Occupational therapy

Occupational therapy, often abbreviated as "OT", incorporates meaningful and purposeful occupation to enable people with limitations or impairments to participate in everyday life. Occupational therapists work with individuals, families, groups and populations to facilitate health and well-being through engagement or re-engagement in occupation. Occupational therapists are becoming increasingly involved in addressing the impact of social and environmental factors that contribute to exclusion and occupational deprivation.

The World Federation of Occupational Therapists defines occupational therapy as a profession concerned with promoting health and well-being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by enhancing the individual's ability to participate, by modifying the environment, adapting the activity to better support participation and/or facilitating physical or mental rehabilitation to maximize functional performance.

Occupational therapy relies on understanding the importance of an activity to an individual, being able to analyze the physical, mental and social components of the activity, and then adapting the activity, the environment, and/or the person to enable them to resume the activity. Occupational therapists address the question, "Why does this person have difficulties managing his or her daily activities (or occupations), and what can we adapt to make it possible for him or her to manage better and how will this then impact his or her health and well-being?”

Occupational therapy gives people the "skills for the job of living" necessary for "living life to its fullest."

Occupational therapy draws from the field of occupational science to provide an evidence base to practice and develop academic and practice links to other related disciplines such as social science and anthropology, and also utilizes a range of generic models to guide the practice of OT.

History of occupational therapy

See also: History of OT in America, History of OT in New Zealand

The earliest evidence of using occupations as a therapeutic modality can be found in ancient times. One-hundred years before the birth of Christ, Greek physician Asclepiades initiated humane treatment of patients with mental illness via the use of therapeutic baths, massage, exercise, and music. Later, the Roman Celsus prescribed music, travel, conversation and exercise to his patients. Unfortunately, by medieval times, the concept of humane treatment of people considered to be insane was rare, if not nonexistent.

In eighteenth century Europe, revolutionaries such as Philippe Pinel and Johann Christian Reil reformed the hospital system. Instead of the use of metal chains and restraint, their institutions utilized rigorous work and leisure activities in the late 1700s. Although it was thriving abroad, interest in the reform movement waxed and waned in the United States throughout the nineteenth century. At the turn of the 20th century, as physicians became increasingly interested in chronic disease, enthusiasm for the reform of the mental healthcare system was revived in the states. Work therapy found its way to America.

The health profession of occupational therapy as we know it was conceived in the early 1910s. Focus was on promoting health in “invalids.” Early professionals merged highly valued ideals, such as having a strong work ethic and the importance of crafting with one’s own hands, with scientific and medical principles. Early adversaries viewed wood carving and crafting by ill patients trivial.

The emergence of occupational therapy challenged the views of mainstream scientific medicine. Instead of focusing on purely physical etiologies, they argued that a complex combination of social, economic, and biological reasons cause dysfunction. Principles and techniques were borrowed from many disciplines—including but not limited to nursing, psychiatry, rehabilitation, self-help, orthopedics, and social work—to enrich the profession’s scope. Between 1900 and 1930, the founders defined the realm of practice and developed theories of practice. In a short 20-year span, they successfully convinced the public and medical world of the value of occupational therapy and established standards for the profession.

A substantial lack of primary sources of information has left today’s occupational therapists with many questions concerning the founders of the field. Information is collected from early training institutions and hospitals, professional writings of practitioners, World War I records from government agencies, newspaper articles, and personal testimonials.

One of the most notable figures in the infancy of occupational therapy was Eleanor Clark Slagle. Slagle was part of the generation of women who challenged women’s “rightful” place as a volunteer and strived for females to have a place in the professional world. At age forty, she was trained in curative occupations and recreations at the Chicago School of Civics and Philanthropy and later took a position at Hull House, where crafts were used to promote mental health.

It is speculated that Slagle’s interest in healthcare stemmed from her personal life, as her father, brother, and nephew all suffered from various disabilities. Seeing the daily struggles of people with disabilities and illnesses may have sparked Slagle to enroll in the Chicago School in 1911. In 1912, renowned psychiatrist Adolph Meyer appointed Slagle to direct a new department of occupational therapy at John Hopkins Hospital. There, she learned habit training—a method of re-educating patients on decent habits of living via substituting healthful habits for bad habits.

Another psychiatrist, William Rush Dunton, Jr., worked diligently to raise the status of psychiatry in medicine in the first decades of the 20th century. He viewed occupational therapy as complementary to psychiatry, as it had the promise of meshing humanitarian values with science. Dunton became interested in the work of European moral therapy advocates. He accepted a position at the Sheppard Asylum, where it was standard practice in the early 1900s for patients to participate in activities such as bowling, gymnastics, art, etc. Dunton and his contemporaries called for the development of a theory to underlie the treatment known as “moral therapy” and “diversional occupation,” among other names. He called for therapists to devise outcome measures so that the neophyte profession would be given the attention and respect he felt it deserved.

Another important figure in the early days of occupational therapy was Susan Tracy, a nurse by trade, who organized activity-oriented classes for nurses at the Adams Nervine Asylum. In 1910, she published a textbook that was widely used for over 30 years. She is credited with expanding the realm of occupational therapy from psychiatric institutions to the homes of patients, which is an important setting in which today’s occupational therapists work. Upon breaking ties with the asylum, she set up her own institution, entitled the Experiment Station for the Study of Invalid Occupations. This training center educated nurses so they could gain control over their practice and not default to being dominated by physicians. By practicing privately in patients’ homes, this batch of occupational therapists expanded the domain of occupational therapy and began using OT to treat physical ailments as well as mental illness.

Herbert J. Hall was a physician with a strong work ethic and practical vision. He believed we could retract social ills by adapting the arts and crafts movement for medical purposes. A graduate of Harvard Medical School, he advised the government on wartime standards for occupational therapy during WWI. He introduced the concept of grading activities—now a hallmark of occupational therapy—to avoid exacerbating patient’s frustration and fatigue.

George Edward Barton, an architect, also aided in promoting the occupational therapy profession. Diagnosed with tuberculosis in 1901, Barton later contracted gangrene and had a partial amputation, after which he was left paralyzed on his left side. He opened Consolation House, a sanctuary for people with physical disabilities, in 1914. There, intensive self-administered occupational therapy “cured” his ailments. He played an integral part in gathering the profession’s leaders and forming the first national society.

The first meeting of the National Society for the Promotion of Occupational Therapy was held in March 1917. Barton (along with his secretary), Eleanor Clark Slagle, William Rush Dunton Jr., Thomas B. Kinder, and Susan Cox Johnson were the only six in attendance. In the fall of 1919, at the third meeting, 300 attendees participated. In 1921, the name of the organization was changed to the American Occupational Therapy Association and the Archives of Occupational Therapy, the first professional journal, began publication.

World War I forced the new profession to clarify its role in the medical domain and to standardize training and practice. In addition to clarifying its public image, OT also established clinics, workshops, and training schools nationwide. Due to the overwhelming number of wartime injuries, “reconstruction aides” (an umbrella term for physical therapists and occupational therapists) were recruited by the Surgeon General. Between 1917 and 1920, nearly 148,000 wounded men were placed in hospitals upon their return to the states. This number does not account for those wounded abroad. The success of the reconstruction aides, largely made up of women trying to “do their bit” to help with the war effort, was a great accomplishment. Post-war, however, there was a struggle to keep people in the profession. Emphasis was shifted from the altruistic war-time mentality to the financial, professional, and personal satisfaction that comes with being a therapist. To make the profession more appealing, practice was standardized, as was the curriculum. Entry and exit criterion were established, and AOTA advocated for steady employment, decent wages, and fair working conditions. Via these methods, occupational therapy sought and obtained medical legitimacy in the 1920s. By the time Slagle retired from the profession in 1937, the profession’s medical identity was well on its way to being established.

Occupational therapy. Toy making in psychiatric hospital. World War 1 era.

Evolution of the philosophy of occupational therapy

The philosophy of occupational therapy has evolved over the history of the profession. The philosophy articulated by the founders that have owed much to the ideals of romanticism , pragmatism and humanism which are collectively considered the fundamental ideologies of the past century.

William Rush Dunton, the creator of the National Society for the Promotion of Occupational Therapy, now the American Occupational Therapy Association, sought to promote the ideas that occupation is a basic human need, and that occupation was therapeutic. From his statements, came some of the basic assumptions of occupational therapy, which include:

• Occupation has an effect on health and well-being.
• Occupation creates structure and organizes time.
• Occupation brings meaning to life, culturally and personally.
• Occupations are individual. People value different occupations.

These have been elaborated over time to form the values which underpin the Codes of Ethics issued by each national association. However, the relevance of occupation to health and well-being remains the central theme. Influenced by criticism from medicine and the multitude of physical disabilities resulting from World War II , occupational therapy adopted a more reductionistic philosophy for a time. While this approach lead to developments in technical knowledge about occupational performance, clinicians became increasingly disillusioned and re-considered these beliefs. As a result, client centeredness and occupation are re-emerging as dominant themes in the profession, perhaps indicating growing maturity and self confidence. Over the past century, the underlying philosophy of occupational therapy has evolved from being a diversion from illness, to treatment, to enablement through meaningful occupation. This became evident through the development and widespread adoption of the Canadian Model of Occupational Performance.

The two most commonly mentioned values are that occupation is essential for health and the concept of holism. However, there have been some dissenting voices. Mocellin in particular advocated abandoning the notion of health through occupation as obsolete in the modern world and questioned the appropriateness of advocating holism when practice rarely supports it. The values formulated by the American Association of Occupational Therapists have also been critiqued as being therapist centred and not reflecting the modern reality of multicultural practice.

Central to the philosophy of occupational therapy is the concept of occupational performance. In considering occupational performance the therapist must consider the many factors which comprise overall performance. This concept is made more tangible using models such as the person-environment-occupation model proposed by Law et al. (1996). This approach highlights the importance of satisfactions in one's occupations, broadening the aim of occupational therapy beyond the mere completion of tasks to the holistic achievement of personal wellbeing.

In recent times occupational therapists have challenged themselves to think more broadly about the potential scope of the profession, and expanded it to include working with groups experiencing occupational deprivation which stems from sources other than disability. Examples of new and emerging practice areas would include therapists working with refugees, and with people experiencing homelessness

Occupation, occupational form and performance

Occupation

Occupation is the dynamic relationship between the occupational form and occupational performance.

Many people see the term occupation as a job one does. However, the meaning of occupation is seen in a much wider context by an Occupational Therapist. A human being can be engaged in a wide range of occupations: leisure, self-care or educational activities are just a few examples of occupation.

Occupational Form

Wu and Lin (1999) stated that the occupational form was the “...objective pre-existing structure or environmental context that elicits or guides subsequent human performance”. The occupational form consists of objective features. These may include materials, human context and socio-cultural dimensions.

Occupational Performance

Occupational performance is the active voluntary human doing of the occupational form.

Occupational therapy process

An Occupational Therapist works systematically through a sequence of actions known as the occupational therapy process. There are several versions of this process as described by numerous writers. Creek (2003) has sought to provide a comprehensive version based on extensive research. This version has 11 stages, which for the experienced therapist may not be linear in nature. The stages are:

• Referral
• Information gathering
• Initial assessment
• Needs identification/problem formation
• Goal setting
• Action planning
• Action
• Ongoing assessment and revision of action
• Outcome and outcome measurement
• End of intervention or discharge
• Review

Areas of practice in occupational therapy

The role of Occupational Therapy allows OT’s to work in many different settings, work with many different populations and acquire many different specialties. This broad spectrum of practice lends itself to difficulty categorizing the areas of practice that exist, especially considering the many countries and different healthcare systems. In this section, the categorization from the American Occupational Therapy Association is used. However, there are other ways to categorize areas of practice in OT, such as physical, mental, and community practice (AOTA, 2009). These divisions occur when the setting is defined by the population it serves. For example, acute physical or mental health settings (e.g.: hospitals), sub-acute settings (e.g.: aged care facilities), outpatient clinics and community settings.

In each area of practice below, an OT can work with different populations, diagnosis, specialities, and in different settings.

Physical health

Occupational therapy during WWI: bedridden wounded are knitting.

• Pediatrics - Schools, Community, inpatient hospital based child OT: Often, children need OT services for the same reasons an adult needs OT services. However, OTs approach intervention in a different way with children. OT delivers approaches treatment through occupation, and the occupations of a child are different from those of an adult; and include play, chores, self-care and schoolwork. Common conditions that are specific to or more common in the pediatric population creating a need for OT services include: developmental disorders, sensory regulation or sensory processing deficits, fine motor developmental delays or deficits, autism, emotional and behavioral disturbances (Lambert, 2005), among others. In addition, children are seen for every injury, illness or chronic condition that may cause a person of any age to have performance deficits in their daily life and thus benefit from OT services.
• Acute care hospitals: Acute care is an inpatient hospital setting for individuals with a serious medical condition(s) usually due to a traumatic event, such as a traumatic brain injury, spinal cord injury, etc. The primary goal of acute care is to stabilize the patient’s medical status and address any threats to his or her life and loss of function. Occupational therapy plays an important role in facilitating early mobilization, restoring function, preventing further decline, and coordinating care, including transition and discharge planning. Furthermore, occupational therapy’s role focuses on addressing deficits and barriers that limit the patient’s ability to perform activities that they need or want to do related to independence in self-care, home management, work-related tasks, and participating in leisure and community pursuits.
• Inpatient rehabilitation (e.g., Spinal Cord Injuries):People with disabilities have the right and the privilege to live meaningful purposeful lives. When a disability occurs it is sometimes possible to recover – when it is not it is important to learn the skills to adapt capacity and environmental supports to be able to participate. OTs use their knowledge to help both with recovery and adaptation.
• Rehabilitation centers (e.g., Traumatic Brain Injury (TBI), Stroke (CVA), Spinal Cord Injuries, Head Injuries)
• Skilled nursing facilities: An occupational therapists role in a skilled nursing facility is centered on each client’s individual needs. Many of the skills an OT works on are known as activities of daily living or self-care such as feeding or dressing. OTs can provide equipment to assist with activities or offer expertise in modifying the environment to maximize independence and facilitate independence. Other OT roles include education in adaptive equipment (shower bench), energy conservation, or task simplification (Hofmann, 2008).
• Home Health: Occupational therapists who work in this area of practice generally work with client’s in the geriatric population who have one or more of the following diagnoses: Alzheimer’s disease, arthritis, depression, CVA, generalized weakness, COPD, or Parkinson’s disease. Occupational therapists working with these client’s evaluate their level of independence, cognition, and safety. Moreover, occupational therapists provide intervention to maximize independence and function through remedial and compensatory strategies, with the ultimate goal of the client’s regaining the ability to live independently at home (Swanson Anderson & Malaski, 1999).
• Outpatient clinics (e.g., Hand Therapy, orthopaedics) Hand therapy is a specialty practice area of occupational therapy that is mainly concerned with treating orthopedic-based upper extremity conditions to optimize the functional use of the hand and arm. Diagnoses seen by this practice area include: fractures of the hand or arm, lacerations and amputations, burns, and surgical repairs of tendons and nerves. Additionally, hand therapists treat acquired conditions such as tendonitis, rheumatoid arthritis and osteoarthritis, and carpal tunnel syndrome. Occupational therapists who work in this field address biomechanical issues underlying upper-extremity conditions. In addition, occupational therapists use an occupation-based and client-centered approach by identifying participation needs of the client, then tailoring intervention to improve performance in desired activities. [1](link for a picture of hand therapy)
• Specialist assessment centres (e.g., Electronic assistive technology, Posture and Mobility services)
• Hospices: An occupational therapists common role in hospice care is modifying and preventing. Modifying the demands of the activity to fit with the abilities of the client. The intervention may be directly with the client or with the client and the client’s caregivers. OT can offer the caregivers support an education. Progress is defined as improved quality of life in hospice care. (Hasselkaus, 1998)
• Assisted Living Facilities: In an assisted living facility OT services are provided by a home health agency, rehab agency, or a private practice. Medicare and some private insurance plans cover OT services in ALFs. Areas of treatment intervention often include: bathing, dressing, grooming, toileting, mobility, money management, laundry, and community participation. Can treat persons with occupational performance decline or at risk for a decline. Increase quality of life so less residents need the services of a long-term SNF. Special areas include mobility device assessment (scooter), continence training, psychosocial needs and low vision programs (Fagan, 2001).
• Productive Aging: An OT practicing in this area would provide skills and services to older adults to maximize independence, participation, and quality of life. Typical issues addressed: Any impairment or condition that would limit their ability to carry out meaningful occupations and tasks that are necessary for daily life. Skills taught include: energy conservation, education in adaptive equipment (such as a shower bench), task simplification, adapting and modifying activities to progress with a client’s changing abilities (Opp Hoffman, 2008), caregiver education and support (AOTA, 2004), safety, social interactions and communication, memory skills training, mobility device assessment and training (i.e. scooters, wheelchairs, walkers), low vision interventions, continence training, and facilitating performance in basic ADL and IADL (Fagan, 2001).
• Work hardening is essentially a specialized program designed to enable people with physical, psychological, and psychosocial issues inhibiting a person’s ability, to successfully return to work. The National Advisory Committee on Work Hardening best describes work hardening:

“Work hardening is a highly structured, goal oriented, individualized treatment program designed to maximize the individual’s ability to return to work. Work hardening programs, which are interdisciplinary in nature, use real or simulated work activities in conjunction with conditioning tasks that are graded to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic and psychosocial functions of the individual. Work hardening provides a transition between acute care and return to work while addressing the issues of productivity, safety, physical tolerances, and worker behaviors” (Ogden-Niemeyer & Jacobs, 1989, p. 1).

• Work conditioning is similar to work hardening, except work conditioning purely involves improving physical capacities, whereas work hardening improves physical, psychological, and psychosocial factors.

Mental health

According to Medicare (2005) guidance, “Only a qualified occupational therapist has the knowledge, training, and experience required to evaluate and, as necessary, re-evaluate a patient’s level of function, determine whether an occupational therapy program could reasonably be expected to improve, restore, or compensate for lost function, and where appropriate, recommend to the physician a plan of treatment.”

According to the American Occupational Therapy Association (AOTA), occupational therapists work with the Mental Health population throughout the life span and across many treatment settings where mental health services and psychiatric rehabilitation are provided (AOTA, 2009). Just as with other clients, the OT facilitates maximum independence in activities of daily living (dressing, grooming, etc) and instrumental activities of daily living (medication management, grocery shopping, etc). According to the American Occupational Therapy Association, OT improves functional capacity and quality of life for people with mental illness in the areas of employment, education, community living, and home and personal care through the use of real life activities in therapy treatments (AOTA, 2005).

Geriatric, Adult, Adolescents, and Children with any kind of mental illness or mental health issues. These conditions include but are not limited to: Schizophrenia, substance abuse, addiction, dementia, Alzheimer’s, mood disorders, personality disorders, psychoses, eating disorders, anxiety disorders (including post-traumatic stress disorder, separation anxiety disorder) (Cara & MacRae, 2005), and reactive attachment disorder (children only) (Lambert, 2005).

Typical issues that are addressed are as follows: Helping people acquire the skills to care for themselves or others including; keeping a schedule, medication management, employment, education, increasing community participation, community access (grocery store, library, bank, etc.), money management skills, engaging in productive activities to fill the day, coping skills, routine building, building social skills, and childcare (Cara & MacRae, 2005).

Areas that Mental Health OT's could work in are as follows:

• Mental health inpatient units
  • Adolescent, adult and older people's acute mental health wards
  • Adult and older people's rehabilitation wards
  • Prisons/secure units (Forensic psychiatry)
  • Psychiatric intensive care unit
  • Specialist units for Eating Disorders, Learning disabilities
• Community based mental health teams
  • Child and adolescent mental health teams
  • Adult and older people's community mental health teams
  • Rehabilitation and recovery and Assertive Outreach community teams
  • Primary care services in GP practices
  • Home treatment teams
  • early psychosis teams
  • Specialist learning disability, eating disorder community services
  • Day services
  • Vocational Services
  • Dementia & Alzheimer Care: OTs focus on adapting activities as the client progresses through the illness (Hofmann, 2008) OT also works with caregivers to teach them how to grade activities to the client’s ability. Interventions are based on using the client’s strengths to increase their quality of life and their relationships with caregivers. Use of social interactions, communication, memory, safety and self maintenance.

Community

Community based practice involves working with people in their own environment rather than in a hospital setting. It often combines the knowledge and skills related to physical and mental health. It can also involve working with atypical populations such as the homeless or at-risk populations. Examples of community-based practice settings:

• Health promotion and lifestyle change: Remaining healthy is the goal of all people in a society, including people with chronic disabling or health conditions. Achieving health requires skills to self-manage conditions that might limit their ability to function in daily life. The occupational therapist helps people acquire these skills (Wilcock, 2005).
• Private Practice
• Aging in place: Occupational therapists implement environmental modifications in senior housing, assisted living, long-term-care facilities, and homes (Yamkovenko, 2008) Environmental modifications can include rearranging furniture, building ramps, widening doorways, grab bars, special toilet seats, and other safety equipment to use performance capabilities to their fullest (Moyers & Christiansen, 2004).
• Low Vision: Occupational therapists help clients use their remaining vision to complete their daily routines with compensation, remediation, disability prevention and health promotion. Compensations or that modifications to the environment may include proper lighting, color contrast, reducing clutter and education on adaptive equipment (Golembiewski, 2004).
• Intermediate care services
• Driving Centers: Driving is an instrumental activity of daily living and an occupational therapist may evaluate and treat skills needed to drive such as vision, executive function or memory. If a client needs more skilled assessment and training they would refer them to an OT Driver Rehabilitation Specialist which could do on the road assessment, training in adaptive equipment and make more specific recommendations.
• Day centres
• Schools
• Child development centres
• People's own homes, carrying out therapy and providing equipment and adaptations
• Work and Industry: To be a healthy successful worker there must be a person environment fit between the task, the equipment, and the person’s skills. Occupational therapists work to achieve that fit (Ellexson, 2000; Clinger, Dodson, Maltchev, & Page, 2007). Populations, conditions, and diagnoses: People of working age and ability who have been born with or developed a condition, injury, or illness that compromises their ability to work (Ellexson, 2000; Clinger, Dodson, Maltchev, & Page, 2007). Settings: Return to work programs, large organizations, consultants to large organizations, work hardening programs, work conditioning programs, transitional return to work programs (Ellexson, 2000; Clinger, Dodson, Maltchev, & Page, 2007). Typical issues addressed: assessment of ability to work, interventions to enhancing work performance by means of work hardening, work conditioning, and improvement of ergonomics in the workplace, identification of accommodations necessary to return-to-work following illness or injury, prevention of work related injury, illness, or disability (Ellexson, 2000; Clinger, Dodson, Maltchev, & Page, 2007).
• Homeless Shelters
• Educational Settings
• Refugee Camps

New Emerging Practice Areas for Therapy

• Children & Youth:
  • Psychosocial Needs of Children & Youth
• Health & Wellness:
  • Health & Wellness Consulting
  • Design & Accessibility Consulting & Home Modification
  • Ergonomic Consulting
  • Private Practice Community Health Services
• Productive Aging:
  • Driver Rehabilitation & Training
  • Low Vision Services
• Rehabilitation, Disability, & Participation:
  • Technology & Assistive Device Development & Consulting
• Work & Industry:
  • Ticket to Work Services
  • Welfare to Work Services

Occupational therapy approaches

Services typically include:

• Teaching new ways of approaching tasks
• How to break down activities into achievable components eg sequencing a complex task like cooking a complex meal
• Comprehensive home and job site evaluations with adaptation recommendations.
• Performance skills assessments and treatment.
• Adaptive equipment recommendations and usage training.
• Environmental adaptation including provision of equipment or designing adaptations to remove obstacles or make them manageable
• Guidance to family members and caregivers.
• The use of creative media as therapeutic activity

Activity analysis

Activity analysis has been defined as a process of dissecting an activity into its component parts and task sequence in order to identify its inherent properties and the skills required for its performance, thus allowing the therapist to evaluate its therapeutic potential

Therapeutic activity

Occupational therapists use therapeutic activity or therapeutic occupation to improve an individual's occupational performance and increase function in activities of daily living (ADLs).

A core and unique feature of occupational therapy practice is the use of occupation as a therapeutic medium. An occupational therapy core skill as defined by The College of Occupational Therapists (COT) is the use of activity as a therapeutic tool.

Occupational therapists have utilized activities, such as crafts, since the profession was founded. The arts and crafts movement in the very early 20th century had ascertained that goal directed activity had a curative effect on the social problems inherent in the newly industrialized societies. The founders of the occupational therapy profession extended this thinking to the treatment of individuals' with mental health problems and as a consequence between 1920 and 1940 much of occupational therapy practice concentrated around the use of crafts as purposeful activities. The emergence of occupational therapy in physical medicine began during World War II and craft activities were utilized to rehabilitate injured soldiers. This method of practice was later termed by Mosey as activity synthesis.

Activity synthesis or occupational synthesis is the core of occupational therapy practice; occupational therapists, in collaboration with clients, design occupational forms to produce a therapeutic occupation or activity, that is meaningful and purposeful to the client. The therapeutic activity or occupation may be used to assess the client’s occupational needs or to achieve a therapeutic goal. The component parts of an activity or occupation are matched with the required occupational performance outcomes. For example, the muscle movements elicited by pottery may address fine motor and gross motor skills to improve shoulder flexion and extension, range of movement and elbow extension and flexion..

Other therapeutic activities or occupations may include cookery activities, such as making a smoothie or a healthy soup. The components of this activity such as planning and following a recipe may address cognitive components of occupational performance such as problem solving, sequencing and learning. Health may be promoted through this occupation, enabling clients to consider healthy eating issues. Occupational therapists may further use therapeutic activities or occupations to assess occupational performance. For example, an occupational therapist may ask a client to make a cup of tea or prepare a simple meal to assess performance in activities of daily living (ADLs). An occupational therapist may use a board or card game to assess cognitive components of occupational performance. This application of therapeutic activity/occupation involves use of the core skills of the occupational therapist, chiefly assessment and problem solving.

Theoretical Frameworks

Occupational Therapists use a number of theoretical frameworks to frame their practice. Note that terminology has differed between scholars. Theoretical bases for framing a human and their occupation being include the following:

Frames of Reference/Generic models

Frames of reference or generic models are the overarching title given to a collation of compatible knowledge, research and theories that form conceptual practice. More generally they can be defined as "those aspects which influence our perceptions, decisions and practice".

Occupational Therapy Frame of References/Models:

• Person Environment Occupation Performance Model (PEOP)
• Model of Human Occupation (MOHO)
• Canadian Model of Occupational Performance (CMOP)
• Biomechanical
• Rehabilitative (compensatory)
• Cognitive Disabilities
• Sensory Integration
• Lifestyle Performance Model (Fidler)

Approaches/Intervention models

These are the methods of carrying out the Frames of Reference. Again, terminology differs depending on your viewpoint and literature base. Using the above author (), approaches can include the Adaptive (based on the compensatory Frame of Reference),

United States

Education Requirements

In many countries, occupational therapists are educated at the baccalaureate level. However, currently in United States and Canada, entry level is at the master’s level. This change occurred in 2007, requiring all occupational therapists who started their educational program after 2007 to continue their education beyond a four-year degree. Currently, six schools in the US offer a clinical doctorate for those who would like to further their education past the Master’s level.

All occupational therapists have a well-rounded knowledge of biomedical, behavioral, environmental and occupational scientists. Occupational therapist base their interventions on the knowledge based on neuroscience, anatomy, applied technology, policy and environmental strategies.

These schools are currently accredited for Master’s level education: [2]

These schools are currently accredited for Doctoral level education: [3]

Employment

According to the Bureau of Labor Statistics, occupational therapists held 99,000 positions in 2006 (2009). States with the most licensed and employed occupational therapists are California, New York, Pennsylvania and Ohio. In 2006, 52.6% of occupational therapists worked in hospitals, early intervention facilities and schools (American Occupational Therapy Association, 2006). The Bureau of Labor statistics reported that 78% of occupational therapists worked full-time in 2006 (Bureau of Labor Statistics, 2009). In addition, the median number of years of experience for occupational therapists was 13 years (American Occupational Therapy Association, 2006). Occupational therapists can work in many different settings, some examples include:

• Hospitals
• Schools
• Early intervention facilities
• Skilled nursing facilities
• Home health care services
• Outpatient care centers
• Government agencies
• Private practice

The field of occupational therapy is projected to see faster growth than other careers. The Bureau of Labor Statistics estimates that the number of jobs will grow to 122,000 in 2016 (2009). Areas of occupational therapy that involve helping older adults will see the most growth. This expansion is due to the large need to provide health care services to the aging baby boom generation (American Occupational Therapy Association, n.d.; Bureau of Labor Statistics, 2009). In addition, the area of school-based occupational therapy will see growth as well.

Earnings

According to the Bureau of Labor Statistics, in 2006 the average salary was $60,470 for occupational therapists (2009). The average starting entry-level salary for occupational therapists was $46,300 (American Occupational Therapy Association, n.d.). In 2006, the salaries of occupational therapists in the 50% percentile ranged from $50,450 to $73,710 (Bureau of Labor Statistics, n.d.). Salary varies according to the setting and the following represents average salaries for some practice areas:

Hospitals	$61,610
School setting	$54,260
Nursing care services	$64,750
Home Health care	$67,600
Facilities of physical, occupational Speech therapists	$62,290
(Bureau of Labor Statistics, 2009)

In addition, according to the Work Force Survey conducted by the American Occupational Therapy Association in 2006, average salaries for some other areas include:

Mental Health	$53,750
Academic	$66,000
(American Occupational Therapy Association, 2006)

Challenges for occupational therapy

A key challenge for occupational therapy is to develop and maintain a definition of its nature and scope assert that while this presents a challenge, it also results in a unique flexibility which allows the discipline to move with the flow of social, cultural and environmental change. This difficulty in definition may be a cause of chronic strain for practitioners and may also contribute to a lack of role definition and subsequent blurring

Recent literature has also called for occupational therapy to address the political nature of who occupational therapists are and what they do (Kronenberg & Pollard, 2005).

Occupational therapy and ICF

The International Classification of Functioning, Disability and Health (ICF) is an outcome measure for health and occupation and illustrates how these components impact one’s function. This relates very closely to the Occupational Therapy Practice Framework as it is stated, “The profession’s core beliefs are in the positive relationship between occupation and health and its view of people as occupational beings” (2008). The ICF is also built into the 2nd edition of the practice framework. Activities and participation examples from the ICF overlap Areas of Occupation, Performance Skills, and Performance Patterns in the framework. The ICF also includes contextual factors (environmental and personal factors) that relate to the context in the framework. In addition, Body functions and structures classified within the ICF help describe the client factors as described in the OT framework (AOTA, 2002).

Further exploration of the relationship between occupational therapy and the components of the ICIDH-2 (revision of the original International Classification of Impairments, Disabilities, and Handicaps (ICIDH); later becoming the ICF) was conducted by McLaughlin Gray (2001). First, the ICF is an international framework and provides an opportunity for the occupational therapy field to become better known across the globe. Second, the ICF provides occupational therapists with a global language to describe their expertise to the larger international health care community. The ICF uses a positive, holistic language emphasizing skills, capacities, and strengths of an individual rather than focusing on one’s deficits and disabilities. This is similar to the outlook of occupational therapists. Third, the ICF includes environmental and personal contextual factors which are incorporated into the theory behind occupational therapy. It is important to take into consideration an individual’s personal, environmental, and occupational factors to develop an effective intervention (Christiansen & Baum, 2005). The last notable application of the ICF to occupational therapy is the recognition of cultural patterns in occupation. Culture has significance on an individual’s activities and participation and it is important to keep this in mind when treating an individual.

Although the ICF can be very useful for occupational therapists, it is noted in the literature that occupational therapists should use specific occupational therapy vocabulary along with the ICF in order to ensure correct communication about specific concepts (Stamm, Cieza, Machold, Smolen, & Stucki, 2006). The ICF might lack certain categories to describe what occupational therapists need to communicate to clients and colleagues. It also may not be possible to exactly match the connotations of the ICF categories to occupational therapy terms. The ICF is not an assessment and specialized occupational therapy vocabulary should not be replaced with ICF terminology. (Haglund & Henriksson, 2003). The ICF is an overarching framework on which to hang current therapy practices.

Research Resources for Occupational Therapy

• American Journal of Occupational Therapy (AJOT)
• [British Journal of Occupational Therapy (BJOT)]
• OT Search database (AOTA)
• World Federations of Occupational Therapists (WFOT)
• Australian Occupational Therapy Journal (AOTJ)
• New Zealand Journal of Occupational Therapy (NZJOT)
• Scandinavian Journal of Occupational Therapy (SJOT)

See also

• Occupational apartheid
• Occupational therapist
• Occupational therapy in the United Kingdom
• History of occupational therapy in America
• History of occupational therapy in New Zealand

References

• American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed). American Journal of Occupational Therapy, 62, 625-683.
• American Occupational Therapy Association. (2006). 2006 AOTA workforce and compensation survey: Occupational therapy salaries and job opportunities continue to improve. [Electronic Version]. OT Practice, 11(17), 10-12.
• American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609–639.
• American Occupational Therapy Association. (n.d.). Workforce trends in occupational therapy. Retrieved February 26, 2009 from http://www.aota.org /Educate/EdRes/StuRecruit/Working/ 38381.aspx
• AOTA, 2009. The American Occupational Therapy Association. Retrieved March 24, 2009 from http://www.aota.org/Practitioners/PracticeAreas.aspx.
• AOTA, 2004. “Occupational Therapy and hospice care”. AOTA Official Documents (web page). Retrieved March 30, 2009 from http://www.aota.org/Practitioners/Official.aspx.
• Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2008-09 Edition, Occupational Therapists, on the Internet at http://www.bls.gov/oco/ocos078.htm (visited July 11, 2008).
• Baum C., & Christiansen, C., (1997), The occupational therapy context: Philosophy - Principles - Practice. In C. Christiansen & C. Baum (Eds.), Occupational Therapy: Enabling Function and Well Being. p. 36. Thorofare, NJ: SLACK
• Bing, R.K. (1981) Occupational therapy revisited: A paraphrastic journey. American Journal of Occupational Therapy, 35(8):499-518.
• Cara, E. & MacRae, A. (2005). Psychosocial Occupational Therapy. Canada: Thompson Delmar Learning.
• Centers for Medicare & Medicaid Services. (2005). Medicare benefit policy manual (CMS Publication No. 100-02). Practice of occupational therapy, Chapter 15, Sec. 230.2.
• Christiansen, C.H., & Baum, C.M. (2005). Occupational therapy: performance, participation, and well-being. New Jersey: Slack Inc.
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• Golembiewski, D., (2004). Living with low vision. In C.H. Chrisitiansen & K.M. Matuska (Eds.) Ways of Living: Adaptive Strategies for Special Needs, (pp. 359–382) Bethesda, MD: AOTA Press.
• Haglund, L., & Henriksson, C. (2003). Concepts in occupational therapy. Occupational Therapy International, 10, 253-268.
• Hasselkus, B. R., & Jacques, N. D. (1998). Occupational therapy and hospice. American Journal of Occupational Therapy, 52,872–873.
• Hobcroft, N. (1949). "Life in the Occupational Therapy Department at Porirua." New Zealand Occupational therapy Newsletter Number Two. (May).
• Hofmann, A.O., (2008 June 24). Living life to its fullest: occupational therapy in skilled nursing facility. Retrieved February 2009, from http://www.aota.org/News/Consumer/42008.aspx
• McLaughlin Gray, J. (2001). Discussion of the ICIDH-2 in relation to occupational therapy and occupational science. Scandinavian Journal of Occupational Therapy, 8, 19-30.
• Moyers, P.A. & Christiansen, C.H., (2004). Planning intervention. In C.H. Christiansen & K.M. Matuska (Eds.) Ways of Living: Adaptive Strategies for Special Needs, (pp. 78) Bethesda, MD: AOTA Press.
• New Zealand Occupational Therapy Registration Board (1950). "Minutes of the New Zealand Occupational Therapy Registration Board." 20 June.
• New Zealand Occupational Therapy Registration Board (1970b 17 July). "Minutes of the New Zealand Occupational Therapy Registration Board."
• New Zealand Registered Occupational Therapists Association (1949). "AGM Minutes."
• NZJOT (1996). New Zealand Journal of Occupational Therapy 47(1): 19.
• NZNJ (1940). "Editorial " New Zealand Nursing Journal 33(11): 346.
• Opp Hoffman, A. (2008). “Living life to its fullest: Occupational therapy in skilled nursing facilities.” Retrieved March 30, 2009 from http://www.aota.org/News/Consumer/42008.aspx.
• Packer, T., & Stickney, Jan (1991). "Advanced Diploma in Occupational Therapy: A comparison of therapists before and after." Journal of New Zealand Association of Occupational Therapists Inc. 42(1): 3-7.
• Quiroga, V. A. M. (1995). Occupational Therapy: The First 30 Years, 1900-1930. Bethesda, Maryland: American Occupational Therapy Association, Inc.
• Skilton, H. (1981). Work for your life - the story of the beginning and early years of occupational therapy in New Zealand. Hamilton, Hudlo Printers.
• Stamm, T.A., Cieza, A., Machold, K., Smolen, J.S., & Stucki, G. (2006). Exploration of the link between conceptual occupational therapy models and the International Classification of Functioning, Disability and Health. Australian Occupational Therapy Journal, 53, 9-17.
• Wilcock, A. A. (2005). Relationship of occupations to health and well-being. In C.H. Christiansen, C. M. Baum, and J. Bass-Haugen (Eds.), Occupational therapy: Performance, participation, and well-being (3rd ed.). Thorofare, NJ: SLACK Incorporated.
• Wilson, L. H. (2004). Role differentiation in a professionalising occupation: the case of occupational therapy, New Zealand Department of Management Dunedin University of Otago PhD.
• Yamkovenko, S., (2008, December 4). Occupational therapy: helping America age in place. Retrieved February 2009, from http://www.aota.org/News/Centennial/40313/Aging/Aging-in-Place.aspx

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