Occupational therapy (OT) focuses on self-care activities and improvement of fine motor coordination of muscles and joints, particularly in the upper extremities. Unlike physical therapy, which focuses on muscle strength and joint range of motion, OT focuses on activities of daily living (ADLs) because they are the cornerstone of independent living. Basic ADLs (BADLs) include eating, dressing, bathing, grooming, toileting, and transferring (ie, moving between surfaces such as the bed, chair, and bathtub or shower). Instrumental ADLs (IADLs) require more complex cognitive functioning than BADLs. IADLs include preparing meals; communicating by telephone, writing, or computer; managing finances and daily drug regimens; cleaning; doing laundry, food shopping, and other errands; managing finances; traveling as a pedestrian or by public transportation; and driving. Driving is particularly complex, requiring integration of visual, physical, and cognitive tasks.

Evaluation: OT can be initiated when a physician writes a referral for rehabilitation, which is similar to writing a prescription. The referral should be detailed, including a brief history of the problem (eg, type and duration of the disorder or injury) and establishing the goals of therapy (eg, training in IADLs). Lists of occupational therapists may be obtained from a patient's insurance carrier, a local hospital, the telephone book, state occupational training organizations, or the web site of the American Occupational Therapy Association.

Patients are evaluated for limitations that require intervention and for strengths that can be used to compensate for weaknesses. Limitations may involve motor function, sensation, cognition, or psychosocial function. Examiners determine which activities (eg, work, leisure, social, learning) patients want or need help with. Patients may need help with a general type of activity (eg, social) or a specific activity (eg, attending church), or they may need to be motivated to do an activity. Therapists may use an assessment instrument to help in the evaluation. One of the many functional assessment instruments is described in Table 3: Rehabilitation: Katz Activities of Daily Living Scale. Patients are asked about their social and family roles, habits, and social support systems. The availability of resources (eg, community programs and services, private attendants) should be determined.

Table 3
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Katz Activities of Daily Living Scale Activity Item Score Eating Eats without assistance 2 Needs assistance only in cutting meat or buttering bread 1 Needs assistance in eating or is fed intravenously 0 Dressing Gets clothes and dresses without assistance 2 Needs assistance only in tying shoes 1 Needs assistance in getting clothes or in getting dressed or stays partly or completely undressed 0 Bathing (sponge bath, tub bath, shower) Bathes without assistance 2 Needs assistance only in bathing one part of the body (eg. back) 1 Needs assistance in bathing more than one part of the body or does not bathe 0 Transferring Moves in and out of bed and chair without assistance (may use cane or walker) 2 Needs assistance in moving in and out of bed or chair 1 Does not get out of bed 0 Toileting Goes to the bathroom, uses toilet, cleans self, arranges clothes, and returns without assistance (may use cane or walker for support and may use bedpan or urinal at night) 2 Needs assistance in going to the bathroom, using toilet, cleaning self, arranging clothes, or returning 1 Does not go to the bathroom to relieve bladder or bowel 0 Continence Controls bladder and bowel completely (without occasional accidents) 2 Occasionally loses control of bladder and bowel 1 Needs supervision to control bladder or bowel, requires use of a catheter, or is incontinent 0 Modified from Katz S, Downs TD, Cash HR, et al: Progress in the development of the index of ADL. Gerontologist 10:20-30, 1970. Copyright The Gerontological Society of America. Katz Activities of Daily Living Scale Activity Item Score Eating Eats without assistance 2 Needs assistance only in cutting meat or buttering bread 1 Needs assistance in eating or is fed intravenously 0 Dressing Gets clothes and dresses without assistance 2 Needs assistance only in tying shoes 1 Needs assistance in getting clothes or in getting dressed or stays partly or completely undressed 0 Bathing (sponge bath, tub bath, shower) Bathes without assistance 2 Needs assistance only in bathing one part of the body (eg. back) 1 Needs assistance in bathing more than one part of the body or does not bathe 0 Transferring Moves in and out of bed and chair without assistance (may use cane or walker) 2 Needs assistance in moving in and out of bed or chair 1 Does not get out of bed 0 Toileting Goes to the bathroom, uses toilet, cleans self, arranges clothes, and returns without assistance (may use cane or walker for support and may use bedpan or urinal at night) 2 Needs assistance in going to the bathroom, using toilet, cleaning self, arranging clothes, or returning 1 Does not go to the bathroom to relieve bladder or bowel 0 Continence Controls bladder and bowel completely (without occasional accidents) 2 Occasionally loses control of bladder and bowel 1 Needs supervision to control bladder or bowel, requires use of a catheter, or is incontinent 0 Modified from Katz S, Downs TD, Cash HR, et al: Progress in the development of the index of ADL. Gerontologist 10:20-30, 1970. Copyright The Gerontological Society of America.

Occupational therapists may also assess the home for hazards and make recommendations to ensure home safety (eg, removing throw rugs, increasing hallway and kitchen lighting, moving a night table within reach of the bed, placing a family picture on a door to help patients recognize their room).

Determining when driving is a risk and whether driver retraining is indicated is best done by occupational therapists with specialized training. Information that can help elderly drivers and their caregivers in coping with changing driving abilities is available from the American Occupational Therapy Association and the American Association for Retired Persons.

Interventions: OT may consist of one consultation or frequent sessions of varying intensity. Sessions may occur in various settings:

• Acute care, rehabilitation, outpatient, adult day care, skilled nursing, or long-term care facilities
• The home (as part of home health care)
• Senior housing developments
• Life-care or assisted-living communities

Occupational therapists develop an individualized program to enhance patients' motor, cognitive, communication, and interaction capabilities. The goal is not only to help patients do ADLs but also to do appropriate preferred leisure activities and to foster and maintain social integration and participation.

Before developing a program, a therapist observes patients doing each activity of the daily routine to learn what is needed to ensure safe, successful completion of the activities. Therapists can then recommend ways to eliminate or reduce maladaptive patterns and to establish routines that promote function and health. Specific performance-oriented exercises are also recommended. Therapists emphasize that exercises must be practiced and motivate patients to do so by focusing on exercise as a means of becoming more active at home and in the community.

Patients are taught creative ways to facilitate social activities (eg, how to get to museums or church without driving, how to use hearing aids or other assistive communication devices in different settings, how to travel safely with or without a cane or walker). Therapists may suggest new activities (eg, volunteering in foster grandparent programs, schools, or hospitals).

Patients are taught strategies to compensate for their limitations (eg, to sit when gardening). The therapist may identify various assistive devices that can help patients do many activities of daily living (see Table 4: Rehabilitation: Assistive Devices). Most occupational therapists can select wheelchairs appropriate for patients' needs and provide training for upper-extremity amputees. Occupational therapists may construct and fit devices to prevent contractures and treat other functional disorders.

Table 4
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Assistive Devices Problem Device Balance problems or weak legs Grab bars on the side and back of the bathtub or toilet Inability to stand for a long time because of weakness or dizziness Shower chairs Balance problems or difficulty getting in and out of the bathtub because of pain or weakness in the legs Bathtub benches Difficulty standing up Raised toilet seats and chair leg extenders (which make the chair's seat higher) Weak grip Eating utensils, shoehorns, and other tools with large, built-up handles Tremors Weighted eating utensils, cups with lids, and swivel spoons Coordination problems Plates with rims and rubber grips (to prevent slipping) Difficulty reaching or limited movement Grabbers that can pick items off the floor or from a shelf Hand problems Tools with spring-loaded or electronic controls Limited movement or coordination Devices that turn electrical appliances (eg, lamps, radios, fans) on or off at the sound of the voice Paralysis of arms or legs or other disorders that greatly limit function Computer-assisted devices Impaired vision Larger dials on telephones and large-print or audio books Hearing loss Telephones and doorbells that display a flashing light when they ring Difficulty remembering Automatic dialing on a telephone, devices that remind people when to take a drug, and pocket devices that record and play back messages (reminders, instructions, lists) at the appropriate time Assistive Devices Problem Device Balance problems or weak legs Grab bars on the side and back of the bathtub or toilet Inability to stand for a long time because of weakness or dizziness Shower chairs Balance problems or difficulty getting in and out of the bathtub because of pain or weakness in the legs Bathtub benches Difficulty standing up Raised toilet seats and chair leg extenders (which make the chair's seat higher) Weak grip Eating utensils, shoehorns, and other tools with large, built-up handles Tremors Weighted eating utensils, cups with lids, and swivel spoons Coordination problems Plates with rims and rubber grips (to prevent slipping) Difficulty reaching or limited movement Grabbers that can pick items off the floor or from a shelf Hand problems Tools with spring-loaded or electronic controls Limited movement or coordination Devices that turn electrical appliances (eg, lamps, radios, fans) on or off at the sound of the voice Paralysis of arms or legs or other disorders that greatly limit function Computer-assisted devices Impaired vision Larger dials on telephones and large-print or audio books Hearing loss Telephones and doorbells that display a flashing light when they ring Difficulty remembering Automatic dialing on a telephone, devices that remind people when to take a drug, and pocket devices that record and play back messages (reminders, instructions, lists) at the appropriate time

Last full review/revision February 2009 by Mathew H. M. Lee, MD; Alex Moroz, MD, FACP

Content last modified February 2012