By Allison Nye, MS, OTR/L
Occupational Therapist
Long Island, NY

Oftentimes, our patients describe difficulties such as decreased balance, poor strength, and a functional decline requiring increased assistance from a caregiver within their functional ADL and IADL tasks. It becomes easy to get stuck in a biomechanical approach where we bring out the resistance bands, weights, and head straight to our go-to balance interventions. 

But as occupational therapists, we have the power to take those interventions and add them to a functional occupation-based approach within our treatment planning. An article published in the American Journal of Occupational Therapy mentions that community-dwelling older adults benefitted from a functional exercise program to improve overall IADL performance.

We are able to identify ADL and IADL dysfunction, as well as perform activity analysis to detect what performance skills and client factors are impaired and impacting our patient’s ADL and IADL tasks.

Occupation-Based Evaluations

Before delving into occupation-based interventions, we should begin by understanding how we can identify what occupations are most impacted. 

When we go into the home on evaluation, along with our body functions evaluation of strength, balance, and coordination, etc., we can also evaluate using an ADL and an IADL evaluating tool. The following evaluating tools can be beneficial in the first step of identifying an occupation-based treatment approach:

• Katz ADL Index 
• Bristol ADL Scale
• Lawton IADL Scale
• Modified Barthel

By choosing an ADL and an IADL evaluation tool, we can assess what areas of our patient’s everyday function can be targeted within our functional approaches.

Occupation-Based Activity Analysis

Once we identify the ADL and IADL tasks that are most affected, we can then start to assess what client factors are causing the dysfunction within their specific functional tasks. Some examples we often identify could look like this:

• Difficulty utilizing their walker in the environment during the functional task
• Poor strength and difficulty lifting the items required during the functional task of laundry
• Difficulty maintaining balance with only unilateral assistance at their walker during the task of reaching for supplies in an overhead kitchen cabinet
• Difficulty remembering the steps of the task, and how to complete it in its entirety
• Difficulty standing for a long enough period of time to complete a task, such as grooming

The list goes on. Once we can analyze the task, we can then start thinking about an occupation-based functional intervention approach.

Occupation-Based Interventions and How to Incorporate Functional Exercise

After identifying the client factors and performance skills impacting the ADL or IADL task, we can then jump in and provide our intervention. Again, it’s easy to break out the resistance bands and weights and give our patients the same balance interventions that we use as our go-to interventions to improve strength and balance. We can also take those same interventions and utilize them within a functional exercise program, or functional IADL interventions. Some examples of this could include the following ideas for the following examples of affected client factors.

Strength

Placing wrist weights onto the patient’s wrists and having them perform the affected IADL.

Examples include:

• Stirring water or food in a pot wearing wrist cuffs
• Folding laundry wearing wrist cuffs
• Transporting various weighted items from the fridge to the countertop
• Brushing their hair wearing wrist cuffs

Balance

Including stepping interventions,  various bases of support stances while performing a functional task and altering levels of upper extremity assistance at their walker. All of these balance interventions can be incorporated into a functional occupation-based task.

Examples include:

• Folding laundry in semi tandem stance 
• Stepping forward and outside of their base of support while pushing a mop, broom, or vacuum. 
• Reaching at different levels while dusting
• Reaching into various places within the home, with unilateral assistance at their walker such as reaching into their fridge or closet for item retrieval.
• Standing on a balance pad while washing dishes
• Carrying items such as trash cans, grocery bags, etc

Activity and Standing Tolerance

Including prolonged standing within a functional occupation-based task, and upgrading interventions to include further tolerance within a functional task.

Examples include:

• Adding a functional task while walking, such as having them retrieve their mail
• Standing while performing a prolonged IADL such as standing during meal preparation
• Folding laundry in standing
• Putting away items in the kitchen
• Performing grooming in standing

Occupational Therapists Can Make a Huge Impact

Overall, as OTs, we are able to provide this patient-specific occupation-based approach to change our patients’ confidence, ease, safety, and ability to continue to live within their home environments at a more independent and safe level. By placing our patients into the functional task itself, and allowing them to perform the task with an added balance, strength, and standing tolerance twist, we can not only increase their confidence, but we can target their affected client factors within a task that directly impacts their ability to perform the functional task itself. 

We also gain the ability to show our patient’s what we do, we are able to distinguish what our expertise is and how we can change their lives within their everyday tasks. Nothing is better than hearing one of our patients distinguish what we as OTs were able to bring to their lives and how we affected their everyday routines.