Occupational therapy practitioners prevent illness, remediate disability, and restore health by enabling participation in meaningful occupations. During World War I, the first occupational therapists, called “reconstruction aides,” treated soldiers who were suffering from wounds and battle neurosis.¹ These early occupational therapists were teachers, secretaries, and artists that contributed to the war effort abroad. To promote healing, the aides used occupation-based activities to engage the mind and hands of patients. They taught handicrafts and vocational skills to distract the injured, increase physical activity, and improve morale (Figs. 78–1 and 78–2).² This philosophy was captured by Mary Reilly in her 1962 Eleanor Clarke Slagle Lecture, “Man, through the use of his hands, as they are energized by mind and will, can influence the state of his own health.”³

In 1917, occupational therapists formed their first professional association, called the National Society for the Promotion of Occupational Therapy (NSPOT). The founding members, including doctors, nurses, architects, and a psychiatrist, were instrumental in the development of occupational therapy as a profession. They were dedicated to building a role for occupational therapy in the health care community and establishing an organization that would expand the profession. In 1923, NSPOT changed their name to the American Occupational Therapy Association (AOTA), with Eleanor Clark Slagle as the first executive director.⁴ When the United States joined World War II in 1941, the expertise of occupational therapists was directed toward the war effort. The increased need for occupational therapists, especially in military hospitals, expanded occupational therapy services to include a broad range of physical and mental conditions.⁵

Between the years 1950 and 1969, occupational therapy became more technical and specialized. During this era, occupational therapists entered pediatric practice to address the needs of children with polio, cerebral palsy, and sensory processing conditions.⁴ Several legislative influences have shaped the profession of occupational therapy. For example, the creation of Medicare and Medicaid and passage of legislation such as the Americans with Disabilities Act, Individuals with Disabilities Education Act, and Affordable Care Act have resulted in new occupational therapy programs and services in outpatient, inpatient, community, and school-based settings.^6–10 During the 1970s, 1980s, and 1990s, the profession embraced a more holistic practice, expanding beyond the hospital and into the community.⁴ New practice areas emerged focusing on quality of life and promoting optimal function and participation in community settings. These new practice areas included prevention and wellness, ergonomics and work programs, assistive technology, and meeting the needs of an aging population.²

Occupational Therapy Practice Framework

Within the Occupational Therapy Practice Framework,¹¹ the profession’s guiding document, occupational therapy is defined “as the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings.” This use of occupation as both process and outcome is unique within the health and rehabilitation professions. Participation occurs when clients are actively involved in carrying out occupations they find purposeful and meaningful. The domain of occupational therapy comprises several aspects, including occupations, client factors, performance skills, performance patterns, and context and environment. All aspects of the domain are of equal value, and together they interact to affect the client’s occupational identity, health, well-being, and participation in life.¹¹ Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health and wellness for clients of all ages with and without disabilities. These services include acquisition and preservation of wellness for those who have or are at risk of developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction.¹¹

Occupational Therapy Theory

The profession of occupational therapy has a rich tradition of assessment and intervention grounded in a diverse set of theory and frames of reference,12 which guide clinical reasoning and decision-making.¹³ Among these, the Person-Environment-Occupation (PEO) model is widely used within the profession to drive assessment and intervention that enable people to successfully participate in meaningful occupations within diverse environments. The PEO model was established by Law et al¹⁴ and is grounded in studies of human ecology and person-environment interactions.^15–21 The model (Fig. 78–3) includes four major components: (1) the person, a unique individual with evolving attributes, life experiences, and roles; (2) the environment, the cultural, socioeconomic, institutional, physical, and context within which behavior occurs; (3) the occupation, a group of self-directed, meaningful, functional tasks and activities in which a person engages over the lifespan;²² and (4) occupational performance, which is defined as “dynamic experience of a person engaged in purposeful activities and tasks within an environment.”¹⁴ These components interact over the course of one’s life, resulting in occupational performance. This lens recognizes that the transactional nature of these components influences the person’s level of satisfaction, function, and quality of life.²³

A Century of Occupational Therapy

In 2017, as the profession marked its 100th anniversary, AOTA adopted its Vision 2025, “Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living.”²⁴ The vision will guide the profession of occupational therapy to be accessible, collaborative, effective, and leaders in policy and systems through the year next decade.

We acknowledge that it is not possible to capture the scope and diversity of a profession with a single text, certainly not with a single chapter. In this chapter, we have attempted to highlight the “big rocks”²⁵ in occupational therapy practice in PM&R. Each topic references current evidence and provides a starting point for rehabilitation professionals to explore how occupational therapy practitioners may contribute to the care for a variety of clients presenting to the health care system.

Mental Health

In the rehabilitation setting, occupational therapists can play a key role in identifying mental health concerns among patients recovering from neurological or orthopedic injury. Carota and Bogousslavsky²⁶ found that as many as 50% of stroke survivors experience psychological or emotional distress, including mood disorders, behavioral or personality changes, delirium, and perception-identity disorders. Current occupational therapy research demonstrates that behavioral interventions targeting problem-solving²⁷ and motivational interviewing²⁸ can be effective in treating depression associated with stroke.

The field of mental health occupational therapy includes assessment, intervention, and program development for psychiatric, behavioral, and substance-use disorders, wellness promotion, and psychosocial concerns associated with disability.²⁹ Occupational therapy practitioners are uniquely skilled to examine and integrate the psychosocial, physical, and environmental factors that influence a person’s participation in daily functions, roles, and routines and promote their independence through engagement in meaningful activity.³⁰ Occupational therapy mental health interventions can target the individuals, groups, or populations. Examples of strategies that may be used in mental health intervention include teaching problem-solving strategies, motivational interviewing, self-advocacy training, routine development, task adaptation, and identifying natural supports.³¹

Practice Settings

Health care providers can expect to encounter occupational therapy practitioners working in traditional PM&R settings including in outpatient clinics, specialized centers, acute rehabilitation, long-term care facilities, subacute, assisted living, home-based, and day treatment. Among these, occupational therapy in the acute care, which responds to life-threatening health conditions and encompasses many sectors and units such as trauma care, acute care surgery, critical care, and short-term inpatient stabilization,³² provides an informative example. An abundance of research supports occupational therapy’s role in early mobilization of patients on mechanical ventilation^33,34 in the intensive care unit to jumpstart the rehabilitative process by engaging patients in meaningful activities to prevent further deconditioning. The therapy protocol described by Pohlman & Schweickert³³ for early mobilization focuses on therapeutic interventions such as active movement in bed, sitting at the edge of bed, and engagement with self-care to attain maximal wakefulness. This resulted in a higher level of functional performance upon discharge, decreased ICU delirium, and increased number of ventilator-free days for these patients who were initially heavily sedated and mechanically ventilated.^33,34 Occupational therapy’s critical role with patients post-stroke addresses the variable cognitive³⁵ and physical deficits in the context of activities of daily living.³⁶ With the use of cognitive retraining and task-specific training,³⁷ occupational therapy changes the focus from impairment-based treatment to a top-down approach through engagement in meaningful occupations.

Through comprehensive patient education on precautions, safety, self-management of chronic illnesses, splint care, and medications, occupational therapy interventions have demonstrated a positive effect on half of the CMS³⁸ identified hospital-acquired conditions. These conditions include “injuries from falls, pressure ulcers, deep venous thrombosis, pulmonary embolisms, poor glycemic management, and venous thromboembolism.”³⁹ Occupational therapy practitioners collaborate closely with the interdisciplinary team to develop a client-centered discharge plan. In addition to identifying key barriers through evaluation of patient factors such as health literacy, visual deficits, and cognitive impairments, the occupational therapy practitioner may recommend home safety modifications, durable medical equipment, and adaptive equipment as part of the discharge plan in order to optimize performance in everyday activities and routine.⁴⁰

Stroke

Stroke is the number one cause of long-term disability in the United States, affecting more than 795,000 people annually.⁴¹ Following a stroke, individuals may experience difficulty with physical, cognitive, and emotional abilities which impede their independence while completing meaningful occupations, such as activities of daily living, education, work, leisure, and social participation.⁴² Occupational therapy is an essential component of stroke rehabilitation as it focuses on increasing independence and quality of life using remediation, compensation, and adaptive strategies. Depending on the severity of the stroke, phase of recovery, and individual goals of the individual, occupational therapy intervention can target a variety of areas, including: (1) activities of daily living, such as dressing, bathing, and eating; (2) neuromuscular weakness and sensory loss; (3) cognitive and visual impairment; (4) functional mobility and community reintegration; (5) home and workplace modifications; (6) coping strategies to promote psychosocial health and well-being; and (7) driving evaluations and rehabilitation programs.⁴³ Research demonstrates the important role of occupational therapy in the stroke rehabilitation process through findings that patients who receive occupational therapy post-stroke are significantly more independent in personal activities of daily living than those who received no intervention or usual care.²⁷ In addition, client-centered occupational therapy improves stroke survivors’ perceived performance and satisfaction with meaningful everyday tasks.⁴⁴

Traumatic Brain Injury

Every year, at least 7.1 million traumatic brain injuries (TBIs) occur in the United States.⁴⁵ TBIs can cause significant impairment, both short- and long-term, which affect cognition, sensation, language, emotion, and physical function.⁴⁶ Depending on the severity of the TBI, these changes might resolve completely, while in others the changes can result in partial or permanent disability. According to the Centers for Disease Control and Prevention, 3.2 million to 5.3 million people in the United States are living with a TBI-related disability.⁴⁵ Occupational therapy practitioners are well-positioned to address neuromuscular, cognitive, and behavioral impairments to promote increased participation in meaningful activities and reintegration into the community. Interventions include addressing memory, problem-solving, attention, executive function, behavioral regulation, neuromuscular impairments/functioning, and participating in meaningful daily routines and occupations. Depending on the severity of the TBI, occupational therapy practitioners customize their intervention to initially focus on remediation, then progress to compensatory strategies and environmental modifications. For example, if a young male presents with a TBI and resulting limitations in community participation due to impairments in psychosocial functioning, memory, and self-awareness, an occupational therapy practitioner will develop an individualized intervention plan to address these areas, such as: (1) client-centered goal-setting to improve self-awareness and communication; (2) physical activity to improve depression and anger; and (3) restorative and compensatory strategies to improve memory recall.⁴⁷

Spinal Cord Injury

In 2017, according to the National Spinal Cord Injury Statistical Center, approximately 285,000 individuals were living with spinal cord injury (SCI).⁴⁸ Spinal cord injury (SCI) can cause significant functional impairments across all aspects of an individual’s life.⁴⁹ The goals of rehabilitation are to improve level of functioning, decrease secondary morbidity, and enhance overall quality of life. Research shows that early intervention with SCIs significantly decreases length of hospitalization, frequency of contracture, medical complications, and overall health care costs.⁵⁰ Occupational therapy practitioners offer a unique role when working with individuals with SCI. Occupational therapy practitioners assess an individual’s functional activity tolerance, participation in daily activities, and independence in order to provide intervention and preventative education to those with SCI and their families. Occupational therapy interventions with the SCI population often target activity tolerance, participation in activities of daily living, home modifications, work reintegration, functional mobility, and community accessibility and driver rehabilitation. Research further supports the role of occupational therapy in SCI rehabilitation as it results in improved functional independence in transfers, wheelchair navigation, and community mobility.⁵¹ Occupational therapy also plays an important preventative role with the SCI population by educating patients and caregivers on safe transfer techniques, home modifications, and adaptive strategies, as well as serious conditions such as autonomic dysreflexia and the development of pressure ulcers. Community-based occupational therapy practice offers a valuable opportunity with this population to comprehensively address lifestyle and environmental factors during intervention with individuals with SCI at risk for pressure ulcer development.⁵²

Productive Aging

Productive aging has been broadly defined as maintaining self-care, engaging in a variety of activities such as volunteer or paid work, assisting with the family,⁵³ and continued education.⁵⁴ Approximately 10,000 people in the United States reach the age of 65 every day.⁵⁵ Over 25% of this population is living with multiple chronic conditions including osteoporosis, arthritis, hypertension, COPD, heart failure, heart disease, dementia, and stroke. Furthermore, the risk of low vision and age-related eye diseases significantly increases for those over the age of 65 impacting the individual’s ability to mobilize safely at home and increasing the risk for falls.⁵⁶ Occupational therapy practitioners work with aging adults and their families to promote independence and safety with performance of daily activities at home and in the community.⁵⁷ In order to maintain function in this growing population, the scope of occupational therapy services include home modifications, fall prevention programs, lifestyle redesign for health promotion, vision rehabilitation, driving and community mobility, and palliative care. Chronic diseases such as rheumatoid arthritis are painful and significantly affect an individual’s ability to perform essential activities of daily living limiting their engagement in life. Interventions aim to address pain management,⁵⁸ joint protection,^58,59 prevention of further deformity, community safety, medication routine adherence,⁶⁰ and energy conservation techniques⁵⁸ to enhance the aging adult’s performance. Occupational therapists conduct home evaluations and recommend assistive technology, adaptive equipment, and home modifications that will create an environment that supports the aging adult and improve quality of life.⁶¹

Alzheimer’s Disease

Alzheimer’s disease (AD) is a progressive form of dementia that results in significant memory loss, language difficulty, and changes in decision-making ability, judgment, and personality.⁶² The Alzheimer’s Association estimates that more than 5 million Americans are living with Alzheimer’s disease, and by 2050, this number could rise as high as 16 million.⁶³ Occupational therapy practitioners are positioned to help the increasing number of individuals with Alzheimer’s disease and their caregivers have the highest quality of life possibly by adapting the environment and focusing on ways to maximize engagement in meaningful occupations, promote safety, and enhance quality of life. These occupational therapy interventions often include remediation, such as routine exercise to improve performance of activities of daily living and functional mobility; maintenance, such as the establishment of necessary supports to maintain meaningful habits and routines; and modification, to ensure safe and supportive environments through adaptation and compensation.⁶⁴ Evidence has found significant positive effects of individualized occupational therapy intervention with individuals with AD and their caregivers, including: (1) improved quality of life, positive affect, activity frequency, and self-care status⁶⁴; (2) decreased caregiver burden⁶⁴; (3) increased cost-effectiveness⁶⁵; and (4) improved patients’ and caregivers’ health status.⁶⁶

Parkinson’s Disease

Parkinson’s disease (PD) is a neurodegenerative disorder that results in progressive decline in motor and cognitive functioning.⁶⁷ According to the Parkinson’s Disease Foundation, 1 million Americans are living with PD.⁶⁸ Occupational therapy practitioners play an important role to support people with PD and help them maintain their independence with self-care, household tasks, caregiving roles, work, and leisure activities for as long as possible; however, when it is no longer possible to maintain the individual’s level of functioning, occupational therapy practitioners adapt and modify the individual’s physical and social environment to develop new meaningful occupations.⁶⁹ Research demonstrates that occupational therapy significantly improves individuals with PD’s self-perceived performance in meaningful occupations as well as satisfaction with performance of daily activities and instrumental daily activities.⁷⁰ In addition, occupational therapy interventions have positive effects on outcomes related to individual with PD’s outcomes related to function during activities and tasks of daily living.⁷¹ Occupational therapy is an essential component to prolonging the quality of life for individuals with Parkinson’s disease.

Multiple Sclerosis

The National Multiple Sclerosis Society estimates that 2.3 million individuals are living with multiple sclerosis (MS) worldwide.⁷² Primary goals for occupational therapy intervention for individuals who have neurodegenerative disorders, such as MS, are to reduce the effects of the disability and to maintain or promote independence and quality of life, such continued participation in chosen tasks and meaningful roles. Many of these patients experience symptoms that contribute to loss of independence and restrictions in social activities, which could lead to a decline in quality of life.⁷³ Although rehabilitation has no direct influence on the progression of diseases like MS, neurorehabilitation has been shown to ease the burden of the symptoms by improving self-performance and independence, which ultimately improves quality of life. Occupational therapy plays an important role in the prolonged quality of life for individuals with MS through adaptive and compensatory strategies, such as energy conservation techniques.