Here you will find resources on various OT topics
including OT assessments, evaluation tips, treatment ideas, and integrative health!
Diplopia Exercises in OT
Double vision, or diplopia, can significantly impact a patient’s ability to perform daily activities safely and independently. As occupational therapists, especially in acute care or neuro settings, we often encounter patients struggling with diplopia due to stroke, TBI, cranial nerve palsies, or other neurological conditions.
This post covers how OTs can support recovery through functional, evidence-informed exercises that improve visual skills and safety.
What Causes Diplopia?
Diplopia occurs when the eyes don’t align properly, leading to two images instead of one. It can be:
Binocular (resolves when one eye is covered – common in nerve palsies)
Monocular (often related to corneal or lens issues – usually ophthalmology managed)
Common causes in OT settings include:
CN III, IV, or VI palsy
Brainstem stroke or TBI
Decompensated strabismus
Post-surgical changes
OT’s Role in Managing Diplopia
While vision therapy and prism prescription are often handled by optometry or neuro-ophthalmology, occupational therapists address functional implications and provide compensatory strategies and graded visual-motor exercises within scope.
Functional OT Exercises for Diplopia
OT interventions to use based on patient tolerance and acuity:
1. Eye Patching or Spot Patching
For binocular diplopia, temporary occlusion can reduce symptoms during functional tasks.
Use a translucent spot patch over the non-dominant eye’s glasses lens to allow light in but block double images.
Apply only during high-risk tasks (e.g., eating, transfers) to avoid over-reliance.
Tip: Avoid full patching long-term—it can promote suppression and worsen alignment.
2. Pencil Push-Ups
Great for convergence insufficiency and mild cranial nerve palsies.
Hold a pencil at arm’s length.
Focus on the tip and slowly bring it toward the nose until double vision occurs.
Pause, then return to starting position.
Repeat 5–10 reps, 2–3x/day.
3. Eye Tracking and Scanning
Targets oculomotor coordination and compensatory awareness.
Tasks:
Follow a moving target (pen light or colored dot) in H and X patterns.
Use letter or number find activities (e.g., word searches, scanning worksheets).
Track an object while maintaining head still.
4. Functional Activities with Controlled Visual Demands
Integrate eye work into daily tasks:
Sorting laundry (find matching socks)
Wiping surfaces (visual scanning)
Folding towels (depth perception)
Reaching for labeled items (eye-hand coordination)
Start seated with large items and progress to standing with smaller, complex visuals.
5. Balance and Gaze Stabilization
For patients with diplopia and dizziness (common post-TBI):
Have the patient fix their gaze on a target while moving their head side-to-side.
Add walking while focusing on a fixed point.
Gradually increase visual and vestibular demand.
Cognitive + Vision Integration
Many patients with diplopia also have attention or memory deficits. Combine tasks:
Find the number “5” in a grid of numbers while scanning (attention)
Recall items found in a visual search (memory)
Cook a simple recipe while tracking ingredients visually
Documentation Sample
“Pt presents with binocular diplopia post-CVA. Completed 10 min of visual scanning and convergence activities with increased compensatory head movements noted. Spot patch applied to L lens for meal setup task, improving performance and safety. Recommend continuation of oculomotor exercises and further vision rehab referral.”
The Clock Drawing Test: A Quick Cognitive Assessment as an OT
As an occupational therapist in acute care, you often need fast, effective tools to assess cognition—especially when time is limited, and your patient might be fatigued, medically complex, or preparing for discharge. One powerful and simple screening tool? The Clock Drawing Test (CDT).
What Is the Clock Drawing Test?
The Clock Drawing Test is a brief cognitive screening tool that evaluates multiple brain functions, including:
Executive functioning
Visual-spatial skills
Numerical understanding
Attention and memory
Motor planning
It’s a quick way to flag potential impairments in patients who may otherwise appear alert and oriented.
How to Administer the CDT
Supplies: Paper and pen/pencil - click here for template
Instructions to the Patient:
“Draw a clock. Put in all the numbers, and set the hands to 10 past 11.”
This specific time (11:10) is recommended because it requires the patient to distinguish two different hand lengths and mentally organize spatial and numerical layout.
What You’re Observing
You’re not just looking at whether they can draw a clock — you're analyzing how they organize information, plan, and execute the task.
Look for:
Are all 12 numbers present and spaced appropriately?
Are the numbers in the correct sequence?
Do the hands clearly represent the time?
Are the hands pointing in the right direction, and is the minute hand longer?
Does the clock resemble a circle?
Why It’s Useful in Acute Care
In acute care, your patient might:
Be recovering from a stroke, delirium, or TBI
Have underlying dementia or neurological changes
Be medically stable but showing subtle signs of confusion or poor safety awareness
How to document
“Clock Drawing Test completed per verbal instructions. Patient placed numbers 1–12 in correct order but spacing was uneven. Hands were placed correctly to indicate 11:10. Minor visual-spatial deficits noted. Results suggest mild cognitive impairment; further evaluation recommended.”
OR
“CDT revealed significant cognitive deficits. Only 8 numbers placed; hands not drawn. Indicates poor executive functioning and visual-spatial processing; OT to continue cognitive assessment and monitor safety with ADLs.”
Testing Proprioception in the Hospital Setting as an OT
Proprioception was first identified in 1826 by a Scottish physiologist, Charles Bell. Bell wrote that “between the brain and the muscles there is a circle of nerve; one nerve (ventral roots) coveys the influence from the brain to the muscle, another (dorsal roots) gives the sense of the condition of the muscle to the brain.” Bell views “muscular sense” to a closed-loop system between the brain and the muscles: the afferent pathway from the brain to the muscles (Han et al., 2014).
Fast forward sixty years later, Henry Bastian, an English anatomist and pathologist introduced the term “kinaethesia” derived from two Greek words “kinein” (move) and “aisthesis” (sensation). Then, in 1960, the English Neurophysiologist Sir Charles Sherrington coined “proprioception” from a combination of the Latin “proprius” (one’s own) and “perception” to give a term for the sensory information derived from (neural) receptors embedded in joints, muscles, and tendons, that enable a person to know where parts of the body are located at any time (Han et al., 2014).
He (Bastian) referred to proprioception as “the perception of joint and body movement as well as position of the body, or body segments, in space.”
What causes poor proprioception?
Injuries or medical conditions that affect the neuromuscular system (muscles, nerves, and the cerebellum)
Consumption of alcohol
Age-related changes
How to Assess
Check level of arousal and cognition.
Ensure clearance for movement (check vitals, lines/tubes, etc.).
Explain what you are doing and why.
Avoid visual cues by asking the patient to close their eyes or look away.
Quick Proprioception Tests (UE-focused)
These are ideal when working at bedside or during an early mobility session.
1. Thumb-Find Test
Ask the patient to close their eyes.
Move their affected arm into space (e.g., above head or out to the side).
Ask them to use their unaffected arm to find and pinch their thumb.
Interpretation: Poor proprioception if they miss or hesitate significantly.
2. Joint Position Sense (JPS) Test
Test one joint at a time (commonly fingers, wrist, elbow).
Method:
Stabilize proximally (e.g., hold forearm while testing finger).
Move the distal segment up or down slowly.
Ask: “Is your [finger/wrist/elbow] going up or down?”
Test Bilaterally for comparison.
3. Mirroring Test (Matching)
Move the uninvolved limb to a position.
Ask the patient to match that position with their involved limb (eyes closed).
Common joints to test:
Shoulder abduction/flexion
Elbow flexion
Wrist extension
Clinical Tips:
Start distally (fingers/toes) and move proximally if deficits are found.
Observe for compensations (visual reliance, muscle guarding).
Document which joints were tested, method, and accuracy.
Relate findings to functional tasks (e.g., difficulty with feeding or transfers).
Reference:
Han, J., Waddington, G., Adams, R., Anson, J., & Liu, Y. (2016). Assessing proprioception: A critical review of methods. Journal of sport and health science, 5(1), 80–90. https://doi.org/10.1016/j.jshs.2014.10.004
Diagnosis-Specific Intervention Ideas in Acute and Inpatient Settings
Here are a few diagnosis-specific intervention ideas in acute and inpatient settings:
Neurological Conditions
1. Stroke (CVA)
Bed mobility, ADL retraining
Hemiplegia management (positioning, one-handed techniques)
Visual-perceptual training
Cognitive assessment and compensatory strategies
UE motor recovery and tone management
2. Traumatic Brain Injury (TBI)
Cognitive stimulation and orientation
ADLs with cues/adaptations
Sensory regulation
Splinting for contracture prevention
Family education
3. Spinal Cord Injury (SCI)
Pressure relief education
Adaptive techniques for self-care
UE strengthening and coordination
Bowel/bladder routine training
Assistive technology introduction
4. Seizure Disorders
Activity tolerance building
Safety education
Cognitive screening
Seizure precautions during ADLs
5. Brain Tumor / Neurosurgery
Fatigue management
Executive function tasks
Equipment needs for ADL independence
Visual scanning and balance retraining
Cardiopulmonary Conditions
6. Congestive Heart Failure (CHF)
Energy conservation techniques
Pacing strategies during ADLs
Education on safe exertion levels (MET levels)
Monitoring vitals with activity
7. Myocardial Infarction (MI) / CABG
Sternal precautions education
Light ADL retraining with monitoring
Adaptive techniques to avoid strain
Home safety education
8. COPD / Respiratory Failure
Pursed-lip breathing with tasks
Dyspnea control techniques
Education on oxygen use with mobility
Simplified self-care routines
Orthopedic Conditions
9. Hip Fracture / Hip Replacement
Hip precautions education
Bed, toilet, and chair transfers
ADL training with adaptive equipment
Fall prevention strategies
10. Spinal Surgery (Laminectomy, Fusion)
Log rolling and spinal precautions
Body mechanics during tasks
ADL retraining with equipment
Adaptive strategies for dressing and bathing
11. Shoulder Surgery
One-handed ADL techniques
Donning/doffing sling
Passive ROM within protocol
Pain management techniques
Medical/Surgical Conditions
12. Sepsis / Multi-organ Failure
Tolerance-building activities
Delirium prevention (orientation, stimulation)
Basic self-care retraining
Positioning to prevent skin breakdown
13. Oncology (Chemotherapy, Post-Surgery)
Fatigue management
Light ADLs and mobility
Pain control strategies
Psychosocial support
14. Burns
Splinting and positioning
Edema control
Scar management
Gentle ADLs
ICU / Critical Care Diagnoses
15. Prolonged Ventilation / Tracheostomy
Basic grooming and hygiene
Positioning for pulmonary hygiene
ROM and early mobility
Communication alternatives (AAC boards)
16. Delirium / Encephalopathy
Sensory stimulation
Orientation activities
Family education
Sleep-wake regulation support
Chronic or Systemic Conditions
17. End-Stage Renal Disease (ESRD)
Energy conservation
ADL retraining around dialysis
UE strengthening
Education on skin integrity
18. Diabetes Complications (e.g., Neuropathy, Amputations)
Foot care education
Adaptive dressing/bathing
Amputation care and desensitization
ADL retraining with DME
Geriatric Syndromes
19. Falls / Deconditioning
Fall recovery techniques
Bed-to-chair transfers
Strengthening through function
Home setup planning
20. Dementia
Routine-based ADLs
Environmental cueing
Caregiver training
Engagement in familiar tasks
Working in acute care as an OT is equal parts challenging and rewarding. You're constantly adapting, thinking on your feet, and learning how to support patients from all walks of life during some of their hardest days.
If you're an OT student, a new grad, or just OT-curious, I hope this gave you a clearer picture of the types of diagnoses we see in acute care and how we help people get back to doing what matters most.
Got questions or want to hear more day-in-the-life stories? Drop a comment or shoot me a message—I'd love to chat!
Evaluating Stroke in the Acute Care Setting
Stroke Evaluation in the Acute Care Setting
Evaluating a patient who has experienced a stroke in the acute care setting is a complex process. As occupational therapists (OTs), our role is to assess various domains that affect patient function and quality of life. I have listed the top 10 key areas to focus on during the evaluation of patients diagnosed with stroke or presenting with stroke-like symptoms in the acute care setting.
1. Assess Motor Function
Motor evaluation begins with assessing the patient’s overall motor control and voluntary movement patterns during normal daily activities.
Areas that should be addressed include:
Functional ability of the arms and legs during engagement in ADLs
Self protection of the arm
Skin integrity
Tone and spasticity
OT assessment measuring tone: Modified Ashworth Scale
“The modified Ashworth scale is a muscle tone assessment scale used to assess the resistance experienced during passive range of motion, which does not require any instrumentation and is quick to perform” (Harb & Kishner, pgs. 358-359, 2023).
0: No increase in muscle tone
1: Slight increase in muscle tone, with a catch and release or minimal resistance at the end of the range of motion when an affected part(s) is moved in flexion or extension
1+: Slight increase in muscle tone, manifested as a catch, followed by minimal resistance through the remainder (less than half) of the range of motion
2: A marked increase in muscle tone throughout most of the range of motion, but affected part(s) are still easily moved
3: Considerable increase in muscle tone, passive movement difficult
4: Affected part(s) rigid in flexion or extension (Harb & Kishner, pgs. 358-359, 2023).
2. Assess Range of Motion
Joint mobility can be affected by both neurological and mechanical factors post-stroke. OTs should measure active and passive ROM in the affected and unaffected limbs, noting any limitations. Strength assessments, typically using manual muscle testing or handheld dynamometry, help gauge the muscle’s capacity to perform functional tasks.
Assess proximal/ distal range of motion because they often return at different rates.
Range of motion should be documented in terms of 0, 1/4, 1/2, 3/4, and full versus ACTUAL degrees.
To improve shoulder ROM, support the hemiplegic or weak arm by holding the humerus approximately 4 inches away from the axialla while maintaining ER with the thumb pointing up towards the ceiling (Smith-Gabai & Holm, p. 360, 2017).
Do NOT test strength on a patient with stroke/ neurological deficits unless the movement appears to be normal.
3. Ask Pain
In individuals diagnosed with stroke, approximately 11% of patients will develop chronic pain for various reasons (e.g., central, subluxation, spasticity, etc) (Smith-Gabai & Holm, p. 360, 2017).
Always assess pain when you are evaluating a patient and ask the location as well as a description of the pain.
4. Assess for a Shoulder Subluxation
Shoulder subluxation, common post-stroke, requires careful assessment. Observing the patient's posture and palpating the shoulder complex can help identify any displacement of the humeral head. Early intervention strategies, including education on positioning and potential use of slings or supports, can reduce complications associated with subluxation.
To test for subluxation, you use the finger-breadth palpation method used for quantifying the size of the subluxation.
Teach the patient’s family proper positioning and precautions. Post written instructions in the patient’s room with pictures to illustrate the arm supported in bed, and when sitting up in a chair (Smith-Gabai & Holm, p. 361, 2017).
Click this link for an explanation of shoulder subluxation and ways to manage symptoms following a stroke. I am not affiliated with Post Stroke on Youtube. I have provided this link for educational purposes only. The video was created by Elyse Newland, an Occupational Therapist.
Image retrieved from ProHealthClinic, 2023
5. Range of Motion Precautions
Specific precautions regarding range of motion should be established based on the individual patient's condition. For example, individuals with significant hemiparesis may have contraindications related to shoulder ROM.
The following information retrieved from (Smith-Gabai & Holm, p. 361, 2017):
The patient must have at least 45 degrees of external rotation with the shoulder fully abducted before evaluating the arm.
The shoulder should not be passively moved beyond 90 degrees of flexion and abduction unless the scapula is upwardly rotated and the humerus is externally rotated.
External rotation to 45 degrees becomes the primary issue with the emergence of flexor synergistic patterning. Without 45 degrees of external rotation the patient will not be able to lift the arm. Limitation in external rotation, have been shown to be a high predictor of developing hemiplegic shoulder pain.
Do not use pulleys with unstable, weak, or flaccid shoulders. They will contibute to shoulder tissue injury becuase the shoulder typically is not properly aligned, nor does it have the stabilizing capability for proper kinematics.
PROM training for families should include instruction of no PROM past 90 degrees so as to minimize painful pathologies as synergistic patterning emerges. Families will need education on proper PROM to avoid extreme flexion or abduction of the hemiplegic UE. Maintaining ER at least 45 degrees is imperative for long-term recovery. If time is available for only exercise or stretch choose external rotation.
6. Utilize Principles of Neuroplasticity
In evaluating cognitive functioning, it's essential to understand the principles of neuroplasticity, which underline the brain’s capacity to reorganize and adapt following injury. OTs should assess the patient's previous engagement in therapeutic activities and their current capacity to participate in interventions that stimulate neuroplastic changes.
Educate the patient and caregiver about how changes in the brain and motor recovery occur even in the early stages of acute rehab.
Examples of interventions to encourage neuroplastiticy include:
Using the affected hand to perform part of a sponge bath.
Self-feeding finger foods.
Sitting on the edge of the bed to increase alterness.
Encourage the caregivers to stand on the affected side to encourage visual attention (Smith-Gabai & Holm, p. 361, 2017).
Weight-bearing activities on the affected upper extremity.
7. Evaluate Sensation
Sensation should be comprehensively evaluated given its role in motor recovery and functional independence.
For a low-level patient who is minimally concsious or comatose, pain assessment can be performed using nail bed pressure, tugging or pinching the ear or arm, or a sternal rub.
A screening method to asses proprioception:
Have the patient flex both shoulders to 90 degrees, close their eyes, and name 5 states. If the patient’s affected arm drifts ask them if their arm is still in the same place. If the answer is yes, then proprioception is likely impaired (Smith-Gabai & Holm, p. 361, 2017).
8. Utilize Splinting
The use of splints can be beneficial in maintaining optimal positioning, facilitating movement, and preventing contractures. OTs should assess the need for custom or pre-fabricated splints based on the patient's specific limitations and goals.
Reasons that necessitate a splint include increasing tone with the fingers flexed so tightly that palmar skin integrity is at risk, edema, fracture, or nerve palsy.
If a splint is necessary, consider using a volar-based resting mitt splint with the wrist in neutral or slightly extended position, fingers minimally flexed and the thumb abducted. This allows for a reflex-inhibiting posture for flexor synergistic tone and can be modified later as needed (Smith-Gabai & Holm, p. 363, 2017).
Consider wearing splint wear for nighttime with limited day time wear (at most 4 hours). Coordinate the splint wear schedule to meet the needs of the patient and the nursing staff. This schedule allows nurses time to put on and take off the splint when they are doing their initial assessments at shift change and during neuro checks every 4 hours (Smith-Gabai & Holm, p. 363, 2017).
9. Assess Cognition
A thorough cognitive assessment is essential for understanding the patient’s readiness to participate in rehabilitation. Evaluating levels of consciousness, attention, memory, executive function, and direction following can help OT’s tailor interventions appropriately. Typically in the acute care setting, cognition is evaluated through functional task performance (participation in ADLs) (Smith-Gabai & Holm, p. 363, 2017). Most often, it is important to ask orientation questions: person, place, time, situation.
Person: “Can you confirm your name and date of birth?”
Time: “What year is it?”
Place: “What State are you in?” “Where are you right now?”
Situation: “Can you tell me why you are in the hospital?”
10. Assess Safety/ Judgment
Lastly, assessing the patient’s safety judgment is crucial, particularly when planning for discharge. Evaluating their insight into their condition, decision-making skills, and ability to follow through with safety measures is essential prior to discharge.
The evaluation of stroke patients in the acute care setting is multifaceted, requiring OTs to gather comprehensive information across multiple domains. By addressing motor function, sensation, cognition, and safety considerations, we can create individualized rehabilitation plans that promote optimal recovery outcomes. Effective evaluations not only help inform immediate care but also lay the foundation for continued rehabilitation as patients progress in their recovery journey!
Please let me know if you have any questions in the comments below or email me at juliannemadeline.ot@gmail.com
References
Harb, A., Kishner, S. (2023). Modified Ashworth Scale. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK554572/#:~:text=The%20modified%20Ashworth%20scale%20is%20a%20muscle%20tone%20assessment%20scale,and%20is%20quick%20to%20perform.
Smith-Gabai, H & Holm, S. (2017). Occupational Therapy in Acute Care 2nd Ed. AOTA Press.
An Occupational Therapist’s Guide to Shoulder Arthroplasty in the Acute Care Setting
Disclaimer
This information is for educational purposes only and is not intended to treat, diagnose, or cure any illness or disease. If you are someone who recently underwent a total shoulder replacement, talk with your doctor and occupational therapist (OT) before participating in any of these exercises. If you are an OT, OT student, or any other health care professional, ensure that you modify these exercises to meet your patient's specific and individual needs.
Whether you’re a new graduate occupational therapist (OT), an OT student, or a health care professional, this blog post is intended to provide introductory knowledge for evaluating and treating patients who have undergone a shoulder replacement. I recently started a job working in the acute care setting, and evaluate and treat joints (shoulder, knee, hip) often. Through my training, research, and experience I use a one-two day protocol with the patients who are admitted. (length of stay typically depends on the doctor). Here is the typical format I follow.
Also, another disclaimer is that each hospital has its own protocols and policies, and each patient has unique needs and goals for therapy! This protocol is based on my training as a new hire, my experiences, and the research I have accumulated.
Post-Operation Day One
Chart review
Check MD’s therapy orders: precautions, weight-bearing status (typically non weight-bearing (NWB)).
Upon entering the patient’s room ask about their:
Pain (*If greater than a 6/10 call/notify RN and ask when pain meds were last issued)
Sensation (upper extremity sensation deficits are common due to nerve block)
Dizziness (dizziness/ nausea is common due to medications)
Ask the patient questions regarding their pain, prior level of function, home environment, adaptive equipment, etc.
Educate the patient/ caregiver about:
Their specific weight-bearing precautions ordered from their doctor (MD) - usually non-weight bearing
Safe positioning - (patient’s elbow supported on pillow and wearing shoulder immobilizer).
*Research suggests a neutral rotation sling with an abduction pillow wedge vs. a traditional internal rotation (IR) sling shows greater external rotation and adduction motion up to one year following surgery as well as reduced night pain at 2 weeks postoperatively (Kennedy et al., p. 5, 2020).
Use or (non use) of thumb strap
Clothing recommendations: (Elastic waist band/ no button up shirts/ loose fitting shirts, etc.)
Facilitate active finger, wrist, and forearm range of motion /passive elbow and shoulder range of motion (10 reps each)
*Tip: Remove the sling prior to completing A/PROM; have the patient’s elbow rest on a pillow to limit shoulder internal/ external rotation.
AROM:
Opening/Closing Hand (“Hand squeezes.”)
Wrist Flexion/Extension (“Slaps".)
AAROM:
Forearm Pronation/Supination (Also called “pancakes.”)
PROM:
Shoulder External Rotation NO MORE THAN 10 degrees (some MD’s do not approved external or internal rotation post shoulder replacement- it depends on the doctor’s orders).
Elbow Flexion/Extension - no more than 90 (Typically, but not always the most painful).
Shoulder abduction/adduction
Provide Home Exercise Plan (HEP) x10 each; complete 2-3 times per day
Opening/Closing Hand (“Hand squeezes.”)
Wrist Flexion/Extension (“Slaps".)
Forearm Pronation/Supination (Also called “pancakes.”)
Post-Operation Day Two
Active/ Passive range of motion: (tip: keep the sling on while completing range of motion to provide more stability; however unfasten the straps.)
Dressing education using compensatory techniques (Donning shirt with affected arm FIRST; taking off shirt with affected side LAST).
Upper Body (UB) Dressing My typical sequence is: 1. Doff sling/gown on top -> 2. don Shirt → 3. don sling (add thumb strap prior to standing) → 4. don pants.
Sling management - Describe to the patient/ patient’s spouse/ caregiver how to don/doff sling.
(OPTIONAL) Shower/ Toilet Transfers - in/out shower with tub transfer bench or shower chair while maintaining precautions/ toilet
Reinforce safety precautions and educate patient about potential discharge plan (Do they have home health/ outpatient/ post acute stay?).
This outline serves as a foundation for understanding shoulder replacement OT rehabilitation. Each patient's journey will differ, necessitating personalized and adaptable strategies. If you have any questions about any step of the protocol, please email me at juliannemadeline.ot@gmail.com or comment below! Thank you for reading, and I hope this information is useful to you as an OT or student!
Reference
Kennedy, J. S., Garrigues, G. E., Pozzi, F., Zens, M. J., Gaunt, B., Phillips, B., Bakshi, A., & Tate, A. R. (2020). The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation for anatomic total shoulder arthroplasty. Journal of shoulder and elbow surgery, 29(10), 2149–2162. https://doi.org/10.1016/j.jse.2020.05.019
3 Valuable Resources as a New-Grad OT in the Acute Care Setting
Disclaimer: I am not affiliated with the listed resources below. This post is for educational purposes only.
I recently accepted a position as an occupational therapist (OT) in the acute care setting. As I prepare for this new role, I have accumulated three valuable resources that provide essential information for anyone entering this specialized field. These resources offer comprehensive insights and practical strategies that are crucial for effective practice in an acute care environment. Here are my three most valuable resources that have significantly aided my preparation for this setting:
Occupational Therapy in Acute Care 2nd Ed.
Edited by Helen Smith-Gabai, PhD, OTR/L, BCPR and Suzanne E. Holm, OTD, OTR/L, BCPR
This textbook, Occupational Therapy in Acute Care, is a great resource for newly graduated OTs. I purchased this textbook a year and a half ago during my rotation in the acute care setting and rediscovered it a few months ago. I really love this resource because it highlights the most important areas to know as an acute care OT and provides the information in a digital format for easy online access.
Directly from text: “Readers who purchased this book directly from AOTA will automatically see this supplemental content on their AOTA Digital Library bookshelf at https://library.aota.org. Readers who purchased this book through a different vendor should contact customerservice@aota.org or call 800-729-2682 to set up a Digital Library bookshelf and access the supplemental content.”
Chapters Included in the Textbook:
Foundations of OT in acute care
E.g., Standardized assessments and G-codes, ethics, discharge planning, and evaluation of acute care patients (provides a comprehensive evaluation template to download and print).
Understanding the acute care environment
E.g., Intensive Care Unit, common diagnostic tests, laboratory values, hospital equipment (great visuals with each description).
Body Systems
Conditions and disorders
E.g., Ortho, Oncology, Trauma, Infectious Disease and Autoimmune Disorders
Working with clients in acute care
E.g., early mobility and movement, pain management, and energy conservation.
Where can I purchase this textbook?
You can purchase the textbook directly on AOTA’s website here.
E-Book is $89.95 as an AOTA member; Non-Member is $128.95.
Physical Book is $99 as an AOTA member; Non-Member is $142.95
You have the option to purchase digital singular chapters if you are interested in a certain chapter or section.
You can also purchase the textbook on Amazon (what I did) or a different vendor. If you choose to purchase through a different vendor other than AOTA, email customerservice@aota.org proof of your purchase and they will email you the digital supplemental content so you have access to printable resources.
2. The Occupational Therapy ToolKit by Cheryl A. Hall, OT
This is an INCREDIBLE resource for patient handouts, intervention planning, and understanding various physical disabilities and conditions commonly seen as an acute care occupational therapist. This resource includes useful treatment guides, ADL and mobility handouts, educational handouts, and therapeutic exercise handouts.
Directly from the website: “Occupational Therapy Toolkit is a comprehensive, 787-page practical resource developed to support occupational therapists working with patients diagnosed with physical disabilities, chronic conditions, and geriatric disorders. The OT Toolkit provides therapists with 97 concisely written treatment guides and a photocopiable collection of 354 full-page illustrated patient handouts that can be used as visual guides both during and after patient treatments.”
Where can I purchase this resource?
You can purchase directly on Cheryl Hall’s website.
The single-user print book
Paperback: $139
Paperback PLUS Spanish handouts (2 book set): $189
Paperback PLUS French handouts (2 book set): $189
Hardcover: $168
The single-user E-Book (I purchased this option).
E-book: $139
E-book PLUS Spanish handouts (2 book set): $189
e-book PLUS French handouts (2 book set): $189
3. The Road Map by Sonoe Oft, OT
I recently discovered OT Road Map on Instagram and find the author's information super useful as an entry-level OT. The author, Sonoe Oft, is an acute care OT with 12 years of experience in the acute care setting. Sonoe shares resources for OT’s to navigate acute care with confidence through educational videos, chart review and evaluation checklists, and 5 ways to boost your confidence in acute care.
Links to OT Road Map are provided below.
Acute Care OT Checklist: Chart Review and Evaluations
5 Ways to Boost Your Confidence in Acute Care
Please contact juliannemadeline.ot@gmail.com if you have any questions! I have found these resources incredibly useful, and I hope you do as well!
Why Task-Specific Training is Important for Neurorehabilitation
Occupational therapy practitioners frequently utilize task-specific training as a fundamental component of their therapeutic approach to enhance clients' abilities. This targeted intervention effectively focuses on improving the performance of meaningful activities, thereby enabling individuals to achieve greater independence and satisfaction in their daily lives. By tailoring these training sessions to the unique needs and goals of each client, therapists can facilitate significant progress in their overall functional capabilities.
What is Task-Specific Training?
Task-Specific Training involves practices activities of daily living (ADLs) or instrumental activities of daily living (IADLs) to improve the specific skills required for those tasks.
What is the relevance of Task-Specific Training to neurorehabiliation?
After a stroke or neurological injury, patients often experience motor, cognitive, or sensory deficits. Task-specific training helps retrain the brain to regain lost abilities.
What are the benefits of Task-Specific Training?
Encourages neuroplasticity (the brain’s ability to adapt and change).
It is holistic, meaning it address all areas including physical, cognitive, and emotional/behavioral skills.
Helps individuals to regain functional independence through focusing on meaningful activities that directly impact a person’s daily life.
What are some examples in neurorehabiliation?
ADLs (Activities of Daily Living): dressing, bathing, brushing teeth, or toileting.
IADLs (Instrumental Activities of Daily Living): Working on complex activities like managing finances, cooking, or shopping.
Motor Function Recovery: Using tasks like folding clothes or buttoning a shirt to improve fine motor skills and dexterity.
Cognitive Recovery: Training patients to follow multi-step instructions for tasks such as making a sandwich or planning a route.
Self-Range of Motion Exercises for Shoulder Weakness Following a Stroke
What is Self-Range of Motion?
Self-range of motion exercises are performed using the unaffected arm and hand and help to improve movement to a joint.
When should self-range of motion exercises be implemented into stroke recovery?
In the early stage of stroke (7 days to 3 months), participating in remedial exercises including passive and self range of motion exercises can improve the function of the upper extremities, muscular flexibility, and improve performance in activities of daily living in patients with acute stroke (Kim et al., 2014).
Although recovery is easier in the initial stages of paralysis, participating in self-range of motion in the middle and later stage of stroke, have been shown to reduce muscle spasticity, enhance blood circulation, and improve joint flexibility.
What are the benefits of utilizing self-range of motion exercises?
Improve paralysis (if implemented in the early stage).
Reduce edema (inflammation) and stiffness in the hands and fingers.
Improves muscular flexibility and strength.
Enhance blood circulation and awareness.
Range of motion (ROM) exercises do not require specialized equipment and can be completed anywhere.
3 Self-Range of Motion Exercises
Shoulder Forward Arm Raise
Shoulder Internal and External Rotation
“Rock the Baby”
Hamilton Health Sciences. (2018). Self-range of motion exercises for the arm and hand. p. 2-4. https://www.hamiltonhealthsciences.ca/wp-content/uploads/2019/08/SelfROMExercisesArmHand-trh.pdf
Kim, H. J., Lee, Y., & Sohng, K. Y. (2014). Effects of bilateral passive range of motion exercise on the function of upper extremities and activities of daily living in patients with acute stroke. Journal of physical therapy science, 26(1), 149–156. https://doi.org/10.1589/jpts.26.149
A Simple Tool For Stroke Rehabilitation: Diaphragmatic Breathing
Image from Research Gate (n.d.)
Disclaimer: Always talk to your doctor before starting a new breathing exercise including diaphragmatic breathing. This information is for educational purposes only and is not intended to diagnose, treat, or cure and illness or disease.
What is the Diaphragm?
The diaphragm is a thin dome-shaped muscle in between the chest and abdomen.
It functions as the main muscle of breathing.
It stabilizes the trunk and spine and aids in balance for performing everyday activities of daily living (ADLs) (Lee et al., 2018).
What is Diaphragmatic Breathing?
Diaphragmatic breathing is a relaxation technique in which an individual takes slow, deep breaths in through the nose and then out through the mouth; bringing awareness to the diaphragm and abdominal muscles.
What are the benefits of diaphragmatic breathing for neurological conditions?
Improves static and dynamic balance
Improves upper extremity motor function
Improves respiratory function
Lowers heart rate and blood pressure
Increases blood oxygenation
Reduces stress hormones
Decreases muscle tension
Improves sleep quality
(Lee et al., 2018); (Liu et al., 2021)
What does the research say?
A study by Lee et al. (2022), investigated the effects of diaphragm training on balance in participants with hemiplegia due to stroke. The results found that diaphragm training could lead to improvements in static and dynamic balance (Lee et al., 2018).
Another study measured the effects of diaphragm training on 45 hemiplegia patients after stroke. The results showed the hemiplegic diaphragm function was positively correlated with extremity motor and balance function of the hemiplegia patients (Liu et al., 2022).
Example of diaphragmatic breathing
Ensure the client is in a comfortable seated or reclined position, then ask them to place one or two hands on their belly.
Instruct the client to inhale through their nose and exhale through pursed lips.
Guide them to expand their belly outward with each inhalation and allow it to relax inward with each exhalation.
When used correctly and consistently, diaphragmatic breathing techniques can significantly improve many deficits commonly seen in various neurological conditions, including balance, motor function, and respiratory function. By incorporating these breathing techniques, particularly diaphragmatic breathing, as a simple yet effective tool in occupational therapy, therapists can facilitate lasting benefits for their patients.
Guide to Yoga Sequencing for Individuals Diagnosed with a Stroke
Disclaimer
This is for educational purposes only and is not intended to treat, diagnose, or cure any illness of disease. Although yoga may have benefits for individuals with stroke, yoga should be used as a tool and not as the sole intervention in a patient’s rehabilitation plan.
Background
Yoga is an ancient practice that originated in India and is characterized as a mind-body discipline aimed at developing concentration and awareness. The word "yoga" is derived from the Sanskrit root "yui," which means "to yoke” or join together.
The Eight Limbs of Yoga
Patanjali’s Yoga Sutra outlines the eightfold path, also called the eight limbs of yoga, serves as a roadmap for living a purposeful, ethical, and meaningful life.
The 8 limbs of yoga are the values of yoga.
Yama (restraint)
Niyama (observances)
Asana (posture)
Pranayama (breath)
Pratyahara (turning inward)
Dharana (concentration)
Dhyana (meditation)
Samadhi (Oneness with all living things)
The 3 limbs that are the most used in healthcare include:
Pranayama (breath control), Asana (posture), and Dhyana (meditation)
Yoga Sequencing
Most yoga sequences involve breathing exercises, physical postures, and meditation. Listed below is a general sequence I follow when planning my yoga sessions for individuals with a history of stroke.
First set the focus of the treatment session to provide a goal.
Choose one breathing exercise to implement into the session.
Examples include: equal belly breathing, alternative nostril breathing, and ujjayi breath.
For breathing scripts refer our scripts here
Proximal Movements: Most individuals benefit from participating in 4 proximal warm-up exercises prior to starting an exercise.
Examples include:
Neck movements (neck flexion/extension/ lateral flexion)
Shoulder shrugs (shoulder elevation/depression)
Unilateral scapular elevation and depression
Self-range of motion (shoulder flexion ~90 degrees; shoulder abduction/adduction; etc).
Incorporate the upper and lower extremities: Select one or more yoga poses from these four categories: (See template for examples of each category).
Weight-Shifting
Weight-Bearing
Contralateral upper extremity (UE) / lower extremity (LE) Movements
Functional reach
(optional) Lastly, select a meditation to close out the session.
Examples include:
Yoga Nidra
Progressive Muscle Relaxation
Mental Imagery
Refer to our scripts here
Click here to download a free yoga sequencing template
Note: Not all elements of the protocol have to be completed together. You can use one element that may benefit your patient’s specific goals in the plan of care.
Protocol developed by Julianne Madeline OTD, OTR/L, RYT-200
My Top 3 Tips to Use Yoga as a Tool in Occupational Therapy
Disclaimer: This is for educational purposes only and not for treating illnesses. Patients should consult their doctor before starting any new yoga or exercise program.
Through my experience working with stroke patients using adaptive yoga techniques, I have compiled some practical tips that may enhance the efficacy of rehabilitation sessions. With over 40 individual and group yoga classes taught, these insights are drawn from direct engagement with this unique population. Research indicates that individuals with a stroke history benefit from incorporating yoga into their rehabilitation, as it allows for adaptable and graded interventions aligned with their individual strengths and limitations. Here are three valuable tips:
Pose Naming: Introduce each yoga pose by its name to help patients create associations they can recall at home. For instance, while focusing on “Warrior II,” encourage them to visualize and remember the pose, reinforcing its importance in their practice.
Graded Progression: Build upon each pose and adapt it based on the patient’s progress or immediate response. This grading approach ensures that each session is tailored to fit their current capabilities while continuously challenging them.
Structured Sequencing: Implement a sequencing protocol (click here for mine) in your sessions to provide a consistent structure to the intervention. A defined sequence can promote familiarity and comfort, making the therapeutic experience more effective.
These tips can help create a supportive and effective environment for stroke patients, facilitating their recovery.
Yoga Poses to Improve Balance Following a Stroke
Asana is one of the eight limbs of yoga and means “physical posture” or “pose.” Asana is one of the most common types of yoga in health care and research shows asana may improve strength, flexibility, and motor control in patients recovering from a stroke.
Following a stroke, many individuals experience paresis (weakness) leading to significant limitations in motor control and activities of daily living (ADLs).
Research indicates engaging in yoga improves balance, coordination and encourages neuromuscular reeducation, thereby leading to improved outcomes in motor function (Yang & Fahey, 2021).
This pilot study utilized a non-controlled pretest-posttest method to explore the feasibility and impact of integrating occupational therapy (OT) and yoga to enhance balance, balance self-efficacy, and management of fall risk factors in individuals who have experienced chronic stroke.
Over an 8-week intervention period, participants engaged in sessions twice a week, each lasting one hour. The results indicated a significant improvement in the Berg Balance Scores, with an increase of 30%.
These findings suggest that yoga serves as an effective intervention for improving balance among individuals with stroke (Schmid et al., 2016).
Exercises to Improve Balance:
Improving sitting balance is essential for individuals with neurological conditions. The following exercises can help enhance stability and control while seated.
1. Seated Marching | Boat Pose
Benefits:
Strengthens the hip flexors, knee extensors, dorsiflexors, and hip abductors.
Improves the alignment of the spine and improves digestion.
Functional carryover:
Improved balance and strength can make it easier to complete transfers from sitting to standing position.
Contraindications:
Individuals with asthma, headache, heart problems, and low blood pressure.
Individuals with an injury at the neck, shoulders, spine, hips, or who have undergone any recent abdominal surgery should avoid this pose.
Modifications
Option to keep hands on the sides of the chair or on thighs for additional support.
Use of yoga strap to lift the affected lower extremity.
Directions:
Sit in a sturdy chair with your back straight.
Lift one knee toward your chest, then lower it back down.
Alternate legs, marching for 1-2 minutes.
Option to lean back in chair, engaging core muscles, raising one or both legs off the ground. Hold for 5 seconds.
Focus on maintaining an upright posture throughout the exercise.
Seated Boat Pose using strap to increase lower extremity range of motion.
2. Weight Shifting | Seated Table Top
Benefits:
Strengthens the scapular stabilizers, muscles of the shoulder, elbow, and wrist, and stretches the wrist and elbow flexors.
Facilitates proprioceptive input to affected shoulder.
Functional carry over:
Increased upper extremity strength and proprioception may increase independence in upper body dressing.
Contraindications
Contraindicated for carpal tunnel syndrome and injury to the wrists or knees.
Props
Place yoga block under affected elbow for greater support.
Directions:
Sit with your feet flat on the floor.
Shift your weight to the right side, lifting the left hip slightly off the chair.
Hold for a few seconds, then return to the center and repeat on the left side.
Perform 5-10 repetitions on each side.
Shift your weight forward, hold for a few seconds, then return to center and shift your weight backward.
3. Seated Side Bends | Seated Triangle Pose
While sitting, place your feet flat on the floor and arms at your sides.
Lean to the right side, reaching your right arm down towards the floor.
Hold for a few seconds and return to the starting position.
Repeat on the left side. Complete 5 reps on each side.
4. Ankle Pumps
Sit with your feet flat and knees bent at a 90-degree angle.
Lift your toes while keeping your heels on the floor and then point your toes down.
Repeat this movement for 1-2 minutes to enhance lower limb stability.
5. Ball Toss | Seated Extended Mountain
Sit upright in a chair and hold a lightweight ball (or a soft object).
Toss the ball gently from hand to hand without losing balance.
Gradually increase the distance between your hands to challenge your stability.
Reference:
Schmid, Arlene., Marieke Van Puymbroeck, Jennifer D. Portz, Karen E. Atler, Christine A. Fruhauf. (2016). Merging Yoga and Occupational Therapy (MY-OT): A feasibility and pilot study. Complementary Therapies in Medicine. Vol. 28, pgs 44-49. ISSN 0965-2299. https://doi.org/10.1016/j.ctim.2016.08.003.
Documenting Integrative Health in Occupational Therapy
Documentation is an essential component of occupational therapy (OT). Documentation allows the OT practitioner to monitor progress over time, create goals, and bill for services. Depending on an OT facility, integrative services may have the option to be billed to the insurance company by coding it as “neuromuscular re-education,” “Therapeutic exercise,” or “therapeutic activities.” (Thomas et al., 2021, p 4).
According to a survey many yoga or rehabilitation therapists included yoga under specific words or codes in the documentation.
Examples include: (*the words in bold are the most commonly used)
• Therapeutic exercise
• Therapeutic activities
• Neuromuscular control exercise
• Neuro re-education
• Patient or family education
• Dynamic balance or postural control
• Activity linked to functional tasks
• Description of the movement or pose (but not the name of the yoga pose).
• Use of or engagement in leisure activities
• Physical benefits of postures, education, and breathing
• Intervention for mental health symptoms
• As a coping mechanism used in mental health but also for people going through painful or stressful physical interventions after the stroke.
• Use of a physical intervention for weight bearing, balance, strengthening, gross motor control, etc.
• Core strength to increase the ability to transfer
• Stress management (Schmid & Van Puymbroeck, 2018).
The integrative health modalities approved by the American Occupational Therapy Association include:
Yoga: weight-bearing asana, self-range of motion asana, sequencing asana.
Tai Chi
Mindfulness: breathing exercises including alternate nostril breathing (connect both hemispheres) and equal belly breathing (creating balance within the body).
In occupational therapy, there are three key approaches to intervention planning:
Remedial: restoring a skill or ability that is impaired.
Compensatory: finding strategies or techniques that work around limitations.
Adaptation: modifying the setting or demands of a task to facilitate performance.
*It is important to note, occupational therapy goals are extremely client-centered and it is essential to create goals around function. These goals must be tailored to meet the individual needs of patients.
Examples of Goals for Stroke Rehabilitation Using Integrative Health Approaches:
Imaginary patient case study:
PMHx of right-sided Stroke presenting with functional deficits related to left-sided upper extremity hemiparesis, decreased sitting balance, and deficits related to memory and sequencing.
Neuromuscular Re-Education/ Therapeutic Activity Goal: To increase functional independence donning/doffing a shirt.
Integrative Health Modality: Weight-Bearing Asana (physical postures) including forward fold, Table Top, Quadruped, and Cat-Cow.
SMART Goal Example: “Patient will participate in four weight-bearing exercises, 2x daily for 4 weeks, to increase strength and control in affected upper extremity to increase functional independence in donning/doffing a shirt.”
Dynamic Sitting Balance Goal/ Functional Reach Goal: To increase balance and functional reach to increase functional independence and safety bathing and completing hygiene tasks.
Integrative Health Modality: Self-Range of Motion Asana (physical postures) including the Circle of Joy (Obtained from the website: Tumme).
SMART Goal Example: “Patient will engage in self-range of motion exercises, 2x daily for 4 weeks, to increase sitting balance and functional reach to improve safety and functional independence with bathing and hygiene tasks.”
Memory and Attention Goal: To increase cognitive skills including memory and attention and increase independence completing AM routine.
Integrative Health Modality: Sequencing Asana including a Seated Sun Salutation.
SMART Goal Example: “Patient will engage in sequencing exercise, and recall the sequence with no more than one verbal cue to improve cognitive skills relating to memory and attention in 2 weeks.”
Created by:
Julianne Madeline OTD, OTR/L, RYT-200
Additional references:
The American Journal of Occupational Therapy. (2023). Complementary health approaches and integrative health in occupational therapy. The American Journal of Occupational Therapy. 77(3). https://research.aota.org/ajot/article/77/Supplement%203/7713410200/25025/Complementary-Health-Approaches-and-Integrative
Schmid, A., Van Puymbroeck. (2019). Yoga therapy for stroke. A handbook for yoga therapists and healthcare professionals. Singing Dragon.
Schmid, A. A., Van Puymbroeck, M., Altenburger, P. A., Schalk, N. L., Dierks, T. A., Miller, K. K., Damush, T. M., Bravata, D. M., & Williams, L. S. (2012). Poststroke balance improves with yoga: a pilot study. Stroke, 43(9), 2402–2407. https://doi.org/10.1161/STROKEAHA.112.658211
Thomas, A., Kirschbaum, L., Crowe, B. M., Van Puymbroeck, M., & Schmid, A. A. (2021). The integration of yoga in physical therapy clinical practice. Complementary therapies in medicine, 59, 102712. https://doi.org/10.1016/j.ctim.2021.102712
Yang, I., Fahey, K. (2021). Adaptive Yoga: Designed for a variety of bodies and conditions. Human Kinetics.
The Domain & Process in Occupational Therapy
Image from: American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001
The domain and process of occupational therapy is the overarching goal of the profession, “achieving health, well-being, and participation in life through engagement in occupation” (AOTA, 2020).
The domain describes what occupational therapy practitioners are “in charge of” and what they make decisions about. The domain is based on the profession’s knowledge of the client.
The domain of occupational therapy includes:
Occupations (e.g., activities of daily living, rest and sleep, work, and education)
Contexts (i.e., environmental and personal factors)
Performance patterns (i.e., habits, routines, roles, and rituals)
Performance skills (i.e., motor skills, process skills, and social interaction skills)
Client factors (i.e., values, beliefs, spirituality, body functions and body structures) (AOTA, 2020).
The process describes the actions when providing services. The process is always client-centered, focuses on function, and used to provide intervention and services to persons, groups, and populations.
The process has three distinct parts: Evaluation, Intervention, and Outcomes.
Important features of the process include:
Service delivery approaches
Practice within various settings
Therapeutic use of self
Clinical and professional reasoning
Occupational and activity analysis (AOTA, 2020).
Reference
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001
4 Exercises for Shoulder Weakness Following a Stroke
Disclaimer: All information presented in this blog post is intended solely for educational purposes only and should not be considered medical advice. It is highly recommended that you consult with your doctor or healthcare provider before starting any new exercise program.
Individuals often experience upper and/or extremity weakness, also called hemiparesis, following a stroke. The following include 4 active-assist and self-range of motion exercises for upper extremity weakness.
Tips:
Complete these exercises slowly and with control.
Avoid holding your breath. Often this leads to an increase in blood pressure.
Make sure you are sitting up tall and keeping your spine straight.
If you have any pain or feel dizzy, stop immediately. Make sure to monitor how you are feeling throughout.
Table Glides: 15-20 reps
Benefit: Encourage shoulder range of motion, strength, and sitting balance.
Directions:
Sit in a comfortable chair at a table.
Clasp hands together.
Slowly and gently stretch your arms forward on the table. (I often put a cone or an object to use as a “target.”)
Table Circles: 20 each side
Benefit: Encourage shoulder range of motion, tolerance to upright position, and strengthens the shoulder muscles.
Directions
Place both hands on a small hand towel, placing one hand on top of the other and make medium circles to the right and then medium circles to the left. (Typically 15 each direction).
Shoulder Abduction and Adduction: 10 each side
Benefit: Stretches the shoulder muscles and increases upper extremity strength.
Directions:
Either sitting or standing.
Cradle your affected arm with your unaffected arm.
Lift both arms to chest level, then move both elbows (without moving trunk or gaze), to the unaffected side.
Hold for 5 seconds and then return to neutral. Repeat 10 times.
Repeat on opposite side.
Shoulder Flexion: 10 reps
Benefit: Increases shoulder range of motion and movement efficiency.
Directions:
Either sitting or standing.
Clasp your hands together and slowly raise your arms as high as you can and hold for 5 seconds.
With hands clasped, lower your hands down.
Repeat 10 times.
Ethical Considerations and Standards of Practice: Integrative Health in Occupational Therapy
Complementary Health and Integrative Health (CHAIH) products and practices are frequently employed by the general public to alleviate symptoms and manage various illnesses and diseases.
The field of occupational therapy adopts a holistic, client-centered approach that supports the integration of CHAIH into practice (AOTA, 2017). However, it is essential to consider ethical and practical implications before implementing holistic practices.
Is Integrative Health Within the Scope of Occupational Therapy?
Yes. The American Occupational Therapy Association (AOTA) approves the use of complementary health and integrative health (CHAIH) products and practices by competent occupational therapy practitioners (OTPs) to prepare and enhance participation and engagement in occupation by persons, groups, and populations (AOTA, 2017).
What are the Criteria for Legally Implementing CHAIH into the Plan of Care?
According to the American Occupational Therapy Association:
“Occupational Therapy Practitioners are required to obtain the requisite training, credentials, or licensure for all CHAIH included in the occupational therapy plan of care” (AOTA, 2017).
“OTPs are required to practice in accordance with federal and state laws, relevant statutes, regulations, and payer policies” (AOTA, 2017).
“Incorporating CHAIH into occupational therapy interventions necessitates awareness of additional regulatory requirements for practice, such as licensure or certification in the scopes of practice for licensed CHAIH professions, and of how the CHAIH approach integrates into the occupational therapy plan of care (AOTA, 2017).
“The risks, benefits, and potential outcomes of occupational therapy interventions including CHAIH must be disclosed to clients as part of client-centered, evidence-based practice (AOTA, 2017).
What are the Criteria for Ethically Implementing CHAIH into the Plan of Care?
The Occupational Therapist must ensure the selected CHAIH is congruent with the client’s cultural practices, priorities, or needs and that they positively affect health, well-being, and participation in daily activities.
The selected CHAIH must align with the client’s health perspectives, be safe to use, and be within the scope of occupational therapy practice (AOTA, 2017).
What is the Process for Implementing CHAIH into a Client’s Plan of Care?
The American Occupational Therapy Association (AOTA) states, incorporating CHAIH into occupational therapy interventions must must be done in the context of an overall occupational therapy process and plan of care.
Must perform an initial evaluation that begins the collaborative process of exploring the client’s characteristics and goals and identifying occupational performance deficits.
An intervention plan is established and implemented to address identified goals and targeted outcomes that support improved performance and enhanced participation in desired occupations.
The client’s progress is monitored and progress toward achieving their goals is reviewed (AOTA, 2017).
The CHAIH Interventions Approved by AOTA
Preparatory Methods and Tasks: Guided Imagery, Yoga for stress reduction prior to ADLs, and Deep breathing.
Occupations: Mindfulness or meditation for pain reduction
Activities: Standing yoga poses and Tai Chi for standing balance during occupations (AOTA, 2017).
Reference
American Occupational Therapy Association. (2017). Occupational therapy and complementary health approaches and integrative health. American Journal of Occupational Therapy, 71(Suppl. 2), 7112410020. https://doi. org/10.5014/ajot.2017.716S08.
Integrative Health in Occupational Therapy
What is Integrative Health?
Healthcare can be categorized into two primary types: conventional biomedical healthcare, which adheres to the principles of Western medicine, and integrative healthcare, which adopts a holistic approach.
In May 2001, the terminology shifted from "complementary and alternative" to "integrative" to highlight the importance of collaboration over competition (Kearney et al., 2007, p. 2).
Definitions of “Integrative Health”
Integrative health refers to the combination of conventional medical care with complementary and alternative medicine (CAM), as well as behavioral and lifestyle medicine (Jonas & Rosenbaum, 2021).
In the context of occupational therapy, integrative health employs holistic practices to meet patients at their current state, thereby utilizing a client-centered approach.
How is Integrative Health used in Occupational Therapy?
(AOTA) recognizes integrative health approaches as effective treatment methods for occupational therapy practitioners (Graham & Plummer, 2018).
According to AOTA, an occupational therapy practitioner can use integrative health approaches as a preparatory method/ technique or purposeful activity when providing occupational therapy services (Graham & Plummer, 2018).
Integrative health approaches in occupational therapy involve blending conventional therapy techniques with complementary and holistic methods to address the physical, emotional, mental, and spiritual well-being of clients. This multidimensional approach aligns with the profession’s focus on promoting health, function, and participation in meaningful activities. Below are examples of integrative health approaches used in occupational therapy:
Yoga Therapy: Incorporating adaptive yoga to improve flexibility, strength, and mental focus.
Meditation and Mindfulness: Teaching mindfulness practices to reduce stress, improve emotional regulation, and enhance focus.
Breathwork: Guiding clients in breathing techniques to manage anxiety, improve pulmonary function, or enhance relaxation.
Stress Management: Addressing lifestyle changes to reduce stress, including ergonomics and time management strategies.
Tai Chi: Incorporating gentle movement practices to improve balance, strength, and mindfulness.
Yoga Therapy
Why It Matters in Occupational Therapy
Integrative health approaches align with the client-centered philosophy of occupational therapy by addressing not just specific impairments but the whole person. These approaches are particularly beneficial for:
Clients with chronic pain or stress-related conditions.
Those seeking non-pharmacological interventions.
Populations interested in improving overall quality of life through sustainable and personalized strategies.
By integrating conventional and holistic practices, occupational therapists can provide comprehensive care that encourages resilience, self-efficacy, and engagement in meaningful life roles.
References
Graham , J., & Plummer , T. (2018, June 20). Perceptions of occupational therapists and yoga practitioners of the effects of yoga on health and wellness. SLACK Journals . https://journals.healio.com/doi/full/10.3928/24761222-20180620-01
Jonas, W. B., & Rosenbaum, E. (2021). The Case for Whole-Person Integrative Care. Medicina (Kaunas, Lithuania), 57(7), 677. https://doi.org/10.3390/medicina57070677
Kearney, G., Cioppa-Mosca, J., Peterson, M. G., & MacKenzie, C. R. (2007). Physical therapy and complementary and alternative medicine: an educational tool for enhancing integration. HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 3(2), 198–201. https://doi.org/10.1007/s11420-007-9055-2
Lawrence, M., Celestino Junior, F. T., Matozinho, H. H., Govan, L., Booth, J., & Beecher, J. (2017). Yoga for stroke rehabilitation. The Cochrane database of systematic reviews, 12(12), CD011483. https://doi.org/10.1002/14651858.CD011483.pub2
Schmid, A., Van Puymbroeck. (2019). Yoga therapy for stroke. A handbook for yoga therapists and healthcare professionals. Singing Dragon.
Yoga Postures for Arm Weakness (Hemiparesis) Following a Stroke
Asana is one of the eight limbs of yoga and means “physical posture” or “pose.” Asana is one of the most common types of yoga in health care and research shows asana may improve strength, flexibility, and motor control in patients recovering from a stroke.
Following a stroke, most patients experience paresis, or weakness, in their upper or lower extremities, leading to significant limitations in motor control and activities of daily living (ADLs). Research indicates that engaging in yoga improves flexibility, strength, coordination and encourages neuromuscular reeducation, thereby leading to improved outcomes in motor function. Research suggests asana increases flexibility, balance, strength, and range of motion (Yang & Fahey, 2021).
The following poses encourage neuromuscular re-education, focusing on weight-bearing and weight-shifting to promote body awareness, reduce pain, improve posture, and increase upper extremity strength.
Seated cat cow
Benefits
Encourages tolerance to an upright position.
Stabilizes the shoulders, elbows, and wrists.
Stretches the wrist flexors and elbow flexors.
Strengthens the core.
Encourages weight-bearing.
Functional carry over
A strong core supports various functional movements, such as reaching, bending, and lifting.
Contraindications
Individuals with an injury at the neck, shoulders, spine, hips, or who have undergone any recent abdominal surgery should avoid this pose.
Seated Forward Fold
Benefits
Encourages bimanual upper extremity range of motion and coordination.
Strengthens the hip flexors at the front of the body.
Functional carryover
Increased core stability increases ability to pick objects off the floor during chore participation.
Contraindications
Individuals should avoid this pose if they have a spinal injury or recent abdominal surgery.
Seated extended side angle
Facilitates proprioceptive input and weight bearing in affected upper extremity.
Strengthens the shoulder girdle, abdominal muscles, and hip flexors.
Child’s pose
Relives stress and tension in the back, shoulders and hips.
Increases strength in the upper extremity for carry over in functional reach tasks.
Scientific Benefits of Yoga for the Stroke Population
Disclaimer: This information provided here is for educational purposes only and is not intended to treat, diagnose, or manage any specific illness or disease. It is always advisable to consult with your healthcare provider or doctor prior to beginning any yoga or exercise program. The information detailed below pertains specifically to stroke rehabilitation and its potential integration with yoga practices.
Yoga Background & Terminology
According to the World Health Organization (WHO), yoga is an integrative health approach occupational therapy practitioners may utilize to provide a holistic client-centered treatment.
Yoga, originating in India, is an ancient practice and is characterized as a mind-body discipline aimed at developing a profound sense of concentration and awareness (Curtis et al., 2017).
"The term 'yoga' comes from the Sanskrit root" "yui," which means "to yoke or join together" (Lawrence et al., 2017, p. 2).
Patanajali's Yoga Sutra outlines the eightfold path as a roadmap for living a purposeful, ethical, and meaningful life.
This path is depicted as a tree with "limbs'' representing universal ethics (Yama), physical postures (asanas), breath control (pranayama), control of the senses (pratyahara), concentration (Dharana), and meditation (dhyana) (Lawrence et al., 2017, p. 2).
Practicing each of these limbs can lead to "Samadhi," a state of spiritual bliss.
The popularity of yoga in the Western world has been growing steadily as a treatment intervention, with physical postures (asana), breath control (pranayama), and meditation (dhyana) being the most widely practiced and recommended by healthcare practitioners (Lawrence et al., 2017).
What is Asana?
Asana, also referred to as physical postures, is recognized as one of the eight limbs of yoga and is one of the most commonly practiced aspect among healthcare practitioners.
The use of physical postures for stroke rehabiliation play a significant role in developing strength, flexibility, and balance, allowing individuals to cultivate a deeper connection with their bodies and minds.
Examples of yoga asana beneficial for stroke recovery:
Weight-bearing Asana: Seated or Quadruped Cat-Cow Pose, Seated Table Top Pose.
Contralateral Movements: Seated Boat pose, Seated Extended Mountain, Tree Pose, Warrior II.
Bilateral Upper Extremity Movements: Chair Pose, Child’s Pose, Extended Mountain, Table-Top, Downward Facing Dog, Cat Cow, and Warrior I/II.
What is Pranayama?
Pranayama, also known as breath control, is frequently utilized in various occupational therapy interventions to enhance physical and mental well-being. This practice involves specific breathing techniques that can help individuals manage stress, improve focus, and promote relaxation. By integrating pranayama into therapeutic sessions, occupational therapists can support clients in achieving a greater sense of balance and overall health.
What are the benefits for stroke?
A meta-analysis by Kang et al. (2022) reported that respiratory muscle exercises enhanced muscular strength and reduced the risk of respiratory complications in patients with stroke.
Additionally, multiple studies on healthy adults have reported a positive effect on breathing exercises on cognitive functional improvements.
Breathing exercises are the synchronization of natural breathing and neuronal activity, which activates the cortex, hippocampus, and amygdala, that are related to memory performance (Kang et al., 2022). Incorporating pranayama or breath control exercises into stroke rehabilitation may contribute to improvements in cognitive function in stroke.
Breathing exercises specific for stroke recovery
Equal belly breathing
Alternate nostril breathing
Ujjayi breathing
What is Dhyana?
Dhyana, also known as meditation, is the seventh limb in the eight limbs of yoga. The National Center for Complementary and Alternative Medicine (NCCAM) defines meditation as "specific postures, focused attention, or an open attitude toward distractions." People use meditation to increase relaxation, improve psychological balance, cope with illness, or enhance general health and wellness" (Srinivasan, 2013).
Dhyana is used as a holistic occupational therapy treatment approach for individuals with cardiovascular disease, pulmonary disease, stroke, and individuals who may benefit from relaxation techniques.
Yoga Nidra encompasses various forms, such as mental imagery, motor imagery, and progressive muscle relaxation.
Scientific Benefits:
The use of dhyana as a treatment intervention for neurological conditions may alleviate stress, anxiety, activate the parasympathetic nervous system, and even alleviate symptoms of depression (Yang, 2023).
Yoga Nidra
An effective evidence-based meditation utilized in stroke rehabilitation is Yoga Nidra. According to Nayak & Verma (2023), Yoga Nidra, referred to as “yogic sleep” or “conscious sleep” is a mental practice that exists between wakefulness and sleep (Nayak & Verma, 2023).
Yoga Nidra is an effective practice for stroke patients due to eliciting neuroplasticity in the brain.
Neuroplasticity: The brain’s ability to adapt and change.
The process of neuroplasticity enables the brain to redirect damaged functions to healthier areas of the brain and can reroute functions from damaged areas to new, healthy regions (Yang, 2023).
Facts about Neuroplasticity:
The brain has a complex neurological map, called the cortical homunculus, which processes sensory and motor functions across the body.
In the cerebral gray matter, distinct centers are allocated to each body part.
The sequencing of awareness rotation in Yoga Nidra mirrors this cerebral map.
Through repetitive rotation in this prescribed order, a profound neural flow is triggered within the brain's homunculus circuitry.
This flow creates a sense of relaxation, believed to mitigate stress and anxiety, stimulate the parasympathetic nervous system, and potentially alleviate symptoms of depression.
There are many forms of Yoga Nidra including mental imagery, motor imagery, and progressive muscle relaxation (Yang, 2019).
Figure I
Image retrieved from: Nourollahimoghadam, p. 760, 2021.
Body awareness has direct affect on brain neurotransmitters, including GABA, which enhance dopamine and serotonin (Nourollahimoghadam, p. 760, 2021). Increased body awareness through meditation, breath control, and controlled physical postures, may decrease stress and increase gray matter volume in the brain. An increase of gray matter in the brain increases an individuals ability to control movement, enhance memory, and control emotions.
What the research says…
Article 1 - Kashyap et al. (2023).
A randomized control trial by Kashyap et al. (2023), reveals that early yoga intervention in stroke patients may lead to improvement in cognition.
The pilot study included a convenience sample size of 40 participants with a history of stroke (Kashyap et al., 2023). The study highlights how structures of the brain are connected by various neural fibers and may be impacted from a stroke leading to cognitive decline (Kashyap et al., 2023).
However, the brain’s ability to formulate new circuits and adapt allows for improvements in cognitive function (Kashyap et al., 2023).
The study revealed improvements in standardized cognitive assessments including MoCA scores increased by 2 points, demonstrating the positive effects of yoga as an intervention for stroke (Kashyap et al., 2023).
Article 2 - Hampson et al. (2017).
Individuals with a history of stroke may be at a higher risk for mood disorders due to changes in cognition. Adaptive yoga has been proven to have positive effects on both physical and mental health, leading to an improved quality of life.
A study by Hampson et al. (2017) explored the effects of a relaxation training program on individuals with long-term neurological conditions such as acquired brain injury, stroke, Parkinson's disease, and Multiple Sclerosis. The study consisted of a five-session relaxation training program and a follow-up session at the participant's homes.
The results showed that relaxation training is an effective treatment for anxiety and depression in individuals living with long-term neurological conditions, leading to better functional outcomes of neurorehabilitation. The study concluded that relaxation training can be offered as an effective first-line intervention in rehabilitation to treat anxiety and depression in people living with long-term neurological conditions.
These findings suggest that adaptive yoga can play a significant role in promoting holistic recovery by addressing functional factors commonly associated with stroke rehabilitation.
Article 3 - Sinha et al. (2013).
Breath control or pranayama is one of the three limbs of yoga and has been shown to enhance the autonomic control of the heart by increasing the parasympathetic modulation (Sinha et al., 2013). A comparative study by Sinha et al. (2013), following a period of six weeks, showed that participants' parasympathetic tone was enhanced through pranayama and alternate nostril breathing.
The participants participated in alternate nostril breathing for fifteen minutes per day. The results of the study demonstrate that yogic breathing exercises improved participants' mood and emotional well-being.
Alternate nostril breathing not only decreased sympathetic activity but improved the participants cardiovascular and respiratory functions as well (Sinha et al., 2013). These findings suggest that adaptive yoga can significantly promote holistic recovery by addressing functional factors commonly associated with stroke rehabilitation.
References:
The American Journal of Occupational Therapy. (2023). Complementary health approaches and integrative health in occupational therapy. The American Journal of Occupational Therapy. 77(3). https://research.aota.org/ajot/article/77/Supplement%203/7713410200/25025/Complementary-Health-Approaches-and-Integrative
Harris, A., Austin, M., Blake, T. M., & Bird, M. L. (2019). Perceived benefits and barriers to yoga participation after stroke: A focus group approach. Complementary therapies in clinical practice, 34, 153–156. https://doi.org/10.1016/j.ctcp.2018.11.015
Lawrence, M., Celestino Junior, F. T., Matozinho, H. H., Govan, L., Booth, J., & Beecher, J. (2017). Yoga for stroke rehabilitation. The Cochrane database of systematic reviews, 12(12), CD011483. https://doi.org/10.1002/14651858.CD011483.pub2
Schmid, A., Van Puymbroeck. (2019). Yoga therapy for stroke. A handbook for yoga therapists and healthcare professionals. Singing Dragon.
Schmid, A. A., Van Puymbroeck, M., Altenburger, P. A., Schalk, N. L., Dierks, T. A., Miller, K. K., Damush, T. M., Bravata, D. M., & Williams, L. S. (2012). Poststroke balance improves with yoga: a pilot study. Stroke, 43(9), 2402–2407. https://doi.org/10.1161/STROKEAHA.112.658211