions around pensions and savings. Because the estimated cost of dementia is too high, modifiable risk factors and early interventions to prevent cognitive decline and dementia are key priorities for policy‐makers and for societies [39].

Many older people are worried that there is a loss of memory, and many are afraid of demen‐ tia, such as Alzheimer's disease [35]. The cause of all cognitive problems is not just Alzheimer's disease. There are a variety of possible causes from drugs, such as side effects from metabolic and/or endocrine changes, delirium from other diseases, or untreated depression. Some of these reasons may be temporary with appropriate treatment or may be reversed. Other causes that cause cognitive problems, such as dementia, cannot be reversed, but symptoms can be treated for a while and families can be prepared for the future [35, 39].

Most patients with memory and other cognitive or behavioral problems want a diagnosis to understand why and what will happen [40–44]. Some patients (or families) are reluctant to express such problems because they are afraid of dementia and the dangers they may bring to the person and environment. In such a case, the prospect of early diagnosis of the patient and the relatives of the patient should be emphasized [39].

Cognitive assessment included an examination of higher cortical functions, particularly memory, attention, orientation, language, executive function (planning activities), and praxis (sequencing of activities). These are common and serious clinical syndromes affecting elderly people. Correct cognitive assessment is very important for diagnosis [45].

Cognitive deficits could also be a precursor to dementia. In that case, it is important to inter‐ vene at an early stage to prevent or delay conversion to dementia and to minimize the impact of these objective or perceived cognitive problems [46–49].

The main objective of cognitive interventions is to stimulate the cognitive system or offer compensatory methods to address difficulties with cognitive functioning. Cognitive interven‐ tions are usually separated into three categories: cognitive stimulation, cognitive training, and cognitive rehabilitation. These are:

Cognitive stimulation in a social setting such as reminiscence with reality orientation is associated with benefits in cognitive functioning as well as the quality of life, well‐being, communication, and social interaction skills. Cognitive stimulation comprises involvement in group activities that are designed to increase cognitive and social functioning in a non‐ specific manner. Cognitive training is a more specific approach, which teaches theoretically supported strategies and skills to optimize specific cognitive functions. Cognitive rehabili‐ tation involves an individualized approach using tailored programs centered on specific activities of daily life. Personally relevant goals are identified, and the therapist, patient, and family work together to achieve these goals (e.g., joining a social group) [49–51].

Reminiscence therapy, since the 1950s, uses a way to increase well‐being for older people. There is no "standard" model for providing this therapy, but in general, the idea is to enable or encourage people to think or talk about personally significant events that occurred in the past [52].

In our country where the elderly population is increasing, ergotherapy is supported by the person‐centered approach to fulfill the activities and roles of the elderly person. It is also aimed at the elderly to acquire or restore their reduced abilities due to disability or social influence and to improve or maintain their quality of life. With home visits, it is aimed to ensure that people stay in their homes for a long time and to make late applications to hospi‐ tal/care centers. Facilitating early and safe discharge from the hospital, thus reducing depen‐ dency and institutionalization are other important points. With the trainings given to parents and caregivers, it is also one of the aims of ergotherapy to support both the elderly person and their caregivers with a more peaceful and quality life.

#### **Author details**

that cause cognitive problems, such as dementia, cannot be reversed, but symptoms can be

Most patients with memory and other cognitive or behavioral problems want a diagnosis to understand why and what will happen [40–44]. Some patients (or families) are reluctant to express such problems because they are afraid of dementia and the dangers they may bring to the person and environment. In such a case, the prospect of early diagnosis of the patient

Cognitive assessment included an examination of higher cortical functions, particularly memory, attention, orientation, language, executive function (planning activities), and praxis (sequencing of activities). These are common and serious clinical syndromes affecting elderly

Cognitive deficits could also be a precursor to dementia. In that case, it is important to inter‐ vene at an early stage to prevent or delay conversion to dementia and to minimize the impact

The main objective of cognitive interventions is to stimulate the cognitive system or offer compensatory methods to address difficulties with cognitive functioning. Cognitive interven‐ tions are usually separated into three categories: cognitive stimulation, cognitive training, and

Cognitive stimulation in a social setting such as reminiscence with reality orientation is associated with benefits in cognitive functioning as well as the quality of life, well‐being, communication, and social interaction skills. Cognitive stimulation comprises involvement in group activities that are designed to increase cognitive and social functioning in a non‐ specific manner. Cognitive training is a more specific approach, which teaches theoretically supported strategies and skills to optimize specific cognitive functions. Cognitive rehabili‐ tation involves an individualized approach using tailored programs centered on specific activities of daily life. Personally relevant goals are identified, and the therapist, patient, and

Reminiscence therapy, since the 1950s, uses a way to increase well‐being for older people. There is no "standard" model for providing this therapy, but in general, the idea is to enable or encourage people to think or talk about personally significant events that occurred in the

In our country where the elderly population is increasing, ergotherapy is supported by the person‐centered approach to fulfill the activities and roles of the elderly person. It is also aimed at the elderly to acquire or restore their reduced abilities due to disability or social influence and to improve or maintain their quality of life. With home visits, it is aimed to ensure that people stay in their homes for a long time and to make late applications to hospi‐ tal/care centers. Facilitating early and safe discharge from the hospital, thus reducing depen‐ dency and institutionalization are other important points. With the trainings given to parents and caregivers, it is also one of the aims of ergotherapy to support both the elderly person and

family work together to achieve these goals (e.g., joining a social group) [49–51].

treated for a while and families can be prepared for the future [35, 39].

people. Correct cognitive assessment is very important for diagnosis [45].

and the relatives of the patient should be emphasized [39].

202 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

of these objective or perceived cognitive problems [46–49].

their caregivers with a more peaceful and quality life.

cognitive rehabilitation. These are:

past [52].

Onur Altuntaş\*, Berkan Torpil and Mine Uyanik

\*Address all correspondence to: fztonurb@hotmail.com

Health Science Faculty, Occupational Therapy Department, Hacettepe University, Ankara, Turkey

#### **References**


[28] Uyanık M, Düger T, Bumin G, Akı E, Kayıhan H. Yaşlılarda denge ve mobilite fonksiyonlarının düşme riskine etkisi. Türk Fizyoterapive Rehabilitasyon Dergisi. Aralık. 1996;**8**(4):34‐39

[12] Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in

[13] Doğan A. Yaşlı ve ergonomi. Turkish Journal of Physical Medicine & Rehabilitation/

[14] Evci D, Ergin F, Beşer E. Home accident in the elderly in Turkey. The Tohoku Journal of

[15] Boyd R, Stevens J. Falls and fear of falling: Burden, beliefs and behaviours. Age Ageing.

[16] Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: A prospective

[17] Güler P, Güler Ç. Yaşlıların ev güvenliği ve denetim listesi. Turkish Journal of Geriatrics.

[18] Toroman A. Yaşlılarda Düşme Riski ve Fiziksel Uygunluk. Bolu: Yüksek Lisans Tezi,

[19] Yeşilbakan. Ö, Karadakovan A. Narlıdere dinlenme ve bakımevinde yaşayan yaşlı bireylerdeki düşme sıklığı ve düşmeyi etkileyen faktörler. Turkish Journal of Geriatrics.

[20] Düger T. Tekerlekli Sandalye Kullanan Paraplejik Hastalarda Ev Rehabilitasyonu. Fizik Tedavi ve Rehabilitasyon Programı Bilim Uzmanlığı Tezi, HacettepeÜniversitesi, Ankara

[21] Kayıhan H. Geriatride Fizyoterapi ve Rehabilitasyon. Akademik Geriatri Dergisi. 2009;

[22] Guisti A, Barone A, Oliveri M, Pizzonia M, Razzono M, Palummeri E, et al. An analysis of the feasibility of home rehabilitation among elderly people with proksimal femoral

[23] Gitlin LN, Hauck WW, Dennis MP, Winter L, Hodgson N, Schinfeld S. Long‐term effect on mortality of a home intervention that reduces functional difficulties in older adults: Results from a randomised trail. The American Geriatrics Society. 2009;**57**:476‐481 [24] Uyanık M. Bakım hizmetlerinde fizyoterapistlerin ve ergoterapinin rolü. T.C. Başbakanlık Aile ve Sosyal Araştırmalar Genel Müdürlüğü Yayınları. V. Aile Surası 'Aile Destek Hizmetleri' Bildirileri; 2008 Kasım. s. 207‐221. Ankara : Afşaroğlu Matbaası. [25] Altuntaş O. Ev Düzenlemelerinin Yaşlıların Yaşam Kalitesine Etkisi. Ankara: Fiziksel Tıp ve Rehabilitasyon Programı Bilimi Doktora Tezi, Hacettepe Üniversitesi; 2010

[26] Rubenstein LZ. Falls in older people: Epidemiology, risk factors and strategies for pre‐

[27] Scheffer AC, Schuurmans MJ, Dijk NV, Der Hooft TV, De Rooij**s** OE. Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons.

fractures. Archives of Physical Medicine and Rehabilitation. 2006;**87**:826‐831

the community. The New England Journal of Medicine. 1988;**319**:1701‐1707

Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi. 2009;**55**:95‐99

study. The Journals of Gerontology. 1991;**46**:M164‐M170

Experimental Medicine. 2006;**209**:291‐301

204 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Abant İzzetBaysalÜniversitesi; 2007

vention. Age and Ageing. 2006;35:S2

Age and Ageing. 2008;**37**:19‐24

2009;**38**(4):423‐428

2002;**5**(4): 150‐154

2005;**8**(2):72‐77

**1**:82‐89


### **Occupational Therapy in Oncology and Palliative Care**

Sedef Şahin, Semin Akel and Meral Zarif

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68463

#### **Abstract**

[41] Weimer DL, Sager MA. Early identification and treatment of Alzheimer disease: Social

[42] Connell CM, Roberts JS, McLaughlin SJ, et al. Black and white adult family members' attitudes toward a dementia diagnosis. Journal of the American Geriatrics Society.

[43] Elson P. Do older adults presenting with memory complaints wish to be told if later diagnosed with Alzheimer's disease? International Journal of Geriatric Psychiatry.

[44] Turnbull Q, Wolf AMD, Holroyd S. Attitudes of elderly subjects toward "truth telling" for the diagnosis of Alzheimer's disease. Journal of Geriatric Psychiatry and Neurology.

[45] Young J, Meagher D, MacLullich A. Cognitive assessment of older people. The BMJ.

[46] Hill NL, Kolanowski AM, Gill DJ. Plasticity in early Alzheimer's disease: An opportu‐

[47] Mol ME, van Boxtel MP, Willems D, Verhey FR, Jolles J. Subjective forgetfulness is asso‐ ciated with lower quality of life in middle‐aged and young‐old individuals: A 9‐year fol‐ low‐up in older participants from the Maastricht aging study. Aging and Mental Health.

[48] Bahar‐Fuchs A, Clare L, Woods B. Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer's disease and vascular dementia. Cochrane Database of

[49] Buschert V, Bokde ALW, Hampel H. Cognitive intervention in Alzheimer disease.

[50] Woods B, Aguirre E, Spector AE, Orrell M. Cognitive stimulation to improve cognitive functioning in people with dementia. The Cochrane Database of Systematic Reviews.

[51] Simon SS, Yokomizo JEİ, Bottino Cássio MC. Cognitive intervention in amnestic mild cognitive impairment: A systematic review. Neuroscience and Biobehavioral Reviews.

[52] Pinquart M, Forstmeier S. Effects of reminiscence interventions on psychosocial out‐

comes: A meta‐analysis. Aging & Mental Health. 2012;**16**(5):541‐558

nity for intervention. Topics in Geriatric Rehabilitation. 2011;**27**(4):257

and fiscal outcomes. Alzheimers & Dementia. 2009;**5**(3):215‐226

206 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

2009;**57**(9):1562‐1568

2006;**21**(5):419‐425

2003;**16**(2):90‐93

2011;**343**:d5042

2009;**13**(5):699‐705

2012;**2**

Systematic Reviews.2013;**6**

2012;**36**(4):1163‐1178

Nature Reviews Neurology. 2010;**6**(9):508‐517

Cancer is a chronic disease that may occur in both children and adults. Occupational therapy focuses on the activity limitations and participation problems in their life. Oncology rehabilitation involves in helping an individual with cancer to regain maximum physical, psychological, cognitive, social, and vocational functioning with the limits up to disease and its treatments in an interdisciplinary team concept. These treatment options are associated with the risk of some side effects, including fatigue, pain, cognitive problems, decrease in bone density and muscle endurance, weight loss, and stress- or anxiety-related psychosocial problems. Occupational therapy approaches are a holistic view in a client center and use training in activities of daily living, assistive technology, education of energy conservation techniques, and management of treatment-related problems, such as pain, fatigue, and nausea. In palliative and hospice care, occupational therapists support clients with cancer by minimizing the secondary symptoms related to cancer and its treatments. At the end of life, occupational therapy offers to identify the roles and activities that are meaningful and purposeful to the client with cancer and try to determine the barriers that limit their performance. Clients with cancer who have childhood cancer or adult cancer can face problems about body structure and functions, activity, and participation, which may limit their participation to their daily life.

**Keywords:** oncology, rehabilitation, palliative care, occupational therapy

#### **1. Introduction**

Cancer is defined as the growth of abnormal cell structures in the body uncontrollably, without purpose, and with a large number. Cancer develops faster when the body's normal defense and control mechanisms do not work. Old cells do not die; instead, they become uncontrolled and replace new cells that are abnormal. These abnormal cells may be called a tumor, while some cancers do not form tumors such as leukemia [1]. Cancer can be anywhere in the body. Cancer

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

is a chronic disease of various types and characteristics in all ages and genders. According to the literature, the most common cancer is breast cancer in females and prostate cancer in males. Moreover, lung and colorectal cancer affect both men and women at high rates [2]. The most common types of cancer in children between 0 and 14 years of age are acute lymphocytic leukemia (ALL), brain and other central nervous system (CNS) tumors, and neuroblastoma. Although pediatric cancer mortality rates have declined by about 70% in the last four decades, it is still one of the most common causes of death in children [3].

There are five primary categories of cancer: carcinomas, sarcomas, leukemia, lymphomas, and central nervous system cancers. This categorization is made according to the body structure involved. For example, carcinomas begin in the skin or tissues, whereas sarcomas start in the bone, cartilage, fat, muscle, or other connective tissues. Leukemia develops in the blood and bone marrow, lymphomas start in the immune system, and central nervous system cancers start in the brain and spinal cord [4].

The survival rate after cancer treatment is increasing day by day due to advances in children, adolescents, and adults [5, 6]. Cancer survivors also can face the risk of cancer recurrence, metastases, or symptoms such as cancer-related pain, fatigue, stress, or lymphedema, etc. More than 60% of cancer survivors with ages between 5 and 19 years reported at least one serious symptom [7]. Some of the treatment options for cancer clients include surgery, chemotherapy, hormonal therapy, radiotherapy, immunotherapy, and targeted therapy. These treatments contain some risks that are closely related to the individual and the treatment dosage. Some side effects of treatments such as fatigue, pain, cognitive problems, decreased bone density, weight loss, and stressful psychosocial problems as well as hot pressures may occur [8]. It is known that due to these side effects, there is a decrease especially in the physical functions, daily activities of life (ADL), and quality of life in clients with cancer [9].

Occupational therapists (OTs) specialized in oncology does not only need to have high quality of skills but also knowledge about cancer, side effects, and evaluation of the treatments of cancer. This perspective requires a holistic and client-centered approach to provide personal care. OTs working in oncological rehabilitation aim to increase quality of life by facilitating physical, mental, emotional, social, occupational and cognitive needs, goal setting, and participation in meaningful occupations [10]. The main goal of OTs is to provide clients to participate in daily activities of life (ADL). OTs change their occupation or environment to better support occupational engagement in an interdisciplinary team concept. With oncologic rehabilitation, care is given to various age groups in a variety of care settings, including hospital, home, inpatient palliative care, or community-based services [11].

#### **2. Cancer rehabilitation**

Cancer rehabilitation is defined by Cromes as "helping a client with cancer to help to reach the maximum physical, social, psychological, and vocational functioning within the limits of disease and treatments" [12]. The functioning is important while engaging in activity and is related with all performance components [13]. In a more contemporary view, the function is a broad vision that encompasses the physical, emotional, cognitive, and psychological states of the individual [14]. The World Health Organization's International Functioning, Disability and Health Classification (ICF) defines a framework in which this multidimensional or biopsychosocial approach focuses on an extensive understanding of the interactions between function, capacity, and performance [13–15]. Cancer treatment itself also can lead to functional problems or impairments in physical, sensorial, or cognitive (body functions and structures), potentially leading to limitations in ADL or instrumental ADL (activity) and participation restriction (participation) [16]. Therefore, as ICF covers all of these domains, it suggests framework and approach regarding diagnosis and evaluation. This framework can also guide treatment programs [17].

Cancer rehabilitation goals are classified as restorative, supportive, palliative, and preventive according to progression of cancer. Generally, restorative care purposes at maximal recovery of residual function of the client. Supportive care aims to increase daily life and mobility by using effective methods such as reducing functional difficulties and compensating for permanent deficits. Palliative care reduces symptoms such as pain and shortness of breath. Preventive care includes in the area of power maintenance and movement after treatment. This process starts right after the diagnosis [18].

Client should be evaluated in terms of goal-oriented activity performance and participation in all contextual areas. Thus, OTs can provide a top-down approach to the clients [19]. **Table 1**

#### **Body functions and body structures**

*Functions* Sensation of pain Energy and innerdrive functions Emotional functions Voice functions Respiration functions Swallowing functions *Structures* Structure of mouth—pharynx-larynx-head and neck region

#### **Activities and participation**

Daily routine activity (Self-care-Eating-Drinking) Social activity (Family and friends relationships) Productivity activity (Economic self-sufficiency-preparing foods)

#### **Personal factors**

is a chronic disease of various types and characteristics in all ages and genders. According to the literature, the most common cancer is breast cancer in females and prostate cancer in males. Moreover, lung and colorectal cancer affect both men and women at high rates [2]. The most common types of cancer in children between 0 and 14 years of age are acute lymphocytic leukemia (ALL), brain and other central nervous system (CNS) tumors, and neuroblastoma. Although pediatric cancer mortality rates have declined by about 70% in the last four decades,

There are five primary categories of cancer: carcinomas, sarcomas, leukemia, lymphomas, and central nervous system cancers. This categorization is made according to the body structure involved. For example, carcinomas begin in the skin or tissues, whereas sarcomas start in the bone, cartilage, fat, muscle, or other connective tissues. Leukemia develops in the blood and bone marrow, lymphomas start in the immune system, and central nervous system can-

The survival rate after cancer treatment is increasing day by day due to advances in children, adolescents, and adults [5, 6]. Cancer survivors also can face the risk of cancer recurrence, metastases, or symptoms such as cancer-related pain, fatigue, stress, or lymphedema, etc. More than 60% of cancer survivors with ages between 5 and 19 years reported at least one serious symptom [7]. Some of the treatment options for cancer clients include surgery, chemotherapy, hormonal therapy, radiotherapy, immunotherapy, and targeted therapy. These treatments contain some risks that are closely related to the individual and the treatment dosage. Some side effects of treatments such as fatigue, pain, cognitive problems, decreased bone density, weight loss, and stressful psychosocial problems as well as hot pressures may occur [8]. It is known that due to these side effects, there is a decrease especially in the physical func-

Occupational therapists (OTs) specialized in oncology does not only need to have high quality of skills but also knowledge about cancer, side effects, and evaluation of the treatments of cancer. This perspective requires a holistic and client-centered approach to provide personal care. OTs working in oncological rehabilitation aim to increase quality of life by facilitating physical, mental, emotional, social, occupational and cognitive needs, goal setting, and participation in meaningful occupations [10]. The main goal of OTs is to provide clients to participate in daily activities of life (ADL). OTs change their occupation or environment to better support occupational engagement in an interdisciplinary team concept. With oncologic rehabilitation, care is given to various age groups in a variety of care settings, including hospital, home,

Cancer rehabilitation is defined by Cromes as "helping a client with cancer to help to reach the maximum physical, social, psychological, and vocational functioning within the limits of disease and treatments" [12]. The functioning is important while engaging in activity and is related with all performance components [13]. In a more contemporary view, the function is a broad

tions, daily activities of life (ADL), and quality of life in clients with cancer [9].

inpatient palliative care, or community-based services [11].

**2. Cancer rehabilitation**

it is still one of the most common causes of death in children [3].

208 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

cers start in the brain and spinal cord [4].

Type a or b personality İnterest Motivation level

#### **Environmental factors**

Products or substances for personal consumption Immediate family Health professionals Work environment

**Table 1.** Impairment of functional health in neck cancer.

shows an example of functional health impairment areas in neck cancer that should be analyzed by OTs [20]. In occupational therapy (OT), rehabilitation generally focuses on these topics:


#### **3. Occupational therapy role in symptom control**

Some clients experience symptoms during the first phase of diagnosis or treatment, while others experience these symptoms due to side effects or long-term outcome of treatment during the treatment phase. The appearance of symptoms can be basically examined in five different phases. The pretreatment phase is first experienced with symptoms of fatigue, pain, and anxiety. In this phase, the client will have difficulty in accepting the idea of the disease, their sleep patterns and routines begin to deteriorate, and problems occur in occupational and social relationships. The second phase is the primary treatment phase; in addition to the symptoms mentioned above, some other symptoms such as inappetency, fever, vomiting, dry mouth, etc. can occur as a result of chemotherapy or other modalities. ADL are interrupted. The post-treatment phase is the third one; the client with cancer experience treatment-related symptoms such as pain, weakness, or constipation after surgery. The influence on the activities and routines are very apparent at this phase. The fourth phase, where the symptoms experienced due to tumor growth occur, is the recurrence phase. Clients with cancer often feel depressive, anxious, fear, and unhappy for repetition. ADL and routines are disrupted with negative emotions and thoughts about their future. In the last phase, the end-of-life phase, the most common symptoms are fear of death and alienation to everything. Client usually cannot even get out of the bed and have lost all interest and the desire to live [13].

Symptoms are multidimensional and changeable in cancer clients. The OT's role in management of symptoms is crucial and important. They must maintain up-to-date professional knowledge of the symptoms and its treatments. They must also investigate the meaning and the impact of the symptom not only to the individual, but also to the caregivers. Besides, in the following sections of this chapter, every title includes client and their family educations for these symptoms, especially. They must search how this situation limits them in carrying out their required objectives in life. Thus, as a priority, realistic and achievable intervention plan can be made for people with cancer to control the symptoms. There are some approaches to control symptoms such as problem-solving strategies, restoration activity, compensation activity, and environmental modification that will be defined in the following sections.

#### **3.1. Problem-solving strategies**

shows an example of functional health impairment areas in neck cancer that should be analyzed by OTs [20]. In occupational therapy (OT), rehabilitation generally focuses on these topics:

Some clients experience symptoms during the first phase of diagnosis or treatment, while others experience these symptoms due to side effects or long-term outcome of treatment during the treatment phase. The appearance of symptoms can be basically examined in five different phases. The pretreatment phase is first experienced with symptoms of fatigue, pain, and anxiety. In this phase, the client will have difficulty in accepting the idea of the disease, their sleep patterns and routines begin to deteriorate, and problems occur in occupational and social relationships. The second phase is the primary treatment phase; in addition to the symptoms mentioned above, some other symptoms such as inappetency, fever, vomiting, dry mouth, etc. can occur as a result of chemotherapy or other modalities. ADL are interrupted. The post-treatment phase is the third one; the client with cancer experience treatment-related symptoms such as pain, weakness, or constipation after surgery. The influence on the activities and routines are very apparent at this phase. The fourth phase, where the symptoms experienced due to tumor growth occur, is the recurrence phase. Clients with cancer often feel depressive, anxious, fear, and unhappy for repetition. ADL and routines are disrupted with negative emotions and thoughts about their future. In the last phase, the end-of-life phase, the most common symptoms are fear of death and alienation to everything. Client usually cannot

• Symptom control • Activity training • Client education • Motor training • Sensory training • Cognitive training

• Vocational rehabilitation

**3. Occupational therapy role in symptom control**

210 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

even get out of the bed and have lost all interest and the desire to live [13].

Symptoms are multidimensional and changeable in cancer clients. The OT's role in management of symptoms is crucial and important. They must maintain up-to-date professional knowledge of the symptoms and its treatments. They must also investigate the meaning and the impact of the symptom not only to the individual, but also to the caregivers. Besides, in the following sections of this chapter, every title includes client and their family educations for these symptoms, especially. They must search how this situation limits them in carrying out their required objectives in life. Thus, as a priority, realistic and achievable intervention plan can be made for people with cancer to control the symptoms. There are some approaches to control symptoms such as problem-solving strategies, restoration activity, compensation activity, and environmental modification that will be defined in the following sections.

Cooper describes problem solving as "analyzing of the client's needs and enabling the client to cope with dysfunction" in approach to symptom control. OT must help to identify physical, emotional, social, and psychological problems and try to resolve them. For solving the problems caused by the symptoms can include: identifying the main problem, discussing another event that may contribute to the induction of the problem, brain storming through occupational therapy models to cope with the problems, setting achievable goals for individual, discussing methods—techniques to cope with the problems, practicing the developed strategies, and checking up the results of problem solving. OT can use problem-solving strategies mostly for clients with HIV/AIDS, cancer, and palliative care [21].

If cancer client have some difficulties on lifestyle, fatigue, and self-esteem, OT could help them to determine their priorities of life, to use energy levels, to recognize that a client's inner feelings and values, to change behavior, and to adapt to their changed lifestyle.

#### **3.2. Restoration activity**

Clients have different activities related to their routines in their life. The focus of the restorative approach is to develop client skills and abilities or increase the activity performance and participation of the client with cancer. In this stage, grading of the activity level can be done according to the following parameters [22]:


such as hospitals and homes. In order to reduce symptoms and improve the performance of the activity, awareness of the activities that they can perform in the environment they are in is extremely important in terms of occupational therapy intervention.

#### **3.3. Compensation activity**

The compensation approach focuses on using the patients' skills to achieve the highest possible stage of functioning in the activities. Despite the symptoms, OTs may teach new methods to increase performances. If the client still needs help, OTs can suggest using assistive equipment. These equipments can decrease symptoms, such as fatigue and pain of cancer, and increase participation in the activities.

#### **3.4. Environmental modification**

Environmental modifications consist of compensation, modification, and adaptation strategy. The compensation approach directly influences client functioning. However, environmental modification approach influences patients' functioning indirectly. OT could give advice to the client with cancer to redesign environments, such as home, work, and school, where the client wants to be. Modifications must be low cost and easily accessible.

#### **4. Occupational therapy in childhood cancer**

Nearly over 300,000 children develop cancer worldwide each year [23]. As many as two-thirds of children with childhood cancer are likely to experience at least one side effect, one-fourth of survivors experiencing a late effect that is severe or life threatening [24]. There are many studies showing that childhood cancer client experience many specific squeal after cancer diagnosis and treatment such as: hair loss, pain and fatigue, loss of fertility, and other changes in body image [25–27]. In children, it is important to be aware of growth and development stages in evaluation and intervention planning. Different from adults, their development can be affected in all components and more from the therapy. As children are also still dependent on caregivers, they are not fully functioning and still developing physical, social, cognitive skills, etc. Sometimes, to save life, surgeries may be harsh resulting with loss of a limb. Therefore, they may struggle to develop with that loss. The majority of the existing studies have shown that children with childhood cancer have increased anxiety, depression, and distress compared to their healthy peers and the general public [28, 29]. In a recent systematic review by Quinn et al., it is emphasized that psychological symptoms often result in impaired quality of life (QoL) [30].

Long-term treatments affect children's ability in the areas of self-care, productivity, and leisure activity. Treatments of cancer, especially treatments, cause a decrease in motor skills [31]. Gross and fine motor skills play an important role in the development of cognitive, academic, and social skills in children [32, 33]. In childhood cancer, the basic problems can be seen in social relationships, educational attainment, and school functions such as writing skills or reading skills, etc. [33]. Understanding the degree of the motor difficulty that the child faces is important for the efforts to improve their quality of life.

such as hospitals and homes. In order to reduce symptoms and improve the performance of the activity, awareness of the activities that they can perform in the environment they are

The compensation approach focuses on using the patients' skills to achieve the highest possible stage of functioning in the activities. Despite the symptoms, OTs may teach new methods to increase performances. If the client still needs help, OTs can suggest using assistive equipment. These equipments can decrease symptoms, such as fatigue and pain of cancer,

Environmental modifications consist of compensation, modification, and adaptation strategy. The compensation approach directly influences client functioning. However, environmental modification approach influences patients' functioning indirectly. OT could give advice to the client with cancer to redesign environments, such as home, work, and school, where the client

Nearly over 300,000 children develop cancer worldwide each year [23]. As many as two-thirds of children with childhood cancer are likely to experience at least one side effect, one-fourth of survivors experiencing a late effect that is severe or life threatening [24]. There are many studies showing that childhood cancer client experience many specific squeal after cancer diagnosis and treatment such as: hair loss, pain and fatigue, loss of fertility, and other changes in body image [25–27]. In children, it is important to be aware of growth and development stages in evaluation and intervention planning. Different from adults, their development can be affected in all components and more from the therapy. As children are also still dependent on caregivers, they are not fully functioning and still developing physical, social, cognitive skills, etc. Sometimes, to save life, surgeries may be harsh resulting with loss of a limb. Therefore, they may struggle to develop with that loss. The majority of the existing studies have shown that children with childhood cancer have increased anxiety, depression, and distress compared to their healthy peers and the general public [28, 29]. In a recent systematic review by Quinn et al., it is emphasized that psychological symptoms often result in impaired

Long-term treatments affect children's ability in the areas of self-care, productivity, and leisure activity. Treatments of cancer, especially treatments, cause a decrease in motor skills [31]. Gross and fine motor skills play an important role in the development of cognitive, academic, and social skills in children [32, 33]. In childhood cancer, the basic problems can be seen in social relationships, educational attainment, and school functions such as writing skills or

in is extremely important in terms of occupational therapy intervention.

212 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

wants to be. Modifications must be low cost and easily accessible.

**4. Occupational therapy in childhood cancer**

**3.3. Compensation activity**

and increase participation in the activities.

**3.4. Environmental modification**

quality of life (QoL) [30].

Assessment is needed at the beginning and end of rehabilitation to evaluate body structure and functions, activities, and participation. As all areas are affected, the level of success in terms of rehabilitation goals can be detected by systematic evaluation. **Table 2** shows the rehabilitation goals and assessment tools used by OTs in childhood cancer. It is important to recognize these rehabilitation goals while planning treatment.



**Table 2.** Rehabilitation goals and the evaluation instruments mostly used for childhood cancer.

It is always beneficial to use a framework while planning the treatment. As we prefer person- environment-occupation or Canadian Model of Occupational Therapy in children, we analyze all parameters according to the model. It is useful to train all skills by using play. Play is formed according to the skill loss of the children. OTs should be more creative while working with children. In literature, as we would like to increase motivation, do not bore and tire the child, all components can be trained with play [34]. The most preferred plays are jenga, monopoly, and dart throwing in our clinic. It is because children have joy while playing and these plays can be used to increase proximal stabilization, gross and fine motor skills, sensory skills, cognitive skills, social skills, and bilateral integration.

*In motor training* it is important to be aware of fine motor skills. Hand strengthening with putty, speed improvement with competitive plays, and endurance training by increasing the time in activities are examples of mostly used trainings. Of course, children should develop in gross motor skills as they participate in school and sports activities. Jumping and climbing are important skills that children should improve. In hospital setting, however, it is harder to train gross motor skills, and via activity, we may train gross and posture muscles.

*In sensory training* both hyper- or hyposensitivity should be trained. Desensitization or sensory reeducation should be done with materials children are familiar with. If a child has severe problem, caregiver should be well educated to prevent injuries like burn, cut, etc. Motor training can be combined with sensory training. For example, while training grasping, materials can be covered with different materials and the child can be asked to differentiate the feature.

*In cognitive training* attention is an important component. In development stage, attention is needed for children to be successful in all areas of daily living but especially in school functioning. For example, attention should be handled in terms of selective attention, shifting attention, and divided attention. These attention parameters can be added while skills training via meaningful activity, e.g., singing song while playing jenga. Processing speed, shortlong term memory, and sequencing ability should also be trained. Memory cards, history telling, making animation, and memory training by watching cartoon and asking questions can be examples. However, every impairment should be recognized and trained well in a structural planning.

It is important for the children to gain problem-solving skills, confidence, self-esteem, etc. Therefore, children should take responsibility in treatment; parents also should let the child to participate in activities. Some brainstorming home works are useful for both child and family education. ADL training is needed, and we should be aware of the sociocultural form of the family. If the child had never learned the skill, we may teach the parameters of the activity [35]. Children should develop social skills. We may form a social environment for the child and let him/her participate in group activities. Children always develop more by playing with their peers like communication, language, etc. Environment also should be assessed and needed adaptations should be provided.

In addition, OTs should be more creative in therapy applications. They should use creativitycontaining methods such as art, music, and dance therapy to increase activity performance and participation in children with cancer [36].

#### **5. Occupational therapy in adult cancer**

It is always beneficial to use a framework while planning the treatment. As we prefer person- environment-occupation or Canadian Model of Occupational Therapy in children, we analyze all parameters according to the model. It is useful to train all skills by using play. Play is formed according to the skill loss of the children. OTs should be more creative while working with children. In literature, as we would like to increase motivation, do not bore and tire the child, all components can be trained with play [34]. The most preferred plays are jenga, monopoly, and dart throwing in our clinic. It is because children have joy while playing and these plays can be used to increase proximal stabilization, gross and fine motor skills, sensory

Increasing Gross & Fine Motor Skills Bruininks Oseretsky Test of Motor Proficiency (BOTMP-

Supporting/developing Quality of Life SF-36, Quality of Life for Cancer Survivors, Childhood

Improving of school function The Evaluation Tool of Children's Handwriting

**Table 2.** Rehabilitation goals and the evaluation instruments mostly used for childhood cancer.

Nine Hole Peg Test

Assessment (SFA)

2edition), Purdue Pegboard, Jebsen Hand Function Test,

(ETCH), Minnesota Handwriting Test, School Function

Health Assessment Questionnaire (CHAQ)

*In motor training* it is important to be aware of fine motor skills. Hand strengthening with putty, speed improvement with competitive plays, and endurance training by increasing the time in activities are examples of mostly used trainings. Of course, children should develop in gross motor skills as they participate in school and sports activities. Jumping and climbing are important skills that children should improve. In hospital setting, however, it is harder to

*In sensory training* both hyper- or hyposensitivity should be trained. Desensitization or sensory reeducation should be done with materials children are familiar with. If a child has severe problem, caregiver should be well educated to prevent injuries like burn, cut, etc. Motor training can be combined with sensory training. For example, while training grasping, materials can be covered with different materials and the child can be asked to differ-

*In cognitive training* attention is an important component. In development stage, attention is needed for children to be successful in all areas of daily living but especially in school functioning. For example, attention should be handled in terms of selective attention, shifting attention, and divided attention. These attention parameters can be added while skills training via meaningful activity, e.g., singing song while playing jenga. Processing speed, shortlong term memory, and sequencing ability should also be trained. Memory cards, history

train gross motor skills, and via activity, we may train gross and posture muscles.

skills, cognitive skills, social skills, and bilateral integration.

**Rehabilitation goals Evaluation instruments**

Family or peer problems Interview Reduction of insomnia Diary Construction of meaning and objective perspectives Interview

214 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

entiate the feature.

There are a total of 14.1 million cancer cases that result in 8.2 million deaths according to the global cancer statistics [37]. Survivors of cancers may have physical, social, cognitive, and emotional problems. For example, in breast cancer which is the most common type of woman, they might experience chronic lymphedema, sexual dysfunction, and cognitive impairment [38, 39]. As well as client with prostate cancer may experience urinary incontinence, peripheral neuropathy, weakness of muscle, sexual problems, and fatigue [22]. Among cancer survivors, psychosocial problems are prevalent and may include economic difficulties related to repetition and fear of death, anxiety and depression, feelings of alienation or isolation, job loss, and discrimination in employment [40]. Because of these reasons, researchers focus on quality of life issues after cancer treatment [41]. The common rehabilitation goals and a couple of examples of instrument for assessing the achievement of this goal are shown in **Table 3**.

According to ICF parameters, **Table 3** shows some examples of the rehabilitation goals and the evaluation instruments which are mostly used by OT for cancer client in adults. Clients with cancer need sensory-motor-cognitive training, breathing and relaxation training, fatigue and pain management, and vocational rehabilitation to support independent, healthy life. It is also important to promote occupational balance and appropriate planning of daily routine in adults. Different than children, adults may have more problems in gaining motivation; they are mostly very pessimistic and sometimes it is hard to initiate the rehabilitation program. Therefore, therapist should use therapeutic skills for communicating well.

In sensory training, it is good to support body image, body awareness, and deep sense. Mindfulness, body awareness training, proprioceptive-kinesthetic training can be added to rehabilitation program. Sensory education should be given for both upper and lower extremity. Many clients have problems in perception of foot sole. Sensory input should be given



**Table 3.** Rehabilitation goals and the evaluation instruments mostly used for adults cancer.

**Rehabilitation goals Evaluation instruments**

216 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Reducing post-surgical problems (scars discomfort,

Reducing hormone deficiency symptoms (vasomotor

seroma)

dysfunction

relaxation

promotions

Reduction of Progression Improving of Hand Function

musculoskeletal system

reactions, osteoporosis)

Increasing of physical performance WHO Activity Index, Karnofsky Performance Score,

Reducing sensory symptoms after treatments Sensitivity Measurement, Vibration Sense, Semmes-

Reduction of fatigue Multidimensional fatigue Inventory (MFI), Cancer

Maintaining/increasing independence of daily life Detailed activity analysis, Functional Independence

Improvement of cognitive performance d2-test (Attention stress test), Benton test (visual

Improving of Quality of Life QLQ-C30, cancer-related modules Breakdown of family and partnership problems Interview, Couples climate scales

(RL) Increasing motivation and interest in activities OQ (Occupational Questionnaire), Interest Checklist and

examination

Reducing pain Visual Analog Scale (VAS), Pain Diary Reduction of lymphedema Clinical observation, rating scale

Improvement in urinary incontinence Biofeedback, diary

Dealing with sexual dysfunction, improvement of erectile

Improvement of functional disorders of the

Promoting disease management, improving selfawareness and self-acceptance, emotional stabilization

Enabling reintegration, initiating professional

Coping with stress and anxiety depressive states and

Harvard Step Test, Ergometry, Muscle Strength Measurement (Vigorimeter, Digimax Muscle Testing), Functional Assessment of Cancer Therapy (G: General, F:

Clinical observation, Visual Analog Scale (VAS)

Clinical observation, Visual Analog Scale (VAS)

Fatigue Scale (CFS), Piper Fatigue Scale (PFS), Functional Assessment of Cancer Therapy, Fatigue (FACT-F), Visual Analog Scale (VAS), EORTC-QLQ-C30, Fatigue Module

Diary, International Index of Erectile Function (IIEF)

Measure (FIM), Barthel Index (BI), Instrumental Activities of Daily Living Scale (IADL), Role Checklist

memory-BT), Multiple Choice Vocabulary Intelligence Test (MWT-B), Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), Mini mental state

"Stress thermometer," Hospital Anxiety and Depression Scale (HADS-D), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Visual Analog Scale (VAS)

EORTC, SF-36, Functional Assessment of Cancer Therapy (G: General, F: Fatigue FACT)

Purdue pegboard, Jebsen Hand Function Test

CIO Community Integration Questionnaire, ISSI (Interview Schedule For Social Interaction)

Fear of Progression Questionnaire

Fatigue, P: Prostate-FACT)

Weinstein monofilament

Range of motion Muscle strength test

Activity Checklist (ICAC)

form planter surface of the foot. Education in upper extremity should be given in a functional manner. Materials and exercises should be selected according to the meaningful activities.

In motor training, according to the areas of weaknesses, muscle strength gain should be aimed. Clients mostly have problems in endurance and control. In hospital setting, activity training should be planned in this manner. For example, for the clients who do not wanted to participate to therapy and can only sit in bed for 5 minutes, we decided to use dart throwing exercise. We asked him to sit in a wheelchair and stand up and throw the dart. First day, he did only one throw; however, second day he stood up three times, and at the end of the week he started walking and participated to the therapy. We should always support antigravity muscles by activities. Endurance and fatigue management should be our priority, afterwards we can aim speed.

Cognitive training will differ according to the effect among cancer clients. However, mostly, programs may include memory, attention, orientation, and executive function. If the client is elderly, cognitive problems may be more visible as with ageing cognitive abilities are decreasing. In working adults, executive functioning gains importance for working skills. It is advisable to start cognitive training as quick as possible because its effect on symptom and fatigue control has been shown.

Breathing and relaxation training consist of learning breathing technique, body/mind relaxation technique, somatic experience technique, and relaxation exercises [21, 22]. The common goal of these techniques is to ensure that people are both physically and cognitively less likely to feel stressed and more comfortable to maintain and participate in their activities.

Fatigue and pain management are most important in rehabilitation. Because nearly every client struggles with fatigue and pain, and these symptoms affect treatment success. Management of these symptoms will closely influence the performance and participation of activities of individuals in their daily lives. OTs should give priority to teach the client to state, sequence, and divide the activity for them to enable to cope with these symptoms. Energy conservation techniques and activity planning should become a part of their lifestyle, so that they can keep their energy for longer or use it more appropriately. In addition, planning sleep routines and daily routines is an intervention that OTs should not forget in adult cancer clients [21].

Leisure activities can also be suggested to these clients. As we aim occupational balance, this area of occupational performance should not be forgotten. Gardening, doing hand crafts, painting, yoga, dance, and pilates are mostly preferred activities. As these activities give joy to clients, some chemicals like serotonin can be released and immune system can be supported. Therefore, we may say that these activities can also have a healing effect.

Adult client may whether continue with their old job or are ready to return to work or whether they will be able to get a new job or not. Thus, vocational rehabilitation may be needed in treatment plan. OTs can make suggestions on improving the physical, psychological, and cognitive skills of the worker about the work, and give suggestions about designing the working activity or modify the work environment.

In conclusion, occupational therapy should carry out a holistic approach including improving endurance and muscle strength, preserving energy for daily living activities, decreasing stress, improving activity performances, and participation in adults' cancer [22, 42].

#### **6. Rehabilitation in palliative care and hospice care**

The role of occupational therapist in palliative care and hospice care is quite similar and important. In these care services, occupational therapists support mostly the secondary symptoms related to cancer client, cancer types, and treatments. End-of-life care of children and adults can include the management of physical, emotional, social or cognitive symptoms, limitations of performance, meaningful roles and activities, family, and social support. They analyze the current activity preferences and the personal and environmental resources to increase client participation. Hospice care generally has been little experienced with children, while it is mostly used as an approach to care during the last stages of life in adults [24]. The main aim of OTs is to improve the quality of life according to the values of the client and to maximize lasting functional skills [43].

#### **7. Conclusion**

OT clinical trial evaluation and interventions focus on functioning and participation by improving the abilities of cancer clients. The care of cancer client prolongs from the start of treatment to the end of the client life. They provide evidence-based interventions in inpatient care, outpatient care, education, and home care and in hospital care settings. Cancer clients may usually need support for ADL, using breathing and relaxation training, lifestyle redesigning and fatigue management, self-esteem, motor skills, cognitive therapy, vocational rehabilitation, and client and caregiver education. The OTs mainly focuses on these subjects and activity and participation restrictions in the rehabilitation community.

#### **Author details**

Sedef Şahin\*, Semin Akel and Meral Zarif

\*Address all correspondence to: sedefkarayazgan88@hotmail.com

Faculty of Health Sciences, Occupational Therapy Department, Hacettepe University, Ankara, Turkey

#### **References**

clients, some chemicals like serotonin can be released and immune system can be supported.

Adult client may whether continue with their old job or are ready to return to work or whether they will be able to get a new job or not. Thus, vocational rehabilitation may be needed in treatment plan. OTs can make suggestions on improving the physical, psychological, and cognitive skills of the worker about the work, and give suggestions about designing the working

In conclusion, occupational therapy should carry out a holistic approach including improving endurance and muscle strength, preserving energy for daily living activities, decreasing

The role of occupational therapist in palliative care and hospice care is quite similar and important. In these care services, occupational therapists support mostly the secondary symptoms related to cancer client, cancer types, and treatments. End-of-life care of children and adults can include the management of physical, emotional, social or cognitive symptoms, limitations of performance, meaningful roles and activities, family, and social support. They analyze the current activity preferences and the personal and environmental resources to increase client participation. Hospice care generally has been little experienced with children, while it is mostly used as an approach to care during the last stages of life in adults [24]. The main aim of OTs is to improve the quality of life according to the values of the client and to

OT clinical trial evaluation and interventions focus on functioning and participation by improving the abilities of cancer clients. The care of cancer client prolongs from the start of treatment to the end of the client life. They provide evidence-based interventions in inpatient care, outpatient care, education, and home care and in hospital care settings. Cancer clients may usually need support for ADL, using breathing and relaxation training, lifestyle redesigning and fatigue management, self-esteem, motor skills, cognitive therapy, vocational rehabilitation, and client and caregiver education. The OTs mainly focuses on these subjects

Faculty of Health Sciences, Occupational Therapy Department, Hacettepe University, Ankara,

and activity and participation restrictions in the rehabilitation community.

\*Address all correspondence to: sedefkarayazgan88@hotmail.com

stress, improving activity performances, and participation in adults' cancer [22, 42].

**6. Rehabilitation in palliative care and hospice care**

Therefore, we may say that these activities can also have a healing effect.

218 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

activity or modify the work environment.

maximize lasting functional skills [43].

Sedef Şahin\*, Semin Akel and Meral Zarif

**7. Conclusion**

**Author details**

Turkey


[28] Dyson GJ, Thompson K, Palmer S, Thomas DM, Schofield P. The relationship between unmet needs and distress amongst young people with cancer. Supportive Care in Cancer. 2012;**20**(1):75-85

[14] Dalton SO, Johansen C. New paradigms in planning cancer rehabilitation and survivorship. Acta Oncologica. 2013;**52**(2):191-194. DOI: 10.3109/0284186X.2012.748216

[15] Egan MY, McEwen S, Sikora L, Chasen M, Fitch M, Eldred S. Rehabilitation following cancer treatment. Disability and Rehabilitation. 2013;**35**(26):2245-2258. DOI:

[16] Weis J, Giesler JM. Rehabilitation for cancer client. In: Goerling U, editor. Psycho-

[17] Holm LV, Hansen DG, Kragstrup J, Johansen C, dePont Christensen R, Vedsted P. Influence of comorbidity on cancer patients' rehabilitation needs, participation in rehabilitation activities and unmet needs: A population-based cohort study. Supportive Care

[18] Dietz JJ. Adaptive rehabilitation in cancer. Postgraduate Medical Journal. 1980;**68**:145-153 [19] Lehmann C, Beierlein V, Hagen-Aukamp C, Kerschgens C, Rhee M, Frühauf S. Psychosocial predictors of utilization of medical rehabilitation services among prostate cancer client. Die Rehabilitation Journal. 2012;**51**(3):160-170. DOI: 10.4414/smw.2015.14214 [20] ICF Research Braunch. Available from: https://www.icf-research-branch.org/images/ ICF%20Core%20Sets%20.Download/Brief\_ICF\_Core\_Set\_for\_Head\_and\_Neck\_

[21] Cooper J. Occupational therapy in oncology and palliative care. In: Cooper J, editor. Occupational Therapy Approach in Symptom Control. USA: John Wiley Sons; 2006.

[22] Huri M, Akel BS, Şahin S. Rehabilitation of client with prostate cancer. Prostate. 2016;**6**:8 [23] Burstein HJ, Krilov L, Aragon-Ching JB, Baxter NN, Chiorean EG, Chow WA, Epstein AS. Clinical cancer advances 2017: Annual report on progress against cancer from the American Society of Clinical Oncology. Journal of Clinical Oncology. 2017; 35

[24] Ward E, DeSantis C, Robbins A, Kohler B, Jemal A. Childhood and adolescent cancer

[25] Leuteritz K, Friedrich M, Nowe E, Sender A, Stöbel-Richter Y, Geue K. Life situation and psychosocial care of adolescent and young adult (AYA) cancer client–study protocol of a

[26] Zebrack BJ, Casillas J, Nohr L, Adams H, Zeltzer LK. Fertility issues for young adult

[27] Geue K, Sender A, Schmidt R, Richter D, Hinz A, Schulte T, Stöbel-Richter Y. Genderspecific quality of life after cancer in young adulthood: A comparison with the general

statistics, 2014. CA: a cancer journal for clinicians. 2014; 64(2), 83-103.

12-month prospective longitudinal study. BMC Cancer. 2017;**17**(1):82

survivors of childhood cancer. Psycho-Oncology. 2004;**13**(10):689-699

population. Quality of Life Research. 2014;**23**(4):1377-1386

Oncology. Berlin, Heidelberg: Springer; 2014. pp. 87-101

220 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

10.3109/09638288.2013.774441

in Cancer. 2014;**22**(8):2095-2105

Cancer.pdf] (Accessed: February)

pp. 27-40.

(12):1341-1367.


[40] Hewitt M, Rowland JH, Yancik R. Cancer survivors in the United States: Age, health, and disability. The Journals of Gerontology Series A: Biological Sciences and Medical

[41] Huri M, Huri E, Kayihan H, Altuntas O. Effects of occupational therapy on quality of life of client with metastatic prostate cancer: A randomized controlled study. Saudi Medical

[42] Pekçetin S, Bumin G, Güngör T, Tunç S. Kemoterapi Alan Jinekolojik Kanserli Hastalarda Algılanan Aktivite Performansının Toplumsal Katılım ve Yaşam Kalitesi Üzerine Etkisi.

[43] Prochnau C, Liu L, Boman J. Personal–professional connections in palliative care occupational therapy. American Journal of Occupational Therapy. 2003;**57**(2):196-204

Journal. 2015;**36**(38):954-961. DOI: 10.15537/smj.2015.8.11461

Ergoterapi ve Rehabilitasyon Dergisi. 2013;**1**(2):31-41

Sciences. 2003;**58**(1):M82-M91

222 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

### *Edited by Meral Huri*

This new book presents the growing occupational therapy knowledge and clinical practice. Occupational therapy, as a health profession, is concerned with preserving well-being through occupations, and its main goal is to help people participate in the activities of daily living. This is achieved by working with people to improve their ability to engage in the occupations they want to engage in or by changing the occupation or the environment to better support their occupational engagement. The topic of the book has been structured on occupational therapy framework and reflects new research, techniques, and occupational therapy trends. This useful book will help students, occupational therapy educators, and professionals to connect occupational therapy theories and the evidence-based clinical practice.

Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Occupational Therapy

Occupation Focused Holistic Practice in

Rehabilitation

*Edited by Meral Huri*

Photo by Manuel-F-O / iStock