PBP Full Paper Edits I and II Draft III

Running Head: POSITIONING FOR OCCUPATION-BASED ACTIVITIES 1
Positioning for Occupation-Based Activities (POBA)
McCall Halvorson
University of Utah
POSITIONING FOR OCCUPATION-BASED ACTIVITIES 2
Introduction
The purpose of this programming is to help to establish a complementary occupational
approach to therapy currently being provided by physical therapists at the Moulay Ali Institute
of Rehabilitation in Marrakech, Morocco. This needs assessment compiles information gathered
through interview and observation of the founder, therapists, clients, and the community in
which they live. Through assessment of the setting and a thorough literature review, this is a
proposal of programming to help with current needs of the setting.
Description of Setting
History
The Moulay Ali Institute of Rehabilitation (MAIR) was founded in 2015 by Dr.
Mohammed Sbai, following his experience with rehabilitation of his late brother after a
traumatic brain injury occurring in Morocco. Dr. Sbai noticed a need for effective neurologic
based therapy in Morocco. It was at this point that he began organizing the MAIR clinic. Over
the years, MAIR has evolved from seeing 2-6 patients a day to now more than 40-50 patients
per day (MAIR, n.d.). Therapists employed by MAIR have had the opportunity to participate in a
variety of different trainings through their partnerships with medical professionals throughout
the United States.
Staff
There are currently three full time therapists working for the MAIR clinic. Each are
dedicated to the clinic and expanding their approach to neuro therapy in Morocco. The stated
mission of the MAIR clinic is “To trigger a neuroplastic change is the foundation of our therapy.
To accomplish maximal recovery is our most important goal.” Each member of the MAIR team
uses this as a guide while working with their patients. Each client and caregiver who comes
through the doors at MAIR is met with compassion and hope for a better future.
Target Population
It is estimated that there are approximately 25,000 new cases of cerebral palsy each
year, in Morocco (M. Sbai, personal communication, October 4, 2018). Many of those cases are
looked upon by their society as nothing more than a useless individual who will not accomplish
anything due to their disability. Other common diagnoses treated at MAIR include stroke,
traumatic brain injury (TBI), autism, hydrocephalus and many other common diagnoses. While
MAIR treats a variety of ages, the majority of their patients range from 1-5 years of age (S.
Berrada, personal communication, October 2, 2018).
Influences
Policy. Shortly after the King of Morocco, Mohammed V came to power in 1957, he
began to make strides in Moroccan policy to promote equality amongst men and women. Since
his death, his son (King Hassan II) and grandson (current King Mohammed VI) have continued to
use their position in politics and in the Islamic church in Morocco, to promote these causes.
Most recently, the Mudawana (also known as the Moroccan Family Code) has been updated to
include basic women’s rights such as making it illegal for a woman to be forced to marry against
her will, granting her the right to initiate divorce proceedings, establishing a minimum marriage
age, as well as many others (The Moroccan Family Code, 2004). With this policy in place,
women are slowly becoming more respected throughout society.
In addition to his strides for women’s rights, Kind Mohammed VI has also implemented
a new constitution (2011) which states that each citizen has the right to universal access to
quality health care (Tinasti, 2015). Even with strides made toward universal healthcare, more
than 88% of total health expenditure is out of pocket. Because of this, many Moroccans choose
to avoid health care services due to inability to pay (Tinasti, 2015). Although policy is making
strides toward universal health care, it still is not readily accessible to many Moroccans. There
are many barriers to receiving quality health care. First and foremost, the cost of healthcare
negatively impacts the ease at which majority of Moroccans can get the care they need. Other
barriers such as the corruption in healthcare also greatly affect health care services. Most
citizens attempting to receive medical care can expect to pay for simple things such as sterile
gauze during a medical procedure. Another common problem with health care services is over-
prescription of medication. In Morocco, a wide variety of medication is readily accessible.
Because of this, it is common for someone to be prescribed medication they don’t actually
need, for the monetary gain of the pharmaceutical companies. This, unfortunately, is
something encountered at MAIR clinic. Over the years they have received many patients who
are heavily sedated on unnecessary medication, which they have had to deal with on top of
other existing conditions.
Policy also influences MAIR clinic directly. Because of the lack of insurance of many of
their patients, it means they often don’t have to worry about “red tape” when it comes to
providing services. They are allowed to see most patients as often as they feel is necessary to
get the needing therapy. For patients who do have insurance, it is often simple to request more
visits from the doctor after visits have run out.
Within MAIR, they have created a contract for each of their therapists. The hope of this
contract is to prevent turn over after training. Currently, therapists of MAIR must sign a 10-year
agreement that they will continue to work for MAIR. This has caused some problems with
staffing, however, as many of their previous therapists refused to sign and were let go.
Geographic. Marrakech is a large city located in central Morocco (north western Africa).
It is known for being surrounded by a wide variety of natural occurrences. The Atlantic Ocean is
located approximately 180 km to the west. To the south and east the renowned, Sahara Desert
can be found. Located near Marrakech is a mountain range known as the Atlas Mountains,
which are home to the highest peak in North Africa (M. Sbai, personal communication, October
6, 2018).
Sociocultural. Due to its predominantly Muslim population, Marrakech is heavily
influenced by the teachings of the Islamic faith. Because of this, gender roles are much more
defined. Men are primarily responsible for providing financially for the family, while women’s
main roles are caregiver children and homemaker. Many women (including the mothers of
patients at MAIR) choose to wear loose clothing as well as the traditional hijab, as a symbol of
their faith.
The sociocultural effects of their society also have a direct effect on services at MAIR.
Due to the involvement of mothers in their children’s care, they also feel a responsibility for
their therapy. This is one of the greatest strengths of MAIR. Mothers of the children are directly
involved in providing therapy sessions. This creates a unique environment in which parents are
much more likely to “buy in” to services and it allows them to understand how services are
being provided so that they can also continue exercises at home. This also helps to create a
community between the mothers, as they are often times experiencing the same challenges of
having a child with a disability. In addition to the unique parental involvement at MAIR, the
therapists also have a strong bond with one another, their patients and caregivers of their
patients. Communication between the therapists is open and strong. Each therapist respects
one another and is able to ask for assistance with patients they may be having difficulty with.
Because of the cohesiveness of the staff of MAIR, clients often feel more comfortable coming in
to the environment.
Economic. The Moroccan economy has strong reliance on a variety of different sectors,
including “agriculture, tourism, aerospace, automotive, phosphates, textiles, apparel, and
subcomponents” (The World Factbook: Morocco, 2018). Agricultural exports include barley,
citrus, olives, and livestock. Currently, the unemployment rate is estimated at approximately
10% (The World Factbook: Morocco, 2018).
Currency used within the country of Morocco is known as the Dirham (MAD). At the
time of this report, $1 USD is the equivalent of 9.48 MAD. While banks and ATMs are common
throughout the country, cash is the form of currency most widely used.
MAIR is fortunate to be in a unique situation where although they are not currently
receiving payment from clients enough to make it self-sustaining, they are able to continue to
operate with donations from outside parties. Another strength of MAIR is that although their
patients come from a variety of different incomes, each patient is required to pay at least
something for their session. This is determined by meeting with a social worker and then
determining, based on income and expenses, how much a patient can afford to pay for services.
This ranges from ~$2-$20/session. This provides the patient to take at least some ownership of
the cost of their therapy services without making it too expensive to access.
Political. Formally known as the Kingdom of Morocco, Morocco is one of the oldest
monarchies in the world. Operating as a constitutional monarchy, Morocco is governed by King
Mohammed VI. Morocco gained its independence from France in 1956, and Mohammed V was
appointed king (The World Factbook: Morocco, 2018). The king is also known as Chief of State,
Supreme Leader of the Army, and Commander of the Faithful (Semlali, 2010). The title
Commander of the Faithful indicates that although he is a political leader, King Mohammed also
plays a role in the leadership of the Islamic faith for the residents of Morocco. The king then
selects a prime minister who is responsible for appointing members of the government and
presides over the Council of Ministers (Semlali, 2010). The current Moroccan prime minister is
Saad-Eddine El Othmani, appointed March 2017 (The World Factbook: Morocco, 2018).
Demographic. The country of Morocco has a current population of approximately 34
million with approximately 976,000 currently residing in the city Marrakech. The CIA currently
estimates approximately 42% of the total population of Morocco between the ages of 25-54
(2018). Gender ratio in Morocco is approximately 1.0 across all age ranges. The population of
Morocco is primarily comprised of Arab-Berber ethnicity (99%) (The World Factbook: Morocco,
2018).
A study cited in Semlali (2010) estimated Morocco’s current poverty rate to be
approximately 9.0% with unemployment rate at approximately 9.8%. While Morocco’s poverty
rate is close to that in the United States, Morocco’s illiteracy rate is significantly higher. It is
estimated that illiteracy rates in Morocco range from approximately 43%, to more than 54%
amongst women (Semlali, 2010).

MAIR provides services for a variety of ages, with most of their clients ranging from 1-5
years of age (M. Sbai, personal communication, September 10, 2018). MAIR clinic itself is
conveniently located in the large city of Marrakech. While the clinic’s central location makes it
accessible my public transportation, much of the area around is not considered accessible by
persons with disabilities. In addition to this, because of the location in downtown Marrakech,
rent for the clinic space is very high for Morocco ($1,700/month for ~2400 sq. ft.) (M. Sbai,
personal communication, October 11, 2018).
Services Provided for Clients of MAIR
Physical therapy. MAIR is primarily a physical therapy neurologic rehabilitation
outpatient clinic. Most patients come to MAIR to work on gross motor physical activities such as
sitting, standing and walking. MAIR is known for their locomotor training and has successfully
created their own equipment to be able to offer it in their clinic to most of their patients. Due
to the MAIR therapists training from a variety of sources, they also have had some experience
with feeding. With this they are also able to provide basic feeding therapy for their clients. This
however, is an area where more training could be beneficial.
Related services. Patients of MAIR often times have access to basic medical care.
However, due to the corruption of the health care system, many patients find it inadequate.
Patients have access to primary care physicians, neurologists, and most types of medical
imaging. While patients have access to these things, due to the corruption in health care, it
many times is not actually accessible. Some challenges to healthcare access include the rural
location of some homes, employees of the university hospital lying about lack of services to get
patients to visit private hospitals and pay more, and the pure lack of medical professionals per
population (1 for approximately 1000) (Semlali, 2010).
Upon observation of a mother’s support group held at MAIR, the vast majority of the
mothers have been told at one time or another by their doctors that their children are
“vegetables” and “will never accomplish anything.” This, unfortunately, is common in Morocco.
Due to the ineffective approach at rehabilitation, many Moroccan doctors look at disability
from the framework of ‘inability’ rather than ‘potential’ (M. Sbai, personal communication,
September 10, 2018).
Funding sources. MAIR is currently funded by a number of different charitable sources.
Sorenson Legacy Foundation and Salt Lake Rotary Club are the two main sources of funds for
the clinic. Both have been contributing to rehabilitation efforts of MAIR since late 2014, when
the clinic was being established. Over the years they have helped to fund payroll, clinic costs,
equipment and training for therapists (M. Sbai, personal communication, October 11, 2018).
Future Plans
MAIR has great aspirations for their future. Their hope is to become a leader for
rehabilitative medicine for Morocco and maybe even all of Africa. Currently, they are saving
money and accepting donations for a new facility. MAIR has been working with architects on
designs for a new state of the art campus. Their hope is to begin with a rehabilitation center
(much like the one they currently have) and expand from there. Aspirations for the campus
include a small medical school, hydro therapy facility, hippotherapy facilities, cafeteria,
apartments for clients traveling from abroad, and suites for visiting clinicians. In addition to
each component of their future plans, they also intend to make the facilities as self-sustaining
as possible using wind and solar energy. Their current plans are estimated to cost
approximately $5-7.5 million. They are currently searching for an appropriate location for these
dream facilities.
Programming Strengths and Areas for Growth
Founder, Therapists’, and Parents’ Perspective
Founder. A combination of semi-structured interview, personal conversation and
observation were used to gather information about strengths and barriers from the view of the
founder of MAIR. Dr. Sbai stated that above all the clinic’s greatest strength is that it is unlike
any other therapy currently provided in Morocco or even France. He explained that while
French neuro science cutting edge, rehabilitation of neurological conditions is inadequate.
Rehabilitation facilities throughout Morocco are often seen utilizing treatments in rehabilitation
that have not been shown to produce any improvement in neurological conditions. MAIR
however, is different. They employ American approaches to neurological rehabilitation and are
seeing great results from their patients. Another great strength identified by Dr. Sbai is the
atmosphere provided by the clinic. He explained that while people with a disability are often
looked down upon in their society, MAIR provides a refuge where persons with a disability or
caregivers of persons with a disability are able to be around others with similar life challenges
and are valued as the people they are.
Dr. Sbai also identified barriers to growth of MAIR. He believes the current location is a
weakness of the clinic, as they do not have enough room to see the overwhelming number of
patients who are on the waiting list. Another main barrier to MAIR’s future growth is the
difficulty retaining therapists. Unfortunately, MAIR has been experiencing a number of

therapists trying to get hired on to use MAIR as a resume builder, but do not intend to stay.
Because of this, there have been many therapists hired and trained in the MAIR specific way of
therapy only to have them quit months later.
Another identified weakness of the clinic is their system of discharge. The lack of a well-
defined discharge program results in patients continuing to be seen rather than working toward
self-sufficiency. This is important to the clinic because many of the potential clients have the
ability to pay more for services than current clients. As the long-term goal of MAIR is to be a
self-sustaining clinic, it is imperative that they begin to work through their wait-list of patients.
In addition to financial implications, continuing to fill therapists’ limited treatment time with
those who do not need it most is not in the best interest of other MAIR clients.
Therapists. Often multiple times a week, clients of MAIR have the opportunity to
interact with the therapists. There are currently 3 full time physical therapists working for
MAIR. Each have undergone specific training in addition to the typical training for a physical
therapist educated in Morocco. In addition to continued education, each of the MAIR therapists
have signed a 10-year contract to continue their work at the facility. Each of the therapists
expressed similar strengths and weaknesses of the facility. Strengths identified included
collaboration amongst the therapists, focus on building rapport with the clients and their
families, and the therapists’ willingness to learn new skills to help their patients (I. Bentahar, S.
Elghazi, S Berrada, personal communication, October 3, 2018). Amongst these strengths, the
therapists also identified one of the greatest strengths of the clinic to be that it is innovative
and unlike any other in the country of Morocco.

Weaknesses of the clinic from the perspective of the therapists were also identified. The
first barrier to service delivery was the lack of clinic space. Due to the demand for this type of
therapy in Morocco, there are hundreds of patients trying to be seen by the MAIR therapists.
They are currently understaffed and do not have enough room to see the vast number of
patients waiting for therapy. Another identified weakness of the clinic is their understanding of
other, more cognitively based, disabilities. Specific areas identified included speech,
communication, attention, and focus (S. Berrada, personal communication, October 8, 2018).
Parent Perspective
Parents of the clients were also interviewed using an informal interview format. Due to
the unique nature of the therapy at the clinic, parents are extremely grateful for any therapy
provided for their children. They also identified a huge strength of the clinic was the feeling of
support that they get the minute they walk through the door. They stated that it is not
uncommon for them to feel like outcasts in their society or for others around them to believe
their child with disabilities will not ever amount to anything. However, due to the positive
environment at MAIR, they feel like they can.
Although it was asked what weaknesses of the clinic were, not one of a variety of
mothers would identify any weaknesses of the clinic. This is likely due to the culture of their
country. Often times disability is looked upon as a curse or punishment. Due to the fact that
MAIR is a place they can go to interact with others working through similar experiences as well
as to get life changing therapy for their child, they are all very grateful.
Occupational Therapy Graduate Student Perspective
A system of informal interviewing, research and observation were compiled to more
fully understand strengths and areas for improvement for The Moulay Ali Institute of
Rehabilitation. Observation included typical treatment sessions, daily staff meeting, mother’s
support group, as well as home visits.
Strengths. MAIR clinic has numerous strengths. First and foremost, the environment
maintained through the therapists and parents of the children fosters improvement and hope.
The therapists all work well together and communication is frequent.
The clinic is also in a unique position to where they are able to use donations from
outside sources to continue to offer services even if their clients are not able to fully pay for
those services. In addition to this, their ability to easily see patients without constraints of
insurance allows them to see patients for as much therapy as they need, rather than within the
lines of the insurance agency. For patients who do have insurance, it is relatively easy for them
to ask the physician for more visits to continue therapy.
The location of MAIR is a strength for them. They are able to be centrally located for
many of their patients. MAIR is easily accessed through public transportation and many of their
clients do not have difficulty getting to the facility.
Another strength of MAIR is the education of their therapists. Each of the physical
therapists have undergone the typical ‘physical therapist’ training through the Moroccan school
system as well as continued trainings. They have had the opportunity to receive continuing
education in neurological rehabilitation, occupational and feeding specific therapies from

American specialists in those areas, which provides unique training not currently available in
Morocco.
Areas for Growth. MAIR clinic also has man barriers they are having to overcome. They
currently do not have the resources (staff and clinic space) to see the vast number of patients
waiting for services at MAIR. This is also affected by their lack of a specific discharge plan for
their patients. Because of this, they often continue to see patients for a significant amount of
time, rather than getting them to a point of self-sufficiency. It would be a benefit to them to
implement discharge planning with specific home programming to help the patients continue
to improve in their rehabilitation after discharge from the clinic.
Due to the physically therapeutic training of their staff members, MAIR does not
specifically focus on function in their therapy. Their main goals to therapy are to gain strength
and coordination. While this is important, there are not occupational therapists to help the
client convert those gains into function. This is something that could easily be incorporated into
current therapy at the clinic. They could specifically benefit from continued education in
positioning of a client and an activity to target specific functional outcomes. In addition to this,
it would be a benefit to train their therapists on task analysis and occupation-based activities.
By synthesizing what they already know and functional positioning with an occupation-based
focus, they would be able to help their clients convert strength coordination gains to functional
improvement.
Finally, therapists of MAIR have minimal to no training in cognitive and sensory
approaches. This is especially important when dealing with their clients with autism. Many
times, they are unable to discern between behavior, cognition and sensory needs of a client. By
educating them on these different approaches to therapy, it could greatly improve their
interactions with clients of those needs.
Evidence-Based Practice
Literature was reviewed to gain a more comprehensive understanding of people with
disabilities in Morocco and their occupational needs, as well as the potential benefits that
occupational therapy could provide. University of Utah online catalogs, American Journal of
Occupational Therapy, and Google Scholar were searched for relevant articles. Search terms
included: occupational therapy, positioning, functional, cerebral palsy, stroke, international,
Morocco, task, environment, arrangement, and support. Articles’ inclusion criteria were based
on relevance to the proposed program development. Articles were mostly limited to the last 10
years with the exception of a couple of older articles which were included due to the
timelessness of the data presented. A total of 12 articles were reviewed and included in the
summary below.
Client Characteristics
Literature was reviewed in order to obtain a more comprehensive understanding of the
population of Morocco, their rehabilitation specialists and persons with disabilities. Common
characteristics of the country include poor access to health care, low monthly household
income, and overall poor access to education for disabled persons.
Poor access to healthcare. One common occurrence with this population is their lack of
access to health care. This stems from a variety of different causes. A study by Hajjioui,
Fourtassi, and Nejjari (2015) estimated that >1 in 5 people had never attempted to receive care
from a medical professional and postulated that the main reasons for this included low monthly
income, negative image of public health services and the low health professional to resident
ratio. First and foremost, Morocco does not have a well-developed system of insurance. When
Mohammed VI came to power, he attempted to implement a state insurance for those with low
income and government workers. While this helped some, most of the state continues to
remain uninsured, meaning all health costs are out-of-pocket. Tinasti (2015) estimated that
more than 88% of all health care spending in Morocco is paid privately by the citizens. Tinasti
also estimated that among the 22 countries in the Eastern-Mediterranean region, Morocco
ranks in the bottom 5 of health care cost expenditure.
Lack of access to health care can be attributed to the inadequate number of health care
providers. It is estimated that in 2012 there were only 305 physiotherapists serving the entire
population of Morocco (Hajjioui et al., 2015). There is also no occupational therapy currently in
Morocco. Because of the general need, many patients are seeking therapy just to regain
strength only, but not functional skills. In some instances, such as at MAIR clinic, the therapists
have had to approach therapy from views of both physical and occupational therapy. Nafai
(2015) also stated that most physical therapists currently working in Morocco are either
foreigners or Moroccans who were educated abroad. This is partially the case of the therapists
at MAIR. While they received their basic physical therapy training for the Moroccan public-
school system, they have all received outside training either in the US or from US-educated
professionals.
Low Household Income. In addition to lack of insurance, many residents of Morocco
have an extremely low annual income. Hajjioui et al., (2015) estimated that approximately 71%
of Moroccans have a monthly household income of $200 USD. While cost of living in Morocco is
significantly cheaper in the U.S., many still live on very small margins. In Morocco it is most
common for the man of the household to work in the community while the woman stays in the
home, caring for it, their children, and often older family members. Insurance plans such as the
Medical Assistance Scheme (RAMED) are now put in to place to help those most vulnerable,
however, it still leaves much of the population without financial help to cover health care costs.
Education. Hajjioui et al., (2015), reported that of their sample of 411 patients in a
university hospital, approximately 58% reported having no education. Unfortunately, this is not
an uncommon occurrence in Morocco. It is currently estimated that 43% of Moroccans are
illiterate (Semlali, 2010). This also affects health care effectiveness due to very low health
literacy of the consumer, overall. Another aspect of the Moroccan education system is the
difficulty that children with disabilities have in trying to participate. In 2012 a report was
released stating that discrimination of children with disabilities was not tolerated in school.
However, Nafai (2015) estimated that 96% of typically developing children were in school
compared to only 32% of children with disabilities.
Disability prevalence in Morocco. Disability in Morocco is not uncommon. It is
estimated that >18% of the population have at least 1 chronic disease (Hajjioui et al., 2015).
Researchers also report that it is likely a much greater statistic due to difficulty gathering data
from different areas of the country. In the same study of a sample of people with disabilities in
Morocco, 25% stated they had gait and balance disorders, while over 42% stated they had
difficulties participating in their activities of daily living. This could likely be due to the access to
physical therapy but not occupational therapy.

Cerebral Palsy
Typical posture. The majority of clients seen at MAIR are diagnosed with cerebral palsy.
Many also have other comorbidities that affect their lives. As such a description of the evidence
regarding typical cerebral palsy (CP) presentation was included in this review. Research among
different studies were highly agreeable about typical presentation of CP. Typical posture for a
person with CP includes flexed upper extremity (UE), extended lower extremity (LE), tight
hamstrings, posterior tilt of the pelvis, with hips adducted and internally rotated (Costigan &
Light, 2011; Stavness, 2006). Stavness (2006) also reported it is common for persons with CP to
sit on their sacrum versus their ischial tubers. This causes the person to lean forward to fight
the effects of gravity. Researchers argue that the person is then in a highly disadvantageous
position for functional movements including eye-hand coordinated movements. Costigan and
Light (2011) also stated that sitting provides more support than in standing and as a result,
more deficits are evident while the person is standing. Finally, Cruz (2017) estimated that over
65% of persons diagnosed with CP also have a co-diagnosis of scoliosis.
Spasticity. Another common effect of CP is spasticity. Abnormal muscle tone and
persisting reflexes can interfere with postural control (Costigan & Light, 2011; Stavness, 2006).
Specifically, spasticity of the UEs and LEs coupled with hypotonus of trunk musculature are
common in persons with CP (Stavness, 2006). Because of the abnormal musculature, and
strength, functional movements and postural control can be greatly affected. Due to this, it is
important that persons with CP are provided enough support to facilitate specific movements
(discussed below). Costigan and Light (2011) also argue that it is imperative that postural
position is attended to to prevent contractures from occurring.

Hip problems. It is also agreed upon by many researchers that hip problems are
common amongst persons with CP. Cruz (2015) estimated that 28-60% of people with CP will
have hip problems. The researchers go on to state that while this is not directly caused by CP,
many develop hip problems due to poor postural alignment. Another common problem caused
by lack of alignment is hip dislocation. Persons with CP are provided as many opportunities for
weight bearing in sitting and standing. This causes the bones in the pelvis to form differently
than they would in a typically developing person, and risk for dislocation increases. Costigan
and Light (2011) estimate that 22-45% of children with CP will deal with dislocation of the hip.
Eating and feeding. An occupation that is significantly affected by CP is that of eating
and feeding. Approximately 90% of children with CP will experience significant oral motor
dysfunction (Snider, Majnemer, & Darsaklis, 2010). This is then exacerbated by poor postural
control (and often positioning) and risk for aspiration increases significantly. In addition to poor
oral motor skills, Snider et al., (2010) stated that 86% of children with some type of paresis
caused by CP will also have feeding difficulties. This will put the child at risk for aspiration as
well as other problems such as inadequate overall intake and growth impairment.
General Impairment. In addition to the beforementioned challenges, persons with CP
experience various other impairments. Preissner (2010) states that neurological conditions can
affect many different aspects of function including cognitive, sensory and
neuromusculoskeletal. These impairments can fall anywhere on a vast spectrum. However, in a
study conducted by Costigan and Light (2011) it was estimated that approximately 87% of
children with CP were considered by their parents to be unstable.

Rehabilitation in Morocco
The current rehabilitation situation in Morocco is extremely lacking. MAIR clinic
employees are some of the only neurologically trained physiotherapists in Morocco. Their
approach to treatment is unlike any other physical therapists in the country. In addition to this
and beforementioned statistics, occupational therapy is a profession vastly underrepresented
in Morocco. A study by Hajjioui et al. (2015) interviewed a hospital’s patients and found that of
the 411 patients, over 20% would greatly benefit from occupational therapy services. Of those
211 patients, 22% reported difficulties with grooming and hygiene, 12% reported difficulties
with gripping and 8% reported difficulties with feeding. It is also important to note that this
sample was taken from the general population in the hospital and did not include much of the
population with disabilities who could not afford medical treatment.
Proposition of occupational therapy programming. The need for occupational therapy
in Morocco is clear amongst all health care professionals who have studied rehabilitation in
Morocco. Nafai (2015) stated that there are currently only six occupational therapy programs in
Arabic speaking countries. Each of these programs is taught in English, using mostly American
textbooks (Nafai, 2015). Because of the frequency of disability specifically related to activities of
daily living, an occupational therapy program is needed in Morocco. Martín, Martos, Millares,
and Björklund (2015) also state it is important that a program be developed in Morocco to
provide the therapists in training with culturally relevant information, rather than being
educated in a different culture and returning to Morocco. This, they argue, will help to increase
the relevance of occupational therapy around the world.

Occupational therapists have specialized training in many different skills that would be
beneficial to the clients of MAIR clinic. These skills include task analysis, positioning for
function, identification of occupational priorities of the client, and training in treatment
centered on regaining occupational deficits as well as many others.
Functional Positioning in Moroccan Rehabilitation
Positioning can greatly affect posture which impacts a wide variety of aspects of
function. These can include speech production, hip alignment, ability to interact with the
environment, respiratory function, muscle tone, stability and safety, participation and
endurance in activities (Costigan & Light, 2011). Functional positioning is imperative in
rehabilitation as it allows the therapist to be able to target specific outcomes. These could
include gross and fine motor movements of the UE which are crucial for participation in
activities of daily living. Preissner (2015) argues that even with cognitive impairments, gains can
be made if the person is set up in an environment that facilitates function.
Posture evaluation. Assessment of posture is multifaceted. Preissner (2010) argues that
proper assessment includes evaluation of role performance, performance tasks selection and
analysis of tasks, specific client factors, performance skills and finally, assessment of the
environment.
Achievement of Proper Posture in Children with CP
Weight bearing. It is commonly agreed upon by researchers that proper weight bearing
is crucial to development. Cruz (2015) stated that standing promoted acetabular development,
which aides in the prevention of hip displacement. Proper weight bearing surfaces in sitting
should include the seat bottom, seat back and foot supports (Costigan & Light, 2011).
Seating. Costigan and Light (2011) state that seating surface should be firm but
comfortable, supporting from the buttocks to two inches proximal to the knee. Angle of the
seating surface should be horizontal or with an anterior tilt of 10° or less (Costigan & Light,
2011; Stavness, 2006). This allows the child to more effectively interact with their environment,
specifically objects within arms-reach. Stavness (2006) also argues that this position reduces the
distance the child has to move their UE to be able to reach what is in front of them, and thus
reduce energy expenditure. Furthermore, this is important for children attempting to interact
with peers through play, as often times objects are involved. They also state that the surface of
the seat bottom should be large enough to allow for shifts in center of gravity, but not so big as
to impede the child’s ability to interact with their environment.
Seat back should be completely vertical, as some recline prevents interaction with the
child’s environment. By stabilizing the lower trunk and lumbar spine via external support, the
child is better able to control their UE and interact during functional activities (Wee, et al.,
2015)
Finally, weight bearing surfaces should include foot supports. This should be adjustable
to the child’s size and should allow for the bottom of the foot to make full contact for support.
Hip abduction. Proper hip abduction is crucial to prevent deformities and increase
participation in children with CP (Cruz, 2015). Hips should be at approximately 20° abduction
with slight external rotation. This position allows for good femoral head contact with the
acetabulum (Cruz, 2015). This positioning of the hip should be maintained in sitting, lying and
standing. Cruz (2015) found that while this position is effective, the child should maintain it for
at least 6 hours/day for more than 18 months to truly see results.

Goal of positioning. It is estimated that children with CP require thousands of dollars in
equipment and technology in order to participate in daily life (Bourke-Taylor, Cotter, &
Stephan, 2013). However, it is postulated that based on data findings, there are many other
options within realistic prospects of Moroccan citizens to achieve similar outcomes. The unique
involvement of the mothers of children with disabilities in Morocco provides great opportunity
to approach these problems from an alternative perspective.
The goal of occupational therapists in this is to provide all caregivers of the client with
difficulties maintaining proper positioning, with training. This is approached with the idea that if
all involved with care for the child are participating in proper positioning techniques, the child
will be less likely to experience challenges presented with improper positioning. Overall, the
goal of positioning in children with CP is to create anatomical alignment of their posture. By
doing so, the child requires less energy expenditure to maintain their posture, which allows for
them to use that energy to work on UE function. This will enable to therapist to target gross
and fine motor movements of the UE and hopefully improve functional movement for
occupational participation.
Summary
In summary, Moroccans share many similar characteristics including lack of access to
health care, low annual household income, and poor education rates. Cerebral palsy is one of
the most common diagnoses in children in Morocco. Cerebral palsy deficits may include atypical
posturing, abnormal muscle tone, hip problems and difficulty participating in fine and gross
motor movements of the UE. Occupational therapy in Morocco is currently non-existent.
However, it is recommended that many people throughout Morocco could greatly benefit from
occupational therapy services. Occupational therapists would provide treatment for individuals
who are experiencing a loss of occupation to help regain those occupations. Recommendations
were made for this programming based on research for proper positioning of children with CP
to enable therapists to target specific occupational participation.
Program Proposal: Positioning for Occupation-Based Treatment
Program Overview
A program focusing on proper positioning of patients with cerebral palsy prior to
treatment can improve a myriad of outcomes. The main outcome discussed in this program
proposal is the improved ability to participate in occupation-based activities. This program will
be beneficial to the MAIR clinic because their education background lacks specific training in
setting up a client for maximal occupational participation. This program is aimed to be
complementary to their current practices. MAIR clinic has a focus on client centered treatment.
With this training, it is hoped that MAIR therapists will have an increased knowledge that is
occupation specific to increase participation throughout their clients’ lives.
This program will be split into modules that increase the therapists’ understanding of
the theory behind proper positioning and task arrangement. Modules will then be educated in
assessment of the client’s needs, from an occupational therapy perspective. Once clients have
been assessed, therapists will be able to identify specific target areas for treatment. This will
allow specific outcomes to be focused on in order to improve certain aspects of a client’s
abilities.
Following education on these topics, the therapists will be prompted to integrate this
information into their current treatment sessions. After practicing these principles, it is
suggested than an occupational therapist travel to Marrakech to fine tune the therapists
learning and offer any further information on the topic.
Once education, practical application and hands on training have been implemented,
the focus will be on evaluation of the program. It will be evaluated by the therapists and
modified based on their feedback. The goal of this programming is to evolve according to the
specific needs of the therapists of MAIR so that they can use the same education in the future
with new therapists coming into the clinic.
Another aspect the program is educating the therapists to a level at which they are able
to train caregivers of their patients. This will aide parents to be able to better provide for the
clients’ needs at home. This will only be realistic once the therapists have a thorough
understanding of the principles of positioning and task arrangement.
Program Value
The purpose of this program is to help increase the MAIR neurotherapists
understanding of principles of positioning and task arrangement to target specific functional
occupation-based outcomes for their clients. This will potentially improve the quality of the
therapy their patients are being provided, as it offers another facet of the neurological
rehabilitation process. Overall, this program is aimed to increase occupational participation for
the children who are clients of the MAIR clinic.
Occupational Justice. Occupational justice will be addressed via improving occupational
apartheid and occupational deprivation. Occupational apartheid is explained as a restriction of
opportunity for occupation based on disability and other factors (Durocher, Gibson, & Rappolt,
2013). This will be addressed by aiming to improve muscular strength and coordination. If these
can be improved, clients will have an increase in occupational participation.
Another aspect of occupational injustice that will be addressed is occupational
deprivation. This is defined as exclusion from occupation based on factors outside of the
person’s control (Durocher et al., 2013). This will be addressed by providing the therapists with
education on how tasks and environment can be adapted to increase the client’s ability to
participate in daily occupations.
Prevention. Due to this program’s target population being clients of a
neurorehabilitation clinic, primary prevention will not be valid. Secondary prevention will be
addressed by providing all patients with cerebral palsy proper positioning. This will aim to
prevent occupational decline and secondary impairments caused by improper positioning of
persons with cerebral palsy. Areas at risk for decline will be assessed by the therapists during
evaluation and identified as areas of focus for treatment.
Tertiary prevention will be the most utilized through this program. Therapists will be
trained in positioning for occupation-based activities which will help their clients who have
already experienced different secondary deformities as well as occupational decline due to
their condition. By implementing the principles learned within the modules, therapists will be
able to prevent further decline in these areas. If the program is successful, therapists will also
be able to train the caregivers of their clients to also help in tertiary prevention.
Rationale for Occupational Therapy’s Role
People with cerebral palsy frequently experience lack of postural control. Decreased
postural control impairs the person’s ability to interact with their environment and participate
in daily occupations. Occupational therapists provide a unique view of this issue with specific
training in occupational assessment, environmental assessment and postural positioning.
Occupational therapists also have specific training in assessing clients and determining
treatment focus based on what is most important to those clients. Combined, these factors
make an occupational therapist ideal to provide training for positioning for occupation-based
treatment. Services provided as part of this programming are considered indirect as it will be
educating the therapists on how to better serve their patients.
An occupational therapist’s role in providing education to the MAIR staff is also crucial in
the fact that occupational therapy in Morocco is virtually non-existent at this time. By having an
occupational therapist provide this training, they will be able to educate the primarily
physiotherapy-trained-neurotherapists in another wide aspect of neurological rehabilitation.
Theoretical Foundation
Frames of reference are various paradigms in which different occupational therapy
approaches fall. Each analyzes occupation-based evaluation and treatment from different views
and via different methods. This section of the proposal will explain the different models
proposed for this program and the reasoning behind using those models.
The main organizing model for this program is the Person-Environment-Occupation
model (PEO). This model approaches occupation participation by assessing the person’s
abilities, the environment in which they are in, and the occupation in which they are attempting
to participate. Treatment based on this model focuses on increasing congruence between each
of these variables. This most frequently occurs as modifications to the environment and
occupation to meet the needs of the client’s abilities. This model is directly applicable to this
programming. Many clients of MAIR are currently unable to participate in desired occupations
because the demands of the environment and occupations are too great for their current
abilities. Postulates of this model state that if these barriers can be identified and modified to
match abilities, participation will improve (Law et al., 1996). This program will focus on adapting
the environment and the occupation to fit their abilities and thus, increase occupational
participation.
The next model that will be used to guide programming is the Neurodevelopmental
Theory model. This is the model that provides reasoning for the positioning of the client. The
postulates of this model state that if the therapist modifies the environment to be congruent
with the child’s abilities, the child will have most potential to develop functional skills (Barthel,
2010). This is done by positioning the client in an upright posture with their weight balanced
and knees, hips, and ankles in a 90°-90°-90° position. Once the client is positioned properly, the
therapists can then present the child with an activity that is centered in their interests.
Postulates of this model also suggest that if the child is engaged in an activity that is stimulating
to them, they are more likely to make neuromotor improvements.
The third frame of reference that will be used in this programming is that of the
Acquisitional frame of reference. This model is applicable whenever new skills are being
learned. Use of this model will focus more on the learning of the therapist rather than actual
implementation to the clients. The overall goal of this model is to master new skills and sub-
skills that fall beneath those (Leubben & Royeen, 2010). In the case of this program, the skills to
be mastered will include assessment of abilities of the client, positioning of the clinic for
occupational participation, as well as task arrangement for optimal participation. Another

aspect of the acquisitional model is the idea that the person it is being used with is able to self-
reflect. This is directly applicable to this program in the sense that the therapists will need to
work on mastering the new skills, while trying to self-reflect on their progress. This will allow
them to identify areas within the lessons they need to improve their learning.
Goals and Objectives
Goal 1: Therapists will have an increased ability to independently implement appropriate
positioning for children with cerebral palsy to increase functional participation.
Objective 1: Within 1 month, therapists will independently assess patient abilities to
identify appropriate positioning for distal upper extremity functional participation.
Objective 2: Within 6 weeks, therapists will independently identify appropriate
positioning for distal upper extremity functional participation.
Goal 2: Therapists will have an increased ability to independently educate caregivers on
appropriate positioning for their children with cerebral palsy to participate in occupations
Objective 1: In 3 weeks, therapists will independently verbalize basic positioning
principles (for occupational participation) to the occupational therapist.
Objective 2: In three months, therapists will independently integrate positioning
caregiver-training in therapeutic services with all patients with cerebral palsy to facilitate
occupational participation.
Positioning and Task Arrangement for Occupation-Based Activities
The positioning and task arrangement for occupation-based activities program will be
designed to be delivered as 3 modules, taking approximately 3 hours a piece to complete. Each
module will be online. The occupational therapist will be able to conference call with the
therapists as they are reviewing the module. The occupational therapist will explain the basics
of each module and will be able to answer questions the therapists have, as needed. Once the
formal education portion of the program is complete, therapists will integrate principles
learned here to be complementary to their current practice. The first module will discuss the
theory behind proper positioning and task arrangement. The second module will discuss
principles of positioning and basic principles of neurodevelopmental treatment. And finally, the
third model will discuss task analysis and arrangement of an activity to target specific
outcomes. The following is an outline discussion of each individual module.
Module One. Module one will focus on theory behind the programming. The first theory
discussed will be the person-environment-occupation model. It will include information about
common functional and postural impairments seen in children with cerebral palsy. We then will
discuss how barriers in the environment can affect participation in occupation. In addition to
these, it will include what basic occupations of children are and common milestones for these
occupations based on age.
The next aspect of this module will include basics of task environment arrangement to
facilitate specific movement patterns. It will include information about development of mass to
specific movement patterns, control from proximal to distal, refined movements and typical
child development (Woolley, 2017). These principles will be tied to the basics of task
arrangement including seating stability and activity placement to target specific gains.
Finally, this module will introduce the Canadian Occupation Performance Measure
(COPM). Therapists will be educated on how the COPM is broken down into different sections
and used to interview caregivers about their main goals. This will be helpful in identifying client-
centered and occupation-based goals (Pollock, Mccoll, & Carswell, 2006). Therapists will then
practice interviewing with one another, using a case study provided. They will be required to
identify specific goals for the client and calculate scores to identify the top 3 goals. An example
of this is in appendix D.
Module Two. The second module will include basics of the neurodevelopmental
treatment (NDT) in pediatrics. It will explain the focus on postural alignment, weight bearing,
and handling for proper interaction with the environment. It will discuss the need to properly
assess the child’s environment, abilities and interests. Aspects of NDT evaluation include
posture, coordination, balance, motivation, arousal, perception and cognition (Friberg, 2017).
The module will explain that if the client is engaged in an activity that they are interested in,
they are more likely to make functional gains.
This module will then explain the basics of postural alignment including the idea of 90°-
90°-90° for hips, knees and ankles as well as shoulders over hips and trunk support for midline
maintenance, as needed. Diagrams of circle (head) on triangle (trunk) atop square (base of
support) will help to visually explain alignment. Finally, the idea of postural synergy will be
discussed. This is the idea that if certain aspects of postural control are facilitated and achieved,
other aspects are more likely to activate (Woolley, 2017).
Module Three. Finally, module three will include information about task analysis and
arrangement for targeting specific outcomes. We will talk about requirements to participate in
a variety of occupations. This could include the strength, coordination, endurance and steps,
etc., required to complete a specific task. Other aspects of task arrangement will include
distance of the tools from the client, size of the tools used and complexity of the activity. It will
then discuss the specific concepts of postural alignment and support to better facilitate distal
control.
To complete this module, we will talk about grading and providing different levels of
assistance to the clients. Grading will be explained by changing aspects required of the task to
make it harder/easier for the client. This would include specific examples to help the therapists
understand the concept. Levels of assistance would then be explained as the amount of aid the
therapist gives the client during an activity. These will be summarized as min, mod, max and
total assistance.
Following completion of the modules, the therapists will be given a quiz aimed at
assessing their learning. This assessment will include the main principles from each module. The
aim of this quiz will be to assess the skills but also to help identify where gaps may fall in the
training. If a therapist scores low on this assessment, they will be given increased aid to
understand the information.
Practical Application. The final aspect of this program will be the in-person training. This
will be provided by the supervising occupational therapist. The therapist will travel to Morocco
for a week to help the therapists fine tune their skills. This will be done by hands on training
and allowing for therapists to ask any more questions they may have. Another aspect of this
visit that will be beneficial to MAIR is that it will allow the occupational therapists to provide
suggestions for how to use what resources they have within the community.
Program Considerations. Due to the geographical location of the MAIR clinic, challenges
will occur. It is not realistic to pay for an occupational therapist to be present for the entirety of
the training. However, therapists at the clinic are very familiar with video conferencing, which
will allow them to talk with an occupational therapist as needed during the training.
Therapist buy in and participation is crucial for success of this program to be a benefit
for the clients of MAIR. Due to this, presenting evidence and integrating the program into
current practices is crucial. The information presented is given with the goal in mind that the
therapists will only have to minimally adapt their current practice to foster these positional
changes for different occupation-based interventions.
Program Start-Up. To introduce the program to the therapists of MAIR, an in-service will
be given by the supervising occupational therapist. This will teach them the basic outline of the
program, how to use the website to access information and how to contact the occupational
therapist with questions. It will also be at this point that it will be discussed that once the
program training is complete, an occupational therapist will travel to Marrakech to help the
therapists improve their techniques and education on the subject. The program will be
evaluated based upon the initial testing with the current therapists and adapted to fit MAIR’s
needs to train future employees.
Space Requirements. This program will not require any additional space than what the
clinic currently has available to them. Because it is a provider training, it will require an area to
sit at a table with a computer to learn the material. In order to practice the material presented,
therapists will need a small seating area within the clinic. This area will need to be big enough
to set up a patient, seated with a workspace in front of them. The clinic currently has
computers, chairs, tables and a space for the therapists to participate in the proposed program.
Time Requirements. The education portion of this program is estimated to take
approximately 10 hours. It is recommended that this is broken up into the suggested modules,
which will take approximately 2-3 hours each. Once the education portion of this program is
completed, the therapists will integrate learned principles into their daily treatment. This will
not require any extra time, specifically, but will be complementary to their current practice.
Finally, any additional time required for this program will be up to the therapists, as they see fit
to counsel with the occupational therapist to increase their learning.
Program Marketing. Due to the nature of this program being provided to all the
therapists at MAIR and only at MAIR, specific marketing outside of the clinic will not be
necessary. However, marketing to increase therapist buy in may be beneficial. This will be done
by providing the therapists with the research compiled in the literacy review of this proposal.
Budget. Budget requirements for this program will be minimal. The main costs of the
program will include the occupational therapist to oversee the training and any supplemental
positioning equipment the clinic may want to purchase after the training. The therapist will
require approximately 1-hour of preparation for each module, after which they will also be
involved during each 2-hour module session. During the sessions the occupational therapist will
be available to help explain concepts as well as answer any questions the therapist may have.
Budget of the occupational therapist’s salary will also include pay for a week for when they
travel to Morocco to aid the therapists in improving their new skills. The next large portion of
the budget will be the travel expenses of this program. Ideally, the therapist will be able to
travel to Morocco to work one on one with the therapists for a week to help them improve
their skills learned in this program. The last large chunk of the budget for this program will be to
purchase positioning equipment. This will be supplementary to the current equipment the clinic
currently owns. It includes a variety of wedges, cubes, and rolls to help position the client
optimally for occupation-based activities.
Funding Options. Funding for this program will likely be provided by the current grants
being awarded the clinic through the Sorenson Legacy Foundation as well as the Salt Lake
Rotary Club. Details about the Sorenson Legacy Foundation donations can be found on
Foundation Directory Online (Professional). Search terms included Morocco and health.
Sorenson Legacy Foundation states their mission is to promote education and scientific
endeavors, along with others to “improve the lives of others and the world in which we live”
(Sorenson Legacy Foundation, n.d.).
Salt Lake Rotary Club has also supported MAIR clinic through grants since their startup.
Rotary Club funding contributions have been involved in supporting a variety of different
aspects of MAIR operations. They state one of their main goals of their global outreach
initiative is to establish an “international network of people who share similar interests and
exchange ideas and opportunities with each other” (Global Outreach, n.d.). Other information
about the Salt Lake Rotary club and the funding they provide is available on their website.
Due to the minimal needs of this program, these funding sources should be sufficient.
Both corporations have given to MAIR with the intention of establishing a self-sustaining clinic.
This means that the funding is available for things such as education of the employees, day to
day operating costs, and supplies the clinic may need.
Expected Outcomes. Outcomes expected for this program are that the therapists have
an increased understanding of positioning, task analysis and arrangement for occupation-based

activities. By providing training, therapists will better be able to target specific abilities of their
clients through positioning. Modules for this training will serve as a source of resources
therapists can refer to, to help their current clientele as well as future patients. Therapists will
also be able to teach basic concepts of positioning to caregivers of their clients. This will then
increase the parent’s ability to continue therapy from home and thus increase gains of the
client. Overall, this will hopefully increase occupational participation for MAIR clients.
Program Evaluation. Evaluation of this program will occur in a number of ways.
Primarily, information will be gathered pre-program, mid-program, and post-program. Prior to
beginning the program, therapists will be asked to fill out the ‘pre-program’ questionnaire,
asking questions about their current knowledge and confidence in positioning for occupation-
based activities. It will also include a question asking the therapists what they hope to gain with
this education. Once the modules have been completed, the therapists will be asked to fill out a
post modules questionnaire. The purpose of this will be for the therapists to provide feedback
about how the information was presented in the modules. Another questionnaire will be
provided following the in-person interaction with the occupational therapist. This questionnaire
will include feedback about the way information was presented in the programming, as well as
how thoroughly the information was learned. Examples of questions to be asked in the pre,
mid, and post questionnaires are included in Appendix C.

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Appendix A: Interview Questions
Physical Therapist/Staff/Administrator questions
What does a typical day at the clinic look like for you?
What specific training have you had?
What types of cases are you typically dealing with?
How often are you seeing each patient?
What do you feel are strengths of the clinic?
What do you feel are weaknesses of the clinic?
What barriers are preventing you from providing services as you would like to?
What are the parents’ roles in the therapy process?
What other types of services (besides typical treatment session) are offered?
What does documentation look like here at the clinic?
What was your schooling like?
What does payment of services look like here at the clinic?
What do your relationships with other medical professionals look like? (i.e. doctors, social
workers, etc.)
What are some things that you have had to work to overcome with working with this
population and their caregivers?
What does training of a new therapist look like once hired on with MAIR?
How do you acquire needed supplies?
Caregiver questions
What is the most discouraging thing you have experienced when it comes to trying to habilitate
your child with a disability?
What has made the most impact on your life as a caregiver of a child with a disability?
What is something impactful you have learned about having a child with a disability in this
specific society?
Appendix B: Budget Table
Source of Specific Costs or Cost

Sources of Income
Start Up Costs
In-Kind Computers (x3; MacBook) $0
In-Kind Chairs (x3) $0
In-Kind Table (1) $0
Direct Costs
Occupational Therapist Salary $1,953.75
($81,269/year [salary.com]
$81,296/52 weeks =$1,563;
$1,563/40 hours=
$39.08/hour
$39.08x 50 hours= $1,953.75)
Positioning equipment
(especialneeds.com)
Kaye positioning system $230.00
Round bolster $65.00
Cube with wedge $205.00
Cube $65.00
In-Kind MAIR staff salary $150
($200/week/40 hours=
$5/hour x 10 hours [module
time] = $50 x 3 therapists=
$150)
Therapist Travel Expenses $1,100
(airfare= ~$1,100)
Therapist Housing Costs $600
(1-week hotel room as Blue
Sea =~$600)
Indirect Costs
In-Kind Space Rental $0
In-Kind Maintenance $0
In-Kind Utilities $0
In-Kind Cleaning $0
Income
None -$0
Net Cost of Program $3,268.75

Appendix C: Examples of Program Evaluation Questions
Pre-Program Question
On a scale from 1-10 how confident do you feel you are to position a child with CP to
target UE function?
What are you hoping to gain from this program?
What are your concerns, if any, about this program?
Mid-Programming Questions
target UE function?
What could be improved about your learning process? (i.e. completing and
understanding the modules better)
Where are gaps in the information, that you would like to know more about?
Based off what you learned from this module, on a scale from 1-10, how well do you
feel you could successfully implement this information?
Post-Programming Questions
Which module in the program did you feel was most helpful to you?
target UE function?
What functional outcomes are you observing when implementing these techniques
compared to previous approaches?
What has been reported by clients after implementing program techniques?
What could be improved about your learning process? (i.e. completing and
understanding the modules better)
Where are gaps in the information, that you would like to know more about?
Based off what you learned from this module, on a scale from 1-10, how well do you
feel you could successfully implement this information?
Appendix D: Case Study Example
Abdu is an 8-year-old male with cerebral palsy. He and his mom are here for an initial
evaluation. You have completed a musculoskeletal and neurological assessment. You are now
going to ask questions to learn a little more about his daily occupations.
What questions would you ask?
As you are talking, mom explains that he is really enjoys being around his siblings, but
he doesn’t ever play, he just watches. She states that he is able to feed himself with his hands
but once he tries to use a utensil, the food just falls off. She says this isn’t too big of a deal,
but it does make a mess. Mom also states he is able to help undress himself, but he takes too
long to dress, so she just does it for him.
Of what mom mentioned, what stands out at you as being a priority?
How would you identify what is most important to mom?
How could you employ what you have learned about positioning to increase
participation?
Using this information write 2 goals for increased occupational participation.

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Running Head: POSITIONING FOR OCCUPATION-BASED ACTIVITIES 1

Positioning for Occupation-Based Activities (POBA)

The purpose of this programming is to help to establish a complementary occupational

of Rehabilitation in Marrakech, Morocco. This needs assessment compiles information gathered

proposal of programming to help with current needs of the setting.

the United States.

Berrada, personal communication, October 2, 2018).

women are slowly becoming more respected throughout society.

prescription of medication. In Morocco, a wide variety of medication is readily accessible.

other existing conditions.

visits from the doctor after visits have run out.

Sociocultural. Due to its predominantly Muslim population, Marrakech is heavily

including “agriculture, tourism, aerospace, automotive, phosphates, textiles, apparel, and

10% (The World Factbook: Morocco, 2018).

monarchies in the world. Operating as a constitutional monarchy, Morocco is governed by King

Demographic. The country of Morocco has a current population of approximately 34

A study cited in Semlali (2010) estimated Morocco’s current poverty rate to be

amongst women (Semlali, 2010).

personal communication, October 11, 2018).

Services Provided for Clients of MAIR

Physical therapy. MAIR is primarily a physical therapy neurologic rehabilitation

however, is an area where more training could be beneficial.

population (1 for approximately 1000) (Semlali, 2010).

September 10, 2018).

Funding sources. MAIR is currently funded by a number of different charitable sources.

Programming Strengths and Areas for Growth

Founder, Therapists’, and Parents’ Perspective

Founder. A combination of semi-structured interview, personal conversation and

French neuro science cutting edge, rehabilitation of neurological conditions is inadequate.

and are valued as the people they are.

difficulty retaining therapists. Unfortunately, MAIR has been experiencing a number of

therapy only to have them quit months later.

and unlike any other in the country of Morocco.

environment at MAIR, they feel like they can.

Occupational Therapy Graduate Student Perspective

A system of informal interviewing, research and observation were compiled to more

support group, as well as home visits.

The therapists all work well together and communication is frequent.

to ask the physician for more visits to continue therapy.

clients do not have difficulty getting to the facility.

education in neurological rehabilitation, occupational and feeding specific therapies from

to improve in their rehabilitation after discharge from the clinic.

Finally, therapists of MAIR have minimal to no training in cognitive and sensory

interactions with clients of those needs.

Literature was reviewed to gain a more comprehensive understanding of people with

included: occupational therapy, positioning, functional, cerebral palsy, stroke, international,

Literature was reviewed in order to obtain a more comprehensive understanding of the

income, and overall poor access to education for disabled persons.

ranks in the bottom 5 of health care cost expenditure.

Low Household Income. In addition to lack of insurance, many residents of Morocco

an uncommon occurrence in Morocco. It is currently estimated that 43% of Moroccans are

compared to only 32% of children with disabilities.

Disability prevalence in Morocco. Disability in Morocco is not uncommon. It is

physical therapy but not occupational therapy.

65% of persons diagnosed with CP also have a co-diagnosis of scoliosis.

Spasticity. Another common effect of CP is spasticity. Abnormal muscle tone and

position is attended to to prevent contractures from occurring.

Eating and feeding. An occupation that is significantly affected by CP is that of eating

General Impairment. In addition to the beforementioned challenges, persons with CP

affect many different aspects of function including cognitive, sensory and

neuromusculoskeletal. These impairments can fall anywhere on a vast spectrum. However, in a

children with CP were considered by their parents to be unstable.

The current rehabilitation situation in Morocco is extremely lacking. MAIR clinic