TY - JOUR A1 - Maritz, R. A1 - Pongpipatpaiboon, K. A1 - Melvin, J.L. A1 - Graves, D.E. A1 - Prodinger, Birgit T1 - Content comparison of the Spinal Cord Injury Model System Database to the ICF Generic Sets and Core Sets for spinal cord injury JF - Spinal Cord N2 - Study design Mapping of the National Spinal Cord Injury Model System (SCIMS) Database (NSCID) to the International Classification of Functioning, Disability and Health (ICF). Objectives To link the content of the latest two versions of the NSCID to the ICF; more specifically (1) to compare the content of the current NSCID 2016–2021 version to its predecessor (NSCID 2011–2016) using the ICF as a neutral reference framework, and (2) to compare the content contained in the NSCID 2016–2021 version with relevant ICF Sets. Setting The forms of the NSCID 2016–2021 and 2011–2016 versions were linked to the ICF and contrasted. Comparability of the current version of the NSCID with the ICF Core Set for Spinal Cord Injury (SCI) in the post-acute and long-term context and the two generic ICF sets— ICF Generic-7 and ICF Generic-30 was then examined. Methods ICF Linking Rules and descriptive statistics. Results The current NSCID 2016–2021 version covers functioning as classified in the ICF with 8 ICF categories more comprehensively than its predecessor does. More than 50% of ICF categories contained in the two ICF Generic Sets were covered. The coverage of the brief ICF Core Sets for SCI by the NSCID 2016–2021 was more than 50%, but the coverage of the comprehensive core sets was low. Results showed the best coverage in the ICF component Activities and Participation. Conclusions This study emphasizes how the ICF and its Sets can serve as a reference framework to foster comparability of existing data sets from both clinical practice and research. KW - Rehabilitation KW - Spinal cord injury Y1 - 2019 UR - https://doi.org/10.1038/s41393-019-0326-9 VL - 57 IS - 12 SP - 1023 EP - 1030 ER - TY - JOUR A1 - Maritz, R. A1 - Tennant, A. A1 - Fellinghauer, C. A1 - Stucki, G. A1 - Prodinger, Birgit T1 - The Extended Barthel Index (EBI) can Be Reported as a Unidimensional Interval-Scaled Metric – A Psychometric Study JF - Physikalische Medizin, Rehabilitationsmedizin, Kurortmedizin N2 - Background: The Extended Barthel Index (EBI), consisting of the original Barthel Index plus 6 cognitive items, provides a tool to monitor patients’ outcomes in rehabilitation. Whether the EBI provides a unidimensional metric, thus can be reported as a valid sum-score, remains to be examined. Objective: To examine whether the EBI can be reported as unidimensional interval-scaled metric for neurological and musculoskeletal rehabilitation. Methods: Rasch analysis of a calibration sample of 800 cases from neurological or musculoskeletal rehabilitation in 2016 in Switzerland. Results: In the baseline analysis no fit to the Rasch Model was achieved. When accommodating local dependencies with a testlet approach satisfactory fit to the Rasch Model was achieved, and an interval scale transformation table was created. Conclusion: The results support the reporting of adapted EBI total scores for both rehabilitation groups by applying the interval scaled transformation table presented in this study. N2 - Hintergrund: Der Erweiterte Barthel Index (EBI), der den Barthel Index um 6 kognitive Items ergänzt, ist ein Assessmentinstrument für die Rehabilitation. Ob der EBI eine eindimensionale Metrik liefert und somit als valider Gesamtscore berichtet werden kann, ist unklar. Ziel: Untersuchung ob der EBI für die neurologische und muskuloskelettale Rehabilitation als eindimensionale intervallskalierte Metrik berichtet werden kann. Methode: Rasch-Analyse einer Stichprobe von 800 neurologischen und muskuloskelettalen Rehapatienten aus der Schweiz. Ergebnisse: In der Basisanalyse wurde keine Übereinstimmung mit den Annahmen des Rasch-Modells erreicht. Nachdem lokale Item-Abhängigkeiten mit 2 Testlets angepasst wurden, wurde die Übereinstimmung erreicht und eine intervallskalierte Transformationstabelle erstellt. Konklusion: Die Ergebnisse unterstützen die Verwendung eines angepassten EBI Gesamtscores für beide Rehabilitationsgruppen unter Anwendung der intervallskalierten Transformationstabelle. KW - activities of daily living KW - assessment instruments KW - outcome assessment KW - rehabilitation KW - Rasch model KW - quality management Y1 - 2019 UR - https://doi.org/10.1055/a-0820-4642 VL - 29 IS - 04 SP - 224 EP - 232 ER - TY - JOUR A1 - Prodinger, Birgit A1 - Hammond, A. A1 - Tennant, A. A1 - Prior, Y. A1 - Tyson, S. T1 - Revisiting the disabilities of the arm, shoulder and hand (DASH) and QuickDASH in rheumatoid arthritis JF - BMC Musculoskeletal Disorder N2 - Background Limitations in upper limb functioning are common in Musculoskeletal disorders and the Disabilities of the Arm, Shoulder and Hand scale (DASH) has gained widespread use in this context. However, various concerns have been raised about its construct validity and so this study seeks to examine this and other psychometric aspects of both the DASH and QuickDASH from a modern test theory perspective. Methods Participants in the study were eligible if they had a confirmed diagnosis of Rheumatoid Arthritis (RA). They were mailed a questionnaire booklet which included the DASH. Construct validity was examined by fit to the Rasch measurement model. The degree of precision of both the DASH and QuickDASH were considered through their Standard Error of Measurement (SEM). Results Three hundred and thirty-seven subjects with confirmed RA took part, with a mean age of 62.0 years (SD12.1); 73.6% (n = 252) were female. The median standardized score on the DASH was 33 (IQR 17.5–55.0). Significant misfit of the DASH and QuickDASH was observed but, after accommodating local dependency among items in a two-testlet solution, satisfactory fit was obtained, supporting the unidimensionality of the total sets and the sufficiency of the raw (ordinal or standardized) scores. Conclusion Having accommodated local response dependency in the DASH and QuickDASH item sets, their total scores are shown to be valid, given they satisfy the Rasch model assumptions. The Rasch transformation should be used whenever all items are used to calculate a change score, or to apply parametric statistics within an RA population. Significance and innovations Most previous modern psychometric analyses of both the DASH and QuickDASH have failed to fully address the effect of a breach of the local independence assumption upon construct validity. Accommodating this problem by creating ‘super items’ or testlets, removes this effect and shows that both versions of the scale are valid and unidimensional, as applied with a bi-factor equivalent solution to an RA population. The Standard Error of Measurement of a scale can be biased by failing to take into account the local dependency in the data which inflates reliability and thus making the SEM appear better (i.e. smaller) than the true value without bias. KW - disabilities of the arm, shoulder and hand Y1 - 2019 UR - https://doi.org/10.1186/s12891-019-2414-6 VL - 20 IS - 1 SP - 41 ER - TY - JOUR A1 - Maritz, R. A1 - Tennant, A. A1 - Fellinghauer, C. A1 - Stucki, G. A1 - Prodinger, Birgit T1 - The Functional Independence Measure 18-item version can be reported as a unidimensional interval-scaled metric: Internal construct validity revisited JF - Journal of Rehabilitation Medicine N2 - Abstract Objective: Since the 1990s the Functional Independence Measure (FIM™) was believed to measure 2 different constructs, represented by its motor and cognitive subscales. The practice of reporting FIM™ total scores, together with recent developments in the understanding of the influence of locally dependent items on fit to the Rasch model, raises the question of whether the FIM™ 18-item version can be reported as a unidimensional interval-scaled metric. Design: Rasch analysis of the FIM™ using testlet approaches to accommodate local response dependency. Patients: A calibration sample containing 946 cases of data from 11,103 patients undergoing neurological or musculoskeletal rehabilitation in Switzerland in 2016. Results: Baseline analysis and the traditional testlet approach showed no fit with the Rasch model. When items were grouped into 2 testlets, fit to the Rasch model was achieved, indicating unidimensionality across all 18 items. A transformation table to convert FIM™ raw ordinal scores to the corresponding Rasch interval scaled values was created. Conclusion: This study provides evidence that FIM™ total scores represent a unidimensional set of items, supporting their use in clinical practice and outcome reporting when applying the respective transformation table. This provides a basis for standardized reporting of functioning. Lay Abstract The aim of this study was to look in detail at the FIM™, an assessment tool often used for patients undergoing rehabilitation. Some users report the FIM™ as 2 scores: one related to motor tasks, the other to cognitive tasks; others recommend reporting it as a single score including both motor and cognitive tasks. This study explored whether it is statistically meaningful to sum all the points into a single FIM™ total score. The results support the current practice of summing the points into a single total score for patients undergoing musculo-skeletal and neurological rehabilitation. The results also allowed an interval scale to be derived from the FIM™, enabling a broad range of calculations to be made using the FIM™ score, such as calculating the change in FIM™ outcomes from the time a patient is admitted to a rehabilitation clinic until their discharge. KW - Functional Independence Measure Y1 - 2019 UR - https://doi.org/10.2340/16501977-2525 VL - 51 IS - 3 SP - 193 EP - 200 ER - TY - JOUR A1 - Dorjbal, D. A1 - Prodinger, Birgit A1 - Zanini, C. A1 - Avirmed, B. A1 - Stucki, G. A1 - Rubinelli, S. T1 - Living with spinal cord injury in Mongolia: A qualitative study on perceived environmental barriers JF - Journal of Spinal Cord Medicine N2 - Context: Environmental factors play a key role in the lives of individuals with a spinal cord injury (SCI). This study identifies environmental barriers and their impacts on daily lives as perceived by individuals living with SCI in Mongolia. Design: A qualitative study with semi-structured interviews was conducted. A topic guide for the interviews was structured around the components of the International Classification of Functioning, Disability, and Health. Setting: Urban and rural areas of Mongolia. Participants: A purposive sample of 16 persons with traumatic SCI. Interventions: Not applicable. Outcome Measures: Not applicable. Results: Seven categories of environmental barriers were mentioned, such as poor access to the physical environment, absence of wheelchair-friendly transportation, negative societal attitudes, inadequate health and rehabilitation services, lack of access to assistive devices and medicines, limited financial resources for healthcare, and inaccurate categorization of disabilities in laws. These barriers were claimed to have an impact on physical and psychological health, limit activities, and restrict participation in almost all areas of life. Conclusion: This study contributes to the identification of targets for interventions aimed at improving the lived experience of persons with SCI in a low-resource context. The findings reveal that while the Mongolian government already has laws and policies in place to improve access to the physical environment, transportation, assistive devices and employment, much more has to be done in terms of enforcement. Specialized SCI care and rehabilitation services are highly demanded in Mongolia. KW - Lived experience KW - Developing country KW - International Classification of Functioning, Disability, and Health KW - Semi-structured interviews KW - Person-centeredness KW - Rehabilitation services Y1 - 2020 UR - https://doi.org/10.1080/10790268.2019.1565707 VL - 43 IS - 4 SP - 518 EP - 531 ER - TY - JOUR A1 - Prodinger, Birgit A1 - Stucki, G. A1 - Coenen, M. A1 - Tennant, A. T1 - The measurement of functioning using the International Classification of Functioning, Disability and Health: comparing qualifier ratings with existing health status instruments JF - Disability and Rehabilitation N2 - Background: The International Classification of Functioning, Disability and Health is the international standard for describing and monitoring functioning. While the categories, the units of the classification, were not designed with measurement in mind, the hierarchical structure of the classification lends itself to the possibility of summating categories into some higher order domain. Focusing on the chapters of d4 Mobility, d5 Self-Care and d6 Domestic Life, this study seeks to ascertain if qualifiers rating of categories (0-No problem to 4-Complete problem) within those chapters can be summated, and whether such derived measurement is consistent with estimates obtained from well-known instruments which purport to measure the same constructs. Methods: The current study applies secondary analysis to data previously collected in the context of validating Core Sets for stroke, rheumatoid arthritis, and osteoarthritis. Data included qualifier-based ratings of the categories in the Core Sets, and the physical functioning sub-scale of the Short-Form 36, and the World Health Organization Disability Assessment Schedule 2.0. To examine qualifier-comparator scale item agreement Kappa statistics were used. To identify whether appropriate gradients of the comparator scales were observed across qualifier levels, an Independent Sample Median Test of the ordinal scores was deployed. To investigate the internal validity of the summated ICF categories, the Rasch model was applied. Results: Data from 2,927 subjects from Europe, Australasia, Middle East and South America were available for analysis; 36.3% had experienced a stroke, 35.8% osteoarthritis, and 27.9% had rheumatoid arthritis. The items from the Short-Form 36 could not match directly the qualifier categories as the former had only 3 response options. The Kappa between World Health Organization Disability Assessment Schedule 2.0 items and categories was low. For all qualifiers, a significant (<0.001) overall gradient was observed across the comparator scales. Only in few of the World Health Organization Disability Assessment Schedule 2.0 items could no discrete level be detected. The aggregation of the qualifiers at the Chapter and higher order levels mostly revealed fit to the Rasch model. Almost all ICF qualifiers showed ordered thresholds suggesting that the current structure and response options of the qualifiers worked as intended. Conclusions: The findings of this study provide supporting evidence for the use of the professionally rated categories and associated qualifiers to measure functioning. Implication for Rehabilitation - This study provides evidence that functioning data can be collected directly with the International Classification of Functioning, Disability and Health (ICF) by using the ICF categories as items and the ICF qualifiers as rating scale. - The findings of this study show the aggregated ratings of ICF categories from the chapters d4 Mobility, d5 Self-care, and d6 Domestic life capture a broader spectrum of the construct than the corresponding summated items from the SF36-Physical Function sub-scale and the corresponding items of the World Health Organization Disability Assessment Schedule 2.0. - This study illustrates the potential of building quantitative measurement by aggregating ICF categories and their qualifier ratings into meaningful domains. KW - ICF KW - health status KW - Rasch model KW - outcome measure KW - WHODAS 2.0 KW - SF-36 Y1 - 2019 UR - https://doi.org/10.1080/09638288.2017.1381186 VL - 41 IS - 5 SP - 541 EP - 548 ER - TY - JOUR A1 - Ehrmann, C. A1 - Prodinger, Birgit A1 - Stucki, G. A1 - Cai, W. A1 - Zhang, X. A1 - Liu, S. A1 - Liu, S. A1 - Li, J. A1 - Reinhardt, J. D. T1 - ICF Generic Set as new standard for the system wide assessment of functioning in China: a multicentre prospective study on metric properties and responsiveness applying item response theory JF - BMJ Open N2 - Objectives: To examine metric properties and responsiveness of the International Classification of Functioning, Disability and Health (ICF) Generic Set when used in routine clinical practice to assess functioning. Design: Prospective multicentre study. Setting: 50 hospitals from 20 provinces of Mainland China. Participants: 4510 adult inpatients admitted to the departments of Pulmonology, Cardiology, Neurology, Orthopaedics, Cerebral Surgery or Rehabilitation Medicine. Main outcome measures: The ICF Generic Set (ICF Generic 6 Set) applied with an 11-point numeric rating scale (0-no problem to 10-complete problem) was fit to the Partial Credit Model (PCM) to create an interval score of functioning. Results: PCM assumptions were found to be fulfilled after accounting for Differential Item Functioning. With an average improvement by 7.86 points of the metric ICF Generic 6 score (95% CI 7.53 to 8.19), the ICF Generic 6 Set proved sensitive to change (Cohen’s f2=0.41). Ceiling and floor effects on detecting change in functioning were cancelled or reduced by using the metric score. Conclusion: The ICF Generic 6 Set can be used for the assessment of functioning in routine clinical practice and an interval score can be derived which is sensitive to change. KW - International Classification of Functioning, Disability and Health (ICF) Y1 - 2018 UR - https://doi.org/10.1136/bmjopen-2018-021696 VL - 8 IS - 12 SP - e021696 ER - TY - JOUR A1 - Liu, S. A1 - Reinhardt, J. D. A1 - Zhang, X. A1 - Ehrmann, C. A1 - Cai, W. A1 - Prodinger, Birgit A1 - Liu, S. A1 - Li, J. T1 - System-wide Clinical Assessment of Functioning Based on the International Classification of Functioning, Disability and Health in China: Interrater Reliability, Convergent, Known Group, and Predictive Validity of the ICF Generic-6 JF - Archives of Physical Medicine and Rehabilitation N2 - Objective To validate the International Classification of Functioning, Disability and Health (ICF) Generic-6 in daily routine clinical practice in Mainland China. Specific objectives were to analyze (1) interrater reliability, (2) convergent validity, (3) known group validity, and (4) predictive validity of the ICF Generic-6. Design Multicenter prospective cohort study. Setting Fifty hospitals from 20 provinces of Mainland China. Participants A total of 4510 patients from departments of rehabilitation, orthopedics, neurology, cardiology, pneumology, and cerebral surgery of the participating hospitals with different health conditions were included in this study. Intervention Not applicable. Main Outcome Measures The assessment was undertaken by nurses with ICF Generic-6 in combination with a numeric rating scale. Interrater reliability was evaluated with intraclass correlation coefficients (ICC). Convergent validity was evaluated with Spearman correlation coefficients between ICF Generic-6 and Medical Outcomes Short Form (SF)-12 items. Known group validity was examined by comparing discharge scores between different discharge destinations. Predictive validity was determined by using ICF Generic-6 baseline scores for estimating length of hospital stay with a loglogistic survival model with gamma shared frailty and cost of in-hospital treatment with a mixed effects generalized linear regression model of the gamma family. Results The interrater reliability of items and score of ICF Generic-6 was good with ICCs ranging from 0.67-0.87. ICF Generic-6 items were further correlated with respective SF-12 items. Discharge scores of patients differed significantly by discharge destination. The ICF Generic-6 admission score was a significant predictor of length of stay and treatment cost. Conclusions The ICF Generic-6 administered in combination with a 0-10 numeric rating scale is a reliable and valid tool for the collection of minimal information on functioning across various clinical settings. KW - International Classification of Functioning KW - Disability and Health KW - Rehabilitation KW - Reproducibility of results Y1 - 2019 UR - https://doi.org/10.1016/j.apmr.2018.11.014 VL - 100 IS - 8 SP - 1450 EP - 1457 ER - TY - JOUR A1 - Hopfe, M. A1 - Prodinger, Birgit A1 - Bickenbach, J. E. A1 - Stucki, G. T1 - Optimizing health systems response to patient’s needs: An argument for the importance of functioning information JF - Disability and Rehabilitation N2 - Background: Current health systems are increasingly challenged to meet the needs of a growing number of patients living with chronic and often multiple health conditions. The primary outcome of care, it is argued, is not merely curing disease but also optimizing functioning over a person’s life span. According to the World Health Organization, functioning can serve as foundation for a comprehensive picture of health and augment the biomedical perspective with a broader and more comprehensive picture of health as it plays out in people’s lives. The crucial importance of information about patient’s functioning for a well-performing health system, however, has yet to be sufficiently appreciated. Methods: This paper argues that functioning information is fundamental in all components of health systems and enhances the capacity of health systems to optimize patients’ health and health-related needs. Results and conclusion: Beyond making sense of biomedical disease patterns, health systems can profit from using functioning information to improve interprofessional collaboration and achieve cross-cutting disease treatment outcomes. - Implications for rehabilitation - Functioning is a key health outcome for rehabilitation within health systems. - Information on restoring, maintaining, and optimizing human functioning can strengthen health system response to patients’ health and rehabilitative needs. - Functioning information guides health systems to achieve cross-cutting health outcomes that respond to the needs of the growing number of individuals living with chronic and multiple health conditions. - Accounting for individuals functioning helps to overcome fragmentation of care and to improve interprofessional collaboration across settings KW - Health systems KW - health service delivery KW - rehabilitation services KW - functioning information KW - patient’s needs KW - fragmentation of care Y1 - 2018 UR - https://doi.org/10.1080/09638288.2017.1334234 VL - 40 IS - 19 SP - 2325 EP - 2330 ER - TY - JOUR A1 - Maritz, R. A1 - Baptiste, S. A1 - Darzins, S. W. A1 - Magasi, S. A1 - Weleschuk, C. A1 - Prodinger, Birgit T1 - Linking occupational therapy models and assessments to the ICF to enable standardized documentation of functioning JF - Canadian Journal of Occupational Therapy N2 - Background The International Classification of Functioning, Disability and Health (ICF) can serve as reference for standardized documentation of health in clinical practice. Purpose This study aims to bridge the gap between the ICF and occupational therapy specific concepts, represented by occupational therapy models and their derived assessments. Method Occupational therapy assessments in relation to their models were systematically linked to the ICF, and a compatibility analysis was conducted. To strengthen reliability of the linkings, feedback from the respective assessment hosts was obtained. Findings Linking tables were developed for the Assessment of Motor and Process Skills, the Canadian Occupational Performance Measure, and the Model of Human Occupation Screening Tool. Similarities and differences between the ICF and the three assessments and their associated models show how they differ from and complement each other. Implications The findings of this study lay the foundation for standardized documentation in occupational therapy and enhance the practicability of the ICF. KW - Assessment KW - Documentation KW - International Classification of Functioning, Disability and Health KW - Standardization KW - Theory Classification internationale du fonctionnement, handicap et santé KW - Documentation KW - Évaluation KW - Standardisation KW - Théorie Y1 - 2018 UR - https://doi.org/10.1177/0008417418797146 VL - 85 IS - 4 SP - 330 EP - 341 ER - TY - JOUR A1 - Prodinger, Birgit A1 - Tennant, A. A1 - Stucki, G. T1 - Standardized reporting of functioning information on ICF-based common metrics JF - European Journal of Physical and Rehabilitation Medicine N2 - BACKGROUND: In clinical practice and research a variety of clinical data collection tools are used to collect information on people’s functioning for clinical practice and research and national health information systems. Reporting on ICF-based common metrics enables standardized documentation of functioning information in national health information systems. The objective of this methodological note on applying the ICF in rehabilitation is to demonstrate how to report functioning information collected with a data collection tool on ICF-based common metrics. We first specify the requirements for the standardized reporting of functioning information. Secondly, we introduce the methods needed for transforming functioning data to ICF-based common metrics. Finally, we provide an example. METHODS: The requirements for standardized reporting are as follows: 1) having a common conceptual framework to enable content comparability between any health information; and 2) a measurement framework so that scores between two or more clinical data collection tools can be directly compared. The methods needed to achieve these requirements are the ICF Linking Rules and the Rasch measurement model. Using data collected incorporating the 36-item Short Form Health Survey (SF-36), the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), and the Stroke Impact Scale 3.0 (SIS 3.0), the application of the standardized reporting based on common metrics is demonstrated. RESULTS: A subset of items from the three tools linked to common chapters of the ICF (d4 Mobility, d5 Self-care and d6 Domestic life), were entered as “super items” into the Rasch model. Good fit was achieved with no residual local dependency and a unidimensional metric. A transformation table allows for comparison between scales, and between a scale and the reporting common metric. CONCLUSIONS: Being able to report functioning information collected with commonly used clinical data collection tools with ICF-based common metrics enables clinicians and researchers to continue using their tools while still being able to compare and aggregate the information within and across tools. KW - International Classification of Functioning, Disability and Health KW - Rehabilitation KW - Delivery of health care Y1 - 2018 UR - https://doi.org/10.23736/S1973-9087.17.04784-0 VL - 54 IS - 1 SP - 110 EP - 117 ER - TY - JOUR A1 - Prodinger, Birgit A1 - Shaw, L. A1 - Stamm, T. A1 - Rudman, D. L. T1 - Enacting occupation-based practice: Exploring the disjuncture between everyday life of mothers with rheumatoid arthritis (RA) and institutional processes JF - British Journal of Occupational Therapy N2 - Introduction: Occupation-based approaches are a hallmark of excellence in occupational therapy practice. This article focuses on the disjuncture between how women with rheumatoid arthritis go about their daily lives, that is to say their occupations, and what is addressed during routine visits at a specialized rheumatology outpatient clinic. Method: Institutional ethnography was employed as a method of inquiry to identify the occupations and related issues that were or were not accounted for in health records and addressed within institutional processes. Interviews and participant observations were conducted with seven women with rheumatoid arthritis who were mothers. Hospital records were analysed as texts mediating between the women's daily lives and the rheumatology outpatient clinic. Findings: The analysis revealed that despite the diversity in the ways that the women managed their daily lives, the things that they did were viewed, understood, and addressed only within the boundaries of the standardizing relations that ruled practice in this clinical setting. Institutional processes grounded in biomedical concepts such as functional status or disease activity, as well as clinical assessments that depict these concepts, both shape and limit opportunities for occupational therapists to advance and enact occupation-based practice. Conclusion: In this setting, the complexity of the participants' daily lives and the occupations they engage in remain unaddressed. KW - Rheumatoid arthritis KW - assessment KW - occupation Y1 - 2014 UR - https://doi.org/10.4276/030802214X14122630932359 VL - 77 IS - 10 SP - 491 EP - 498 ER - TY - JOUR A1 - Carrier, A. A1 - Prodinger, Birgit T1 - Visions of possibility: Using institutional ethnography as a theory and method for understanding contexts and their ruling relations JF - Occupational Therapy Now KW - Occupational Therapy KW - institutional ethnography Y1 - 2014 VL - 16 IS - 2 SP - 18 EP - 21 ER -