Optimizing Occupations,Habits,and Routines for Health and Well-Being With Lifestyle Redesign ® : A Synthesis and Scoping Review

Abstract

Importance: Lifestyle Redesign^® originated as a preventive occupational therapy intervention for healthy older adults, and it was found to be both effective and cost effective in the Well Elderly Studies initiated in the 1990s. Building on that empirical foundation, the scope of Lifestyle Redesign has been greatly expanded as a general intervention framework addressing prevention and chronic condition management in a wide range of populations, settings, and conditions. Yet until now, its full scope, defining characteristics, and supporting evidence have not been clearly and succinctly described, limiting its potential reach and impact.

Objective: To outline the definition and key characteristics of Lifestyle Redesign, provide a scoping review of its evidence base and future directions for research, describe its current applications, and make recommendations for its use in clinical practice.

Evidence Review: We searched PubMed and CINAHL, tables of contents of 10 occupational therapy journals, and citations in two seminal Lifestyle Redesign publications to identify articles published in 1997–2020 that described quantitative outcomes (for n ≥ 20) of interventions meeting the defining characteristics of Lifestyle Redesign.

Findings: Our scoping review yielded 12 publications providing supportive evidence for Lifestyle Redesign’s positive impact on a range of health and well-being outcomes among both well populations and those with chronic conditions.

Conclusions and Relevance: Lifestyle Redesign has the potential to meet a growing need in clinical and community settings for health care services that address prevention, health promotion, and chronic disease management.

What This Article Adds: Current evidence supports the use of Lifestyle Redesign to improve health and well-being for a range of client populations. This review outlines its defining characteristics and current applications to improve its implementation in clinical practice and expand related research efforts.

This synthesis and scoping review outlines the defining characteristics and applications of Lifestyle Redesign^® and highlights current evidence that supports the use of the occupational therapy intervention to improve health and well-being for a range of client populations.

Since its inception, a key hallmark of occupational therapy has been its emphasis on the rich potential of occupation to promote health and well-being, a theme etched in the seminal work of the profession’s early leaders, such as Eleanor Clarke Slagle (1934) and Adolf Meyer (1922/1977). A contemporary occupational therapy intervention framework, Lifestyle Redesign ^® , 1 harnesses the power of occupation to achieve therapeutically targeted health outcomes, particularly in the context of preventing and managing chronic conditions. In this regard, we conceptualize health as broadly encompassing physical, mental, and social well-being (World Health Organization, 1948/2009). The Lifestyle Redesign concept, first articulated in the 1990s (Clark et al., 1997; Jackson et al., 1998), was influenced by several historical trends in occupational therapy, including (1) the revival of occupation-based practice, beginning in the 1960s after a period of reductionistic practice trends during World War II and the postwar period (Kielhofner & Burke, 1977; Reilly, 1962; Yerxa, 1998); (2) the rise in the mid-1980s of occupational science, an academic discipline designed to elucidate the role of daily activity in relation to human health and well-being (Clark et al., 1991; Yerxa, 1990); and (3) a growing emphasis on health promotion and wellness as important, underdeveloped practice areas within occupational therapy (Jaffe, 1986; Reitz, 1992).

Although Lifestyle Redesign as originally provided to healthy older adults has been well described (Clark et al., 2015; Jackson et al., 1998; Mandel et al., 1999), this intervention approach has since been extended to many different populations, settings, and conditions in both clinical practice and research. Ironically, in part because of the successful dissemination of the Well Elderly Study at a time when other applications of Lifestyle Redesign were nascent in their development, many in the occupational therapy and larger health care community have a misconception that the Well Elderly intervention is the only application of Lifestyle Redesign. Moreover, at its outset, Lifestyle Redesign lacked a systematic plan for dissemination and implementation to promote widespread clinical adoption (Clark et al., 2013). These factors, among others, have adversely affected the reach and impact of Lifestyle Redesign on occupational therapy research, education, policy and advocacy, and clinical practice. The purpose of this review is to describe the Lifestyle Redesign intervention framework as currently practiced in a variety of contexts, by (1) defining it and articulating its chief characteristics, (2) reviewing its evidence base and directions for future research, and (3) reviewing its current and potential future clinical applications.

What Is Lifestyle Redesign?

We define Lifestyle Redesign as an occupational therapy intervention framework that promotes awareness of the relationship between everyday activities and health and guides people in the process of orchestrating occupations, habits, and routines to enhance health and well-being. It is typically delivered over a period of several months and may include individual and group sessions (in person or via telehealth). Lifestyle Redesign interventions have been delivered in various settings, including community based, outpatient, and primary care, with both well populations and those with or at risk for chronic conditions. The intervention is centered on the development of health-promoting performance patterns through the therapist’s selective application of core techniques, such as occupational self-analysis, narrative reasoning, collaborative problem-solving, and autonomy-enhancing communication, coupled with ancillary intervention strategies when relevant.

Lifestyle Redesign has five defining characteristics. We view these as definitional for two reasons. First, they reflect necessary elements of Lifestyle Redesign—namely, its strategic intent, scope, implementation, and practitioner requirements. Second, they correspond to, or are tightly intertwined with, mechanisms or active ingredients that are responsible for Lifestyle Redesign’s targeted beneficial effects. The defining characteristics are discussed in the following sections.

Therapeutic Focus on the Orchestration of Daily Activities, a Key Point of Differentiation From Other Lifestyle Interventions

The most crucial feature distinguishing Lifestyle Redesign from other health promotion interventions is its detailed focus on the dynamically organized complexities of regularly performed activities, habits, and routines. Although orchestration of daily activities into a lifestyle that promotes well-being has been a long-standing goal of occupational therapy (e.g., Christiansen & Matuska, 2006; Meyer, 1922/1977; Wagman et al., 2012), most occupational therapy interventions foreground performance skills (which include motor, process, and social interaction skills). In contrast, Lifestyle Redesign incorporates a methodical, in-depth focus on performance patterns, which encompass “the acquired habits, routines, roles, and rituals used in the process of engaging consistently in occupations [that] can support or hinder occupational performance” (American Occupational Therapy Association [AOTA], 2020, p. 12).

Although many health promotion interventions developed outside of occupational therapy address habits and routines, they typically target individual health behaviors (such as medication adherence or physical activity) through the use of discrete habit formation strategies (e.g., Conn et al., 2015). Such interventions are far narrower in scope than Lifestyle Redesign, which considers daily participation in activities, per se, as the subject of intervention and holistically addresses both specific activities and the patterning of activities as being health promoting, health compromising, or neutral. For example, the degree to which activities over the course of a day are restorative versus depleting affects a person’s overall levels of stress, energy, and fatigue, irrespective of the impact of each activity considered independently. Lifestyle Redesign practitioners thus teach clients occupational self-analysis, or the process of reflecting on how activities in their daily life contribute to health, both generally and in relation to one or more desired health outcomes, and adjusting their activity patterns to promote well-being (Mandel et al., 1999). For example, a person with anxiety disorder who spends weekdays engaged in cognitively demanding but sedentary tasks and weekends participating in physically demanding recreational activities may experience better overall well-being by learning to distribute cognitively and physically taxing activities more evenly throughout the week. Given that contextual circumstances and daily activity patterns continue to evolve over time, developing the skills to monitor and adapt one’s lifestyle on an ongoing basis using occupational self-analysis is essential to maintaining the benefits of Lifestyle Redesign over the long term.

As part of its focus on orchestrating daily activities, Lifestyle Redesign teaches clients through didactic content and occupational self-analysis how seemingly ordinary daily activity choices can have a large, radiating impact on function, health, and well-being when embedded within routines and carried out habitually for weeks, months, or years. For example, spending one’s break from work walking outdoors while listening to an audiobook rather than sitting at one’s desk and reading news online may affect well-being only minimally on a particular day. Yet, routinely making the choice to engage in this activity, which leads to decreased sedentary behavior, increased time outdoors, and a cognitive break compared with the alternative, is likely to have a substantial impact on one’s health over time. By understanding how routine daily activities affect health and engagement in meaningful occupations, greater importance is placed on the performance of seemingly ordinary activities, which is a key component of treatment success.

Applicability to Any Person Who Faces a Lifestyle-Related Challenge to Maintaining Optimal Health and Well-Being

Lifestyle Redesign interventions commonly aim to address threats to health that stem from particular medical conditions, such as multiple sclerosis (Uyeshiro Simon & Cunningham, 2017), diabetes (Pyatak et al., 2018, 2019), and chronic pain (Uyeshiro Simon & Collins, 2017). Yet its scope is not limited to particular medical diagnoses but rather is appropriate for any person who has the potential to alter their daily lifestyle components, as carried out over time, to enhance their health and quality of life. Lifestyle Redesign’s relevance to both well people and those with chronic conditions or disabilities is somewhat unique among occupational therapy interventions. Moreover, it has been shown to be beneficial for clients from a wide range of backgrounds, including those who experience inequitable access to care and face other barriers to attaining good health (e.g., Clark et al., 1997; Pyatak et al., 2018, 2019; Schepens Niemiec et al., 2018). For clients whose circumstances restrict their opportunities to exercise autonomy and choice, Lifestyle Redesign interventions capitalize on whatever resources, no matter how limited, people have available to attain better health and quality of life. For example, when working with a client who experiences food insecurity, meal preparation may focus on identifying palatable meals that accommodate the client’s nutritional needs, selected from among the groceries provided by a food pantry.

Because Lifestyle Redesign can be applied broadly, it is considered a general intervention framework (rather than a specific intervention approach relevant only to a particular population) that can be adjusted in content or mode of delivery to meet the needs of specific settings and populations. Such adaptations can be supported by following a systematic approach, such as the ADAPT-ITT model (Wingood & DiClemente, 2008), that typically incorporates preliminary qualitative research or needs assessments (e.g., Jackson et al., 2010; Schepens-Niemiec et al., 2015) and formal manualization of the adapted intervention (e.g., Blanche et al., 2011; Pyatak et al., 2015).

Use of Techniques That Facilitate Therapist–Client Collaboration and Individualization to Best Address Each Client’s Needs, Strengths, and Goals

Lifestyle Redesign’s emphasis on clients’ autonomy and intrinsic motivation is consistent with a vast amount of theory and research in the social sciences (e.g., Burke, 1977; de Charms, 1983; Deci & Ryan 2000) that view people as actively engineering their life circumstances to achieve their personal goals. Moreover, a wealth of research has indicated that intrinsically motivated activities are more likely to persist over the long term than those that are compelled by external reasons (Deci & Ryan, 2000 ; Doble, 1988). Consistent with the Model of Patient Empowerment (Funnell & Anderson, 2003), Lifestyle Redesign practitioners view clients as experts on their own lives who have an innate drive to develop and exercise personal capacities that enable them to flourish. We highlight this perspective, a common element of occupational therapy practice, because it is essential to the success of Lifestyle Redesign. Put simply, Lifestyle Redesign will fail without a strong collaborative partnership that draws on the expertise of both clients and therapists.

A common therapeutic tool in Lifestyle Redesign is the cocreation and analysis, by the client and therapist, of a client’s life story (Clark, 1993; Jackson et al., 1998, Pyatak et al., 2015). In doing so, therapists and clients develop a shared understanding of how a client’s occupational history and imagined future influence participation in daily activities in the present. This shared understanding in turn directs the development of treatment goals and activities that support continuation of a client’s desired life narrative. Linking discrete health-relevant behaviors—such as getting adequate rest, following a healthy diet, or taking prescribed medications—to one’s ability to enact a desired life narrative is a powerful mechanism to bring meaning to the activities necessary to preserve health. The use of narrative reasoning, in which therapists create and tell stories to bring coherence to a client’s lived experience (Mattingly, 1991), is particularly emphasized as a means to identify how each client’s past and present life circumstances, and future goals, affect their performance of daily activities. Narrative reasoning is often crucial in guiding the individualization of Lifestyle Redesign and helps to ensure that each client’s approach to embedding health-promoting activities into daily life is feasible, personally relevant, and consistent with their desired life narrative.

Concern With a Wide Range of Health-Relevant Outcomes

In Lifestyle Redesign, health is conceptualized as broadly encompassing physical, mental, cognitive, social, spiritual, and emotional well-being. Although Lifestyle Redesign is often tailored to address a specific medical condition, it nonetheless induces radiating benefits that extend to a broad suite of health-relevant outcomes. This expectation distinguishes Lifestyle Redesign from health behavior interventions with a narrower ultimate focus (e.g., Sumamo et al., 2011). For example, by conducting an occupational profile and guiding a client through occupational self-analysis and problem solving, a client with obesity and their therapist may collaboratively identify dance lessons, an occupation the client previously enjoyed in childhood, as a particularly desirable form of exercise. In doing so, the client may address the proximate goal of increased physical activity while simultaneously experiencing enhanced social well-being by forming new relationships and achieving a sense of meaning by resuming an important childhood pursuit.

As with all areas of occupational therapy, Lifestyle Redesign uses both objective and patient-reported outcomes to demonstrate the need for skilled services, track progress, and document resulting benefits. Because Lifestyle Redesign often leads to proliferating or serendipitous outcomes, as described earlier, comprehensive assessments of intervention effectiveness should include both diagnosis-specific and more general health-relevant outcomes. Currently, Lifestyle Redesign practice settings incorporate an array of measures to assess outcomes, including occupational performance (e.g., Canadian Occupational Performance Measure [COPM]; Law et al., 2019), overall health status (e.g., 12-item Short-Form Health Survey [Jenkinson & Layte, 1997], EuroQol–5D [Herdman et al., 2011]), and health management capability (e.g., Patient Activation Measure [Hibbard et al., 2004]; Pain Self-Efficacy Questionnaire [Nicholas, 2007]). As appropriate, practitioners also use diagnosis-specific measures to assess outcomes, such as body mass index, depressive symptoms, or fatigue.

Administration by an Occupational Therapy Practitioner With Advanced Training in Lifestyle Redesign

Stakeholders considering implementing Lifestyle Redesign programs frequently ask whether laypeople or health care practitioners other than occupational therapists can provide Lifestyle Redesign interventions. In response, we emphasize that occupational therapists have unique expertise in occupation and its relationship to function, participation, and well-being (AOTA, 2020). Domains of occupational therapy training particularly relevant to Lifestyle Redesign include the relationship of occupation to health (Law et al., 1998; Wilcock, 1998 ; Yerxa, 1998); habit formation, maintenance, and discontinuation (Clark et al., 2007; Fritz & Cutchin, 2016; Kielhofner & Burke, 1980); and motivation and volition (Burke, 1977; Florey, 1969; Kielhofner & Burke, 1980). Lifestyle Redesign also draws extensively on activity analysis, an essential tool in occupational therapy (Creighton, 1992). For these reasons, although Lifestyle Redesign shares some characteristics with health behavior change interventions delivered by other health care practitioners or laypeople, it necessitates occupational therapy expertise and is thus always administered, at least in part, by a licensed occupational therapist. Supporting this point, at least 1 study has suggested that interventions informed by Lifestyle Redesign, but administered solely by laypeople or paraprofessionals with no direct contact between occupational therapists and clients, are unlikely to positively affect health outcomes (Mountain et al., 2017).

For some applications, it may be possible for therapists to partner with care extenders (e.g., lay health workers or paraprofessionals) in delivering Lifestyle Redesign interventions (e.g., Schepens Niemiec et al., 2018), whereas other applications are sufficiently complex to require delivery by an occupational therapist with specialized expertise in working with particular populations and conditions (e.g., Pyatak et al., 2018). Similarly, although occupational therapy assistants have not provided Lifestyle Redesign services to date, we envision that an occupational therapy assistant who meets specific competencies and demonstrates proficiency could successfully carry out appropriate components of a Lifestyle Redesign treatment plan under the supervision of a Lifestyle Redesign–trained occupational therapist. Finally, Lifestyle Redesign is often provided by occupational therapists on interprofessional teams, where the occupational therapist’s specialized skill set works synergistically with the expertise of other health care practitioners to address clients’ needs.

As with other specialized practice areas, occupational therapists require advanced training to competently provide Lifestyle Redesign. The rationale for advanced training is threefold. First, the therapeutic use of occupation in Lifestyle Redesign is nuanced and highly complex, and it requires the ability to carefully blend multiple techniques. Thus, added training is needed to successfully navigate Lifestyle Redesign’s intricacies—a conclusion frequently voiced by occupational therapists learning to use this approach. Second, because Lifestyle Redesign is a prominent occupational therapy intervention used in addressing chronic conditions, it is critical to ensure that it is delivered with high fidelity to obtain accurate research results and achieve optimal treatment success. Third, specialized training is needed to customize intervention delivery to address the specific needs of client populations and the complex and often comorbid chronic conditions they must manage. The requirement for specialized training in Lifestyle Redesign echoes what is common in other occupational therapy clinical settings that expect and provide this training. For example, in addition to foundational occupational therapy skills, practitioners in many acute care settings must possess additional competencies to treat clients’ medical conditions and address safety and environmental issues.

The current model of advanced training in Lifestyle Redesign at USC includes didactic learning and clinical training. Books, articles, manuals, continuing education courses, and academic courses serve to introduce Lifestyle Redesign and guide practitioners in integrating its principles into their practice. Comprehensive training includes adequate supervised practice hours and mentored practice to develop the necessary competencies. We recognize a pressing need to provide a training model that is readily accessible to a sufficient number of occupational therapists.

Case Example Illustrating Lifestyle Redesign in Practice

As an illustration of the defining characteristics of Lifestyle Redesign we have outlined, we offer the following case study based on the experiences of Lifestyle Redesign clients with chronic migraine. Clients with chronic migraine are typically seen for approximately eight sessions over 4 to 5 mo. In this example, an older adult man is referred by his neurologist to an outpatient occupational therapy clinic for evaluation and treatment of chronic migraine. At the time of evaluation, the occupational therapist addresses medical and therapy history, including medication management, comorbidities, symptoms, and therapies and treatments used for chronic migraines. This is followed by taking an extensive occupational history, incorporating occupational storytelling to explore the client’s values, past and current performance patterns, engagement in self-care behaviors and meaningful activities, migraine triggers and management strategies, and more.

After administering assessments and patient-reported outcome measures (e.g., COPM [Law et al., 2019], Headache Management Self-Efficacy Scale [French et al., 2000], Migraine Disability Assessment Test [Stewart et al., 2001]), the occupational therapist engages the client in collaborative goal setting and in doing so gains insight into the client’s motivation and readiness to change. The client’s identified goal areas include sleep hygiene, community and social participation, meal preparation and planning, and medication management. While carrying out the plan of care, the occupational therapist draws on techniques such as didactic education, collaborative problem solving, narrative reasoning, autonomy-enhancing communication, and guiding clients in occupational self-analysis to support the development of health-promoting performance patterns and achievement of the identified long-term goals. Table 1 provides an overview of the most salient factors influencing the therapist’s plan of care for a client with chronic migraine and specific techniques and strategies used in intervention sessions. These considerations are prioritized and drawn on selectively in each intervention session, depending on the client’s presenting concerns and short-term goals.

Table 1.

Case Study: Clinical Considerations for a Lifestyle Redesign^® Client With Chronic Migraine Headaches

Migraine Risk Factors	Clinical Recommendations and Notes	Collaboratively Based Recommended Strategies
Medications
Skipping medications, waiting too long to take medications, not having medications available as needed	▪ Engage client in decision-making exercises to increase awareness of and education on early migraine triggers and symptoms. ▪ Identify common barriers to medication adherence and having medications present as needed.	▪ Implement medication management strategy, such as a pill organizer or apps to track medications. ▪ Take acute medications as soon as symptoms arise.
Comorbidities All comorbidities: mild traumatic brain injury, asthma, fibromyalgia, insomnia, chronic arthritis in neck, prediabetes
Fibromyalgia, common cold, effects of seasonal allergies	▪ Address assertive communication and advocacy in health care settings to manage risk factors. ▪ Short-term environmental temperature drops are a reliable migraine trigger; teach client to monitor upcoming weather changes (see environmental strategies).	▪ Decrease sensory exposures (listed below) and reduce exercise when experiencing symptoms. ▪ Pay especially high attention to all risk factors during March or November.
Sensory Exposure All other risk factors exacerbate the effect of sensory exposure.
Visual	▪ Recommend regular eye exams. ▪ Engage client in tracking time use to identify current activity tolerance and behavior patterns around taking breaks.	▪ Minimize television viewing. ▪ Take frequent breaks and use proper lighting when using computer. ▪ Use proper eyewear with the appropriate prescription as needed.
Auditory	▪ Engage in problem solving and planning to anticipate contexts when client may be exposed to auditory triggers. ▪ Practice role-playing assertive communication to express sensory needs and requests.	▪ Avoid noisy environments (e.g., loud parties, movie theaters). ▪ Always maintain access to earplugs (keep in wallet). ▪ Reduce time speaking with loud or fast talkers.
Environmental	▪ Provide education regarding the impact environmental factors have on managing chronic migraines. ▪ Identify environmental factors that are in client’s control to inform action steps.	▪ Wear hat and sunglasses when leaving home (keep extras in car). ▪ Remain indoors on hot, sunny days. ▪ Manage room temperature, track barometric pressure, and monitor weather changes.
Driving or riding in a car	▪ Vacations almost always induce migraines for this client. ▪ Train client in seated body mechanics, adaptive equipment, and ergonomic supports for cars.	▪ Avoid driving long distances. ▪ Take frequent driving breaks. ▪ Drive at night when possible.
Personal hygiene	▪ Provide education and training regarding proper body mechanics. ▪ Provide education and training in activity pacing and energy conservation strategies.	▪ Use proper body mechanics when engaging in activities of daily living such as hair washing or brushing teeth. ▪ Create a weekly schedule to simplify and schedule personal hygiene tasks throughout the week to avoid triggering a migraine.
Physical Activity
Lack of physical conditioning	▪ Exercise with precaution because of asthma and prior surgeries. ▪ Client has a high baseline activity level, which makes avoiding overexertion challenging. ▪ Physical activity is one of the client’s primary coping mechanisms.	▪ Maintain physical fitness via running, stair machine, or moderate weight lifting. ▪ Use headphones with music and record keeping to increase motivation to exercise.
Physical overexertion	▪ Reduce exercise during times when comorbidities are operative. ▪ Develop varied exercise plans so that the client has physical activity options regardless of symptom presentation. ▪ Introduce self-monitoring and symptom-tracking tools to increase awareness of activity thresholds for improved activity pacing.	▪ Avoid highly strenuous exercise and activity. ▪ Do not lift weights in the morning. ▪ Refrain from spontaneous physically challenging activities (e.g., playing tag with daughter). ▪ Avoid fast flurries of activity even when feel able. ▪ Do not increase the amount or intensity of planned exercise too quickly.
Sleep Hygiene
Too little sleep (<7 hr)	▪ In consultation with doctor, avoid all sleep medications, which elevate migraine risk for this client. ▪ Instead, adhere to similar daily sleep and wake schedules, including weekends.	▪ Adhere to a consistent, early bedtime. ▪ Do not eat sugary food or large meals too close to bedtime. ▪ Avoid screen time before sleep. ▪ Turn off telephone at night and in the morning. ▪ Use all other techniques for sleeping well.
Too much sleep (>9 hr)	▪ Adhere to similar daily sleep and wake schedules, including weekends.	▪ Set alarm and establish morning routines to avoid excessive sleep. ▪ Cut back on exercise and sensory exposure when sleeping too long.
Improper sleep positioning	▪ Educate client on sleep positioning for preferred position, appropriate supports, and ways to modify towels, blankets, and clothing if proper supports are not available.	▪ Assess available pillows and support upon arrival, and request additional supports as needed.
Eating Routines and Diet
Skipping meals or eating light meals	▪ Explore adequacy of overall nutritional intake with client. ▪ Refer to dietitian as needed.	▪ Ensure that high-protein food is readily available to eat when feeling weak, hungry, or faint. ▪ Coordinate with family members who grocery shop to ensure availability of high-protein foods.
Avoid migraine-inducing foods	▪ Engage in tracking of food choices and migraines to identify patterns. ▪ Determine whether client has been recommended an elimination diet to identify intolerances to specific foods.	▪ Do not eat trigger foods (e.g., chocolate, nuts, aged foods). ▪ Keep trigger foods out of house. ▪ Minimize dining at restaurants or view menus ahead of time.
Stress Client strengths to combat stress: strong spiritual orientation, positive life outlook, loves to sing
Professional stressors (periods of high work volume)	▪ Client has difficulty with boundary setting in work and professional life (i.e., reasonable and necessary accommodations, assertive communication). ▪ Use self-advocacy strategies. ▪ Client has poor time awareness and difficulty estimating how long tasks take to complete and planning and scheduling appropriately. ▪ Conduct ergonomic evaluation of workspace and environment to ensure appropriate fit.	▪ Start all work early to avoid last-minute scrambling. ▪ Take frequent breaks during work sessions. ▪ Remember to exercise during periods of heavy work. ▪ Submit reasonable and necessary workplace accommodation requests to human resources to improve migraine management in the workplace.
Personal stressors (caregiving and interpersonal relationships)	▪ Client provides care for an adult with a developmental disability. ▪ Client reports long-standing interpersonal conflicts in familial relationships. ▪ Address assertive communication strategies in personal relationships. ▪ Review stress symptom inventory and identify specific triggers.	▪ Access outside caregiving help. ▪ Silence phone when relaxing to avoid unpleasant phone conversations. ▪ Consider ways to forge more positive relationships with family members. ▪ Exercise as soon as possible after experiencing a stressful situation. ▪ Practice relaxation and breathing techniques.
Secondary Preventive Strategies
Migraine prodrome or threat of migraine	▪ Encourage client to continue engaging in self-monitoring routines when traveling.	▪ Increase rest time. ▪ Temporarily restrict risk-inducing occupations (e.g., television, driving).
Relapse due to ongoing migraine	▪ Client has ability to carefully monitor bodily states for internal signs of migraine risk as a result of experiencing >700 prior attacks; integrate this strength into personal action plan.	▪ Reframe the challenges of ongoing migraines with positive thinking. ▪ Soak hands in hot sink water to minimize vasoconstriction with rebounding.

Illustrating the depth of attention devoted to occupations, a typical session for this client involves the therapist and client collaboratively developing a customized plan to achieve long-term goals. The topic of the session is planning a road trip to increase community and social participation while attending to relevant migraine risk factors and management strategies outlined in Table 1. Successful migraine management begins with effective planning to minimize triggers while traveling to the destination, including factors such as keeping a hat and sunglasses in the car to minimize overexposure to light; avoiding travel when a prodrome or triggers such as a fibromyalgia flare or seasonal allergies are present; ensuring an appropriate amount of sleep before departing; taking frequent breaks; eating properly before departing and ensuring that food is available in the car to avoid skipping meals; practicing neck and shoulder relaxation techniques when behind the wheel; and ensuring that all potentially necessary medications are organized and packed.

Once the client arrives at the destination, factors to consider include planning for self-evaluation of potential triggers throughout the trip; scheduling activities that start and end at appropriate times to achieve adequate duration of sleep; engaging in consistent physical activity while minimizing the risk of overexertion; adhering to a consistent eating routine by consuming food brought on the trip and avoiding triggers such as sugar, caffeine, and alcohol when trying new restaurants; planning enjoyable, novel activities without causing overwhelm and stress; and adhering to the aforementioned strategies for minimizing sensory exposure.

Upon return from the trip, the occupational therapist encourages allowing time for adequate rest and recovery, resuming participation in established habits and routines by having food and medications stocked upon return, and engaging in appropriate self-care. Using Lifestyle Redesign, the occupational therapist attends to a range of dynamic, interrelated lifestyle factors that contribute to migraine risk throughout the plan of care. In doing so, the client experiences increased self-efficacy for managing migraine headaches, optimal participation in desired activities, and enhanced overall health and well-being.

Evidence Base and Future Research Directions

Lifestyle Redesign’s efficacy has been studied among diverse populations and practice settings, both within the United States and internationally. These studies range from pilot and feasibility work to large-scale randomized controlled trials. Given the diversity of studies, we identified a scoping review as the most appropriate strategy to provide an overview of Lifestyle Redesign’s evidence base. In undertaking this review, we sought to answer the question “What impact do interventions meeting the defining characteristics of Lifestyle Redesign have on outcomes related to health and well-being?” We did not register a protocol for this scoping review. We considered peer-reviewed journal articles that met the following eligibility criteria: (1) the intervention (as described in publications) met the defining characteristics of Lifestyle Redesign as outlined in this review, (2) at least 20 study participants received the intervention, and (3) the study reported quantitative outcomes relevant to health and well-being. If a study resulted in multiple publications, only the publication reporting the study’s primary outcome was included in the review. These criteria were chosen to ensure that the interventions reflected our conceptualization of Lifestyle Redesign and to exclude small studies that generate limited evidence pertaining to intervention effects.

Elizabeth A. Pyatak and Kristine Carandang used three search strategies. First, they searched PubMed and CINAHL using the term lifestyle redesign. Second, they included all citations that referenced one or both seminal Lifestyle Redesign articles (Clark et al., 1997 ; Jackson et al., 1998), as indexed in the Web of Science Core Collection. Finally, they hand-searched the tables of contents of 10 occupational therapy journals: the American Journal of Occupational Therapy; British Journal of Occupational Therapy; Canadian Journal of Occupational Therapy; Australian Journal of Occupational Therapy; Journal of Occupational Rehabilitation; OTJR: Occupation, Participation and Health; Occupational Therapy International; Occupational Therapy in Health Care; Journal of Vocational Rehabilitation; and Physical and Occupational Therapy in Pediatrics. All searches were conducted for articles published from 1997 (the publication year of the original Well Elderly Study) through October 2020. All article titles and abstracts were screened by one or more of the three reviewers (Pyatak, Carandang, and a research assistant) and eliminated if they reflected nonintervention studies (e.g., qualitative or cross-sectional studies) or indicated that fewer than 20 participants received the intervention. Next, Pyatak and Carandang screened full-text articles to identify whether they were appropriate for review; disagreements were resolved through discussion with the full authorship team. Pyatak and Carandang developed a data charting form to extract information from the studies selected for review. Data items extracted included the population, intervention characteristics, study design, funding sources, and outcomes pertaining to health and well-being. The evidence selection process is outlined in Figure 1.

Figure 1.

Flow diagram of the evidence selection process.

In total, 12 journal articles met the selection criteria and were synthesized in a narrative review. Studies identified by their authors as evaluating Lifestyle Redesign were termed self-identified as Lifestyle Redesign, and studies in which the intervention met our definitional criteria, yet was not identified as Lifestyle Redesign, were termed concordant with Lifestyle Redesign. The characteristics and findings of the 12 studies are presented in Supplemental Table A.1 in the Supplemental Appendix, available online with this review at https://research.aota.org/ajot, and summarized here.

Four articles investigated wellness and prevention for older adults who are generally healthy but at risk for functional decline and negative health outcomes. The first large-scale Lifestyle Redesign randomized controlled trial, the Well Elderly Study, evaluated the efficacy of a 9-mo intervention for independent-living older adults. In comparison with usual care and a generalized social activity program, older adults who received Lifestyle Redesign evidenced significantly better self-rated physical and mental health, quality of life, and functional outcomes (Clark et al., 1997). Three other studies, including the Well Elderly 2 trial (Clark et al., 2012), evaluated preventive interventions informed by the Well Elderly Study, using a variety of intervention dosages, delivery models, and targeted populations of late midlife and older adults (Matuska et al., 2003; Schepens Niemiec et al., 2018). Taken together, these studies suggest that preventive Lifestyle Redesign improves multiple domains of health-related quality of life, in particular mental and social functioning. A recent systematic review of Lifestyle Redesign interventions focused on community-living older adults also produced generally supportive results for Lifestyle Redesign in this population (Levesque et al., 2019).

As indicated in Table A.1, Lifestyle Redesign has been adapted to address chronic conditions in various practice settings. The goals of such interventions, which were identified in 8 articles, are to incorporate health behavior changes into daily routines and develop strategies to address symptoms and disease management tasks while engaging in meaningful occupations. For example, a Lifestyle Redesign intervention targeting diabetes significantly improved glycemic control, quality of life, and overall health status in community settings (Pyatak et al., 2018) and in a safety-net primary care setting (Pyatak et al., 2019). Clinical outcomes from an outpatient occupational therapy practice also support the benefits of Lifestyle Redesign for people with chronic pain (Uyeshiro Simon & Collins, 2017). Lifestyle Redesign’s efficacy has also been investigated among stroke survivors (Lund et al., 2012) and older adults with chronic health conditions (Johansson & Björklund, 2016). These latter 2 studies demonstrated null findings, potentially as a result of treatment contamination (Lund et al., 2012) and a small sample size (Johansson & Björklund, 2016). Finally, two similar interventions, Redesigning Daily Occupations (ReDO) and Balancing Everyday Life (BEL), have been investigated among women with stress-related disorders (Eklund & Erlandsson, 2011, 2014) and people with mental illness (Eklund et al., 2017). Among women with stress-related disorders, ReDO reduced perceived stress, increased self-esteem and satisfaction with daily occupations, and supported return to work. The BEL intervention enhanced occupational engagement, occupational balance, symptom severity, and psychosocial functioning among people with mental illness.

We note that several studies important to understanding the evidence base for Lifestyle Redesign did not meet the criteria for the scoping review. For example, studies investigating secondary outcomes of Lifestyle Redesign interventions, such as those reporting on the cost-effectiveness (Hay et al., 2002) and long-term carryover (Clark et al., 2001) of the Well Elderly intervention, were excluded. Moreover, interventions very similar to Lifestyle Redesign, such as the Lifestyle Matters program (Mountain et al., 2017), but that did not meet the definition outlined in this review, were not included. Surprisingly, despite our broad search strategy, an intervention for pressure ulcer prevention derived from Lifestyle Redesign (Carlson et al., 2019) and tested at USC also did not meet the inclusion criteria for our search: The term Lifestyle Redesign did not appear in the article, it was not published in an occupational therapy journal, and the hand search determined it did not cite the seminal articles. Finally, there are myriad smaller, primarily qualitative studies of interventions concordant with Lifestyle Redesign (e.g., Cassidy et al., 2017; Levasseur et al., 2019; Maeir et al., 2021) that were excluded because of our emphasis on measurable outcomes.

Although the bulk of the current evidence supports the benefits of Lifestyle Redesign, several gaps remain in its evidence base. First, until this point, intervention delivery has been insufficiently standardized to support broader dissemination and implementation. Thus, an important next step in strengthening its evidence base is to establish a fidelity measure that clearly identifies the required intervention elements to ensure its intended delivery across future Lifestyle Redesign clinical trials and in real-world practice (Allen et al., 2018). Second, additional mechanistic studies would continue to strengthen understanding of Lifestyle Redesign’s active ingredients and ideal dosage, frequency, duration, and delivery method.

Third, research is needed to better document the effectiveness of Lifestyle Redesign for populations and conditions other than those addressed in the articles listed in Table A.1. Because the Lifestyle Redesign framework may benefit a wide variety of populations through different modes of delivery, we suggest that adaptations to the Lifestyle Redesign framework be systematically documented in such trials (e.g., using the Framework for Modifications and Adaptations; Wiltsey Stirman et al., 2019) to increase the understanding of the nuances of each adaptation and to clarify the populations for whom Lifestyle Redesign is most effective and under what conditions (Baumann et al., 2018). Last, further research assessing its impact on health care costs and cost-effectiveness is needed to facilitate its broader adoption (Raghavan, 2018). These outcomes must be disseminated to payers, policymakers, and other stakeholders to communicate the need to incorporate Lifestyle Redesign into routine health services for the benefit of clients (Clark et al., 2013). Addressing the gaps in research outlined here will facilitate greater uptake of Lifestyle Redesign in clinical practice.

Current Applications and Future Directions for Practice

As health care moves into the future, there is great potential to extend Lifestyle Redesign to new client populations, practice settings, and modes of delivery. In current clinical practice, reimbursement structures typically dictate who is eligible to receive Lifestyle Redesign interventions, often on the basis of a narrow definition of medical necessity. Yet, Lifestyle Redesign has excellent potential to address prevention and population health while advancing reimbursement models that can sustain clinical practice.

Despite spending more on health care than any other country, health outcomes in the United States lag behind those of other high-income nations. Thus, discussion about how to contain costs while improving outcomes has been ongoing (Abrams & Tikkanen, 2020). Although the future direction of the U.S. health care system is largely unknown, certain trends are evident. For example, the number of older adults will continue to rise, increasing the need for affordable, novel solutions to address their health care needs (He et al., 2016). Of the trillions of dollars spent on health care annually, 90% is allocated to chronic conditions (Buttorff et al., 2017) influenced by lifestyle choices. Taken together, these factors demonstrate that more health care practitioners will be needed to prevent shortages in care delivery and that health care services must increasingly shift their focus to chronic disease prevention and management (Bodenheimer & Smith, 2013). Similarly, payers and practitioners need to move away from volume-based to value-based service models to improve clinical outcomes while containing cost (Kaplan & Porter, 2011). Interventions such as Lifestyle Redesign have the potential to address these issues by increasing clients’ preventive and self-management behaviors and facilitating access to services while improving clinical outcomes. Next, we identify emerging opportunities for occupational therapists who provide Lifestyle Redesign interventions.

Populations

Current applications of Lifestyle Redesign encompass a broad range of chronic conditions, such as metabolic disorders; chronic pain; headaches (Reeves & Uyeshiro Simon, 2016); movement disorders, such as Parkinson’s disease and multiple sclerosis (Uyeshiro Simon & Cunningham, 2017); mental health diagnoses; and prevention and wellness. Beyond these applications, we envision that Lifestyle Redesign may be suitable for other populations and settings, with appropriate modifications. It is significant that Lifestyle Redesign has not yet been applied with populations who do not have the higher order cognitive abilities or autonomy in making daily lifestyle choices necessary to participate in such an intervention independently, such as people with significant cognitive impairments or young children. Yet, we believe these people, with their social unit’s active participation in the intervention, may have great potential to benefit from Lifestyle Redesign. Collaboration with social units such as families, friends, or caregivers is warranted not only to facilitate lifestyle changes for the referred client but also to provide meaningful context regarding how the person’s chronic condition and social unit influence one another. Moreover, Lifestyle Redesign has the potential to provide ideal tools and support to caregivers and others in social units in which one or more members are affected by a chronic condition.

Settings and Modes of Delivery

As noted earlier, research has documented the effectiveness of Lifestyle Redesign in community-based, primary care, and outpatient private practice settings. Other settings in which Lifestyle Redesign is being implemented (but not formally evaluated in empirical research) include outpatient hospitals and rehabilitation centers, schools, and workplaces. To improve access, telehealth may be an appropriate option for Lifestyle Redesign because the intervention meets all of the defining characteristics even if the practitioner and the client are not in the same physical location. Telehealth is currently being used for clients for whom limitations such as transportation, distance, or symptoms affect outpatient visit attendance, and a large-scale randomized controlled trial investigating Lifestyle Redesign’s efficacy for clients with diabetes when delivered via telehealth is currently underway (Pyatak, 2019).

Reimbursement Models

Lifestyle Redesign has been provided in clinical practice for nearly two decades. As a unique therapeutic intervention in a medical model–dominated health care system, reimbursement has been secured through various avenues, including contracts, grants, fee-for-service medical billing, and value-based service contracts when services are considered medically necessary. Given the costly nature of chronic conditions, health care payers are beginning to incorporate reimbursement models that include prevention and self-management interventions (Centers for Disease Control and Prevention, 2018; Szanton et al., 2016). Although much progress has been made with regard to occupational therapy’s presence in these emerging practice areas, occupational therapists are not always considered by payers to be qualified providers of these services (Centers for Medicare and Medicaid Services, 2019, para. 230.2). Continued advocacy and evidence are necessary to support sustainable extension into new practice areas.

Implications for Occupational Therapy Practice

Societal trends such as demographic changes and shifts in health care policy suggest that more health care practitioners are needed to address prevention, health promotion, and management of chronic conditions. Lifestyle Redesign is an intervention framework well poised to equip occupational therapists with the skills and expertise necessary to meet these growing needs.

▪ Lifestyle Redesign has been demonstrated to improve a range of health and quality-of-life outcomes among both well populations and those with various chronic conditions.

▪ Occupational therapy practitioners trained in Lifestyle Redesign are well positioned to incorporate its treatment principles in both current and emerging practice settings.

Conclusion

In this review, we have outlined the defining characteristics and supporting evidence for Lifestyle Redesign. Next steps will aim at disseminating this approach by creating rigorous training opportunities, developing a more robust evidence base, and advocating for reimbursement by payers and workplaces. Given the current state of health care and evolving demographic trends, we are optimistic about the future potential for Lifestyle Redesign. This intervention framework can enhance the stature of the occupational therapy profession, improve the quality of health care, and promote the well-being of people and society as a whole.

Supplemental Material

Supplemental Appendix

Supplementary material for Optimizing Occupations, Habits, and Routines for Health and Well-Being With Lifestyle Redesign®: A Synthesis and Scoping Review

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2022.049269.pdf for Optimizing Occupations, Habits, and Routines for Health and Well-Being With Lifestyle Redesign®: A Synthesis and Scoping Review by Elizabeth A. Pyatak, Kristine Carandang, Chantelle Rice Collins and Mike Carlson in The American Journal of Occupational Therapy

Footnotes

Acknowledgments

We gratefully acknowledge Florence Clark, Grace Baranek, Stacey Schepens Niemiec, Jesus Diaz, Katie Jordan, Camille Dieterle, Jennifer Raymond, Michael Harris, and anonymous peer reviewers for their insightful comments on previous versions of this review.

1

The University of Southern California (USC) maintains the service mark for Lifestyle Redesign, an occupational therapy service aiming to develop, implement, and enact a customized routine of health-promoting and meaningful daily activities (U.S. Federal Trademark Serial Number 76592296). The authors do not have a personal financial interest in Lifestyle Redesign.

*

Indicates studies included in the scoping review.

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