Abstract
It is the position of the American Occupational Therapy Association (AOTA) that occupational therapy practitioners are distinctly qualified to address the impact of chronic conditions on occupational performance and participation across the life span. The purpose of this position statement is twofold. First, it defines chronic conditions and describes the multiple factors associated with the development of one or more chronic conditions. Second, it provides an overview of how the field of occupational therapy has a distinct impact on improving the health and wellness of persons, groups, and populations with or at risk for chronic conditions through health promotion, disease prevention, and intervention.
AOTA’s new position statement describes occupational therapy’s role in addressing the impact of chronic conditions on occupational performance and participation across the life span and improving the health and wellness of persons.
Definition and Prevalence of Chronic Conditions
Chronic conditions are physical diseases, mental health disorders, or neurodevelopmental conditions, typically lasting 1 year or more, that require continuous medical monitoring and significantly affect one or more activities of daily living (ADLs; Centers for Disease Control and Prevention [CDC], 2019a). Common chronic conditions include, but are not limited to, heart disease, cancer, diabetes, obesity, anxiety, bipolar disorder, depression, Alzheimer’s disease, cerebrovascular accident, chronic obstructive pulmonary disease, autoimmune disorders, and chronic pain. Chronic conditions often have a complex etiology, including nonmodifiable risk factors (e.g., genetic, environmental), potentially modifiable risk factors (e.g., excessive alcohol use, smoking, exposure to secondhand smoke, poor nutrition, lack of physical activity), and social determinants of health (SDOH; e.g., food insecurity, unemployment, neighborhood safety; CDC, 2019a). Potentially modifiable risk factors play a significant role in the development of complications, disease progression, and limitations in occupational performance and engagement.
According to the CDC (2019b), 6 in 10 adults living in the United States have a chronic condition, and 4 in 10 have two or more chronic conditions. The most prevalent chronic conditions in the United States include hypertension (27% of U.S. adults), lipid disorders (22%), mood disorders (12%), diabetes (10%), and anxiety disorders (10%; Buttorff et al., 2017). Adults age 65 and older have elevated rates of chronic conditions; 8 in 10 have at least one chronic condition (National Council on Aging, n.d.), and nearly 7 in 10 have two or more chronic conditions (Centers for Medicare & Medicaid Services, 2015). Children and youth are no less impervious to chronic conditions; 1 in 4 have a chronic condition, and 1 in 20 have multiple chronic conditions (CDC, 2019d; Van Cleave et al., 2010). Some of the most common chronic conditions affecting children and youth include asthma, obesity, cerebral palsy, Type 1 diabetes, epilepsy, and neurodevelopmental conditions such as attention deficit hyperactivity disorder (Jin et al., 2017; Miller et al., 2016).
Although chronic mental health conditions such as mood disorders can and do occur in the absence of a physical illness, people who have been diagnosed with a chronic physical condition are at greater risk for developing a chronic mental health condition, such as major depressive disorder, anxiety disorder (Pinquart & Shen, 2011), or substance use disorder (Bahorik et al., 2017; National Institute of Mental Health [NIMH], 2019; Wu et al., 2018). Conversely, people living with chronic mental health conditions are far more likely to develop a chronic physical condition, such as cardiovascular disease or diabetes (NIMH, 2019). The high comorbidity of physical and mental health chronic conditions can be related to medication side effects (e.g., weight gain leading to metabolic syndrome) and is often directly related to SDOH. According to the CDC (2021), “conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes . . . are known as social determinants of health.” SDOH play a major role in the health or ill health of persons, groups, and populations across the life span (Cockerham et al., 2017). SDOH such as adverse childhood events (Chanlongbutra et al., 2018; Sonu et al., 2019) and disparities in access to adequate nutrition (Brown et al., 2008), safe and stable housing (Chhabra et al., 2020), work opportunities (Robert Wood Johnson Foundation, 2008), education (Hahn et al., 2015), and health care (Reed et al., 2019), as well as discrimination and racism, have all been linked to chronic health conditions (Abramson et al., 2015).
Significance and Impact of Chronic Conditions
Chronic conditions are the leading causes of disability and mortality in the United States (CDC, 2019b). Functional limitations are common in people with chronic conditions, and they escalate dramatically with multiple chronic conditions. Among people with one or two chronic conditions, 9% have physical limitations, such as difficulty walking, climbing stairs, or grasping objects; 6% have limitations in performing work or school activities; 2% have limitations in instrumental activities of daily living (IADLs), such as shopping or preparing meals; and 1% have limitations in ADLs, such as bathing or dressing (Buttorff et al., 2017). In contrast, among those with five or more chronic conditions, 51% have physical limitations, 42% have limitations in performing work or school activities; 18% have IADL limitations, and 11% have ADL limitations (Buttorff et al., 2017). People with chronic conditions often face higher mortality rates than their counterparts; on average, each chronic physical condition reduces one’s life span by 1.8 years (DuGoff et al., 2014). Similarly, people with severe chronic mental health conditions have their life expectancy reduced by 10 to 25 years, with most of these deaths attributable to comorbid chronic physical conditions (World Health Organization [WHO], n.d.). These complex comorbidities are largely attributable to SDOH and the subsequent disparities in access to preventive care and other resources to support engagement in health-supporting behaviors among people with chronic mental health conditions (Price et al., 2016).
The implications of a chronic condition are not limited to the person; they may also affect families, groups, and populations. Family members and friends often serve as unpaid care partners to people with chronic conditions. Approximately 53 million U.S. adults provide care to an adult or child each year (AARP Public Policy Institute & National Alliance for Caregiving [NAC], 2020), the majority of whom have chronic (vs. short-term) conditions. These care partners spend an average of 24 hours/week in this role. Forty percent report a high burden of care, and 21% report that their own health is fair to poor, compared with only 10% of those in the general population who do not identify as care partners. Implications for these individuals include physical, emotional, and financial stress as well as potential changes to work routines to accommodate the demands of providing care (AARP Public Policy Institute & NAC, 2020).
Last, the financial cost of chronic conditions is significant. According to the CDC, 90% of annual health care expenditures, or $3.3 trillion per year, related to health care is spent on medical care for people with chronic physical and mental health conditions (CDC, 2019c). Another $226 billion per year is lost because of missed days of work as a result of managing a chronic condition (CDC, 2019e).
Impact of Chronic Conditions on Occupation
Living with one or more chronic conditions has a significant impact on activity patterns and occupational performance (Collins et al., 2005; Crespo et al., 2013; Lai et al., 2020). Self-management of a chronic condition requires engagement in a wide range of health management occupations to maintain health, manage symptoms, and delay or prevent complications. Health management occupations may include symptom and condition management, communication with the health care system, medication management, exercise, and nutrition management (AOTA, 2020). These activities can be extremely time consuming, with one study estimating that people with chronic conditions and their care partners spend approximately 2 hours/day on such activities (Jowsey et al., 2012). In addition, to making time in daily routines to perform health management occupations, the symptoms and sequelae of chronic conditions often affect the performance of other occupations (Pyatak, 2011). For example, people with diabetes may have their workday disrupted to treat an emergent episode of hypoglycemia; those experiencing the symptoms of depression may have difficulty sleeping or initiating their morning self-care routine; and those with arthritis may have pain or weakness that limits their ability to perform activities related to home management.
Scope of Occupational Therapy Practice in Chronic Conditions
Use of an occupation-based approach within the three-tiered public health model can provide the necessary framework for occupational therapy practitioners to successfully influence the genesis and trajectory of chronic conditions. The three-tiered model includes universal services or health promotion (Tier 1), targeted services or disease prevention (Tier 2), and intensive services or intervention (Tier 3) and has been commonly used in approaches to health and wellness (Miles et al., 2010; O’Connell et al., 2009 ; WHO, 2001). Tier 1, or universal services provided by occupational therapy practitioners, includes the promotion of health and wellness through education and opportunities to engage in health-promoting occupations for everyone, regardless of health status. Examples of Tier 1 services include workplace wellness initiatives providing education on stress management and healthy body mechanics, school-based programs addressing positive mental health through community building and peer mentoring activities, and consulting on universal design for public spaces to promote accessibility for all. Tier 2, or targeted services, focuses on people who are at risk for developing a chronic condition, such as those who were exposed to adverse childhood experiences or who have potentially modifiable risk factors (CDC, 2019a; Chanlongbutra et al., 2018; Sonu et al., 2019), as well as those who have developed a chronic condition and are at risk for developing further complications. Targeted services include early identification of risk factors, education, provision of environmental supports or modifications, facilitating the performance of health management occupations, and supporting participation in occupations to enhance health and wellness (Garvey et al., 2015, Kyler et al., 2020). Tier 3, or intensive services, includes interventions to enable participation for people experiencing functional limitations secondary to a chronic condition, such as a person with diabetic peripheral neuropathy who is seeing an occupational therapy practitioner for interventions to address impaired lower body dressing and functional mobility.
Occupational Therapy Process
The changes to occupational performance and engagement attributable to a chronic condition can be significant over time, leading to occupational injustices, most notably occupational imbalance and occupational deprivation. The time and energy required to manage a chronic condition, coupled with often-challenging symptoms, can disrupt activity patterns and occupational engagement. This disruption, in turn, can potentially exacerbate the condition, creating a negative cycle. This scenario exemplifies the unique impact of chronic (vs. acute) conditions that is important to consider in the occupational therapy process. Moreover, it highlights the need to intervene holistically, to consider interconnections among mind, body, and spirit that are inextricably linked. The occupational therapy practitioner’s role is in understanding the unique needs of the person, group, or population in context, as it relates to the occupational impact of the chronic condition.
The typical occupational therapy process encompasses evaluation, intervention, and assessment of outcomes. The occupational therapy evaluation should include consultation and screening, an occupational profile, analysis of occupational performance, and a synthesis of all information gathered (AOTA, 2020). Particular evaluation considerations for chronic conditions can include assessing the temporal dimensions of the condition (e.g., waxing and waning of symptoms), fatigue, and impact on current and desired life roles and activity patterns. Occupational therapy intervention encompasses occupations and activities, interventions to support occupations, education and training, advocacy, virtual interventions, and group interventions (AOTA, 2020). Special considerations for clients with chronic conditions may include care partner education and training (e.g., regarding self-care and compassion fatigue), integrating condition-specific health management activities into daily routines, self-advocacy in expressing health needs and ensuring they are met, and identifying resources for ongoing support. Outcomes are often related to occupational performance, role competence, well-being, and quality of life, and they may vary according to person- and context-specific needs and desires. A unique consideration for outcomes among chronic conditions includes acknowledging the client’s agency in identifying desired outcomes, given the potential for the erosion of self-efficacy that is due to frequent interfacing with health care systems, which can be perceived as disempowering. In Table 1 we provide examples of intervention strategies for three exemplar chronic conditions (obesity, arthritis, and depression), as delivered at Tier 1, Tier 2, and Tier 3 levels of intervention. In the Appendix, the occupational therapy intervention process is presented in further detail for people diagnosed with chronic conditions. The examples in both Table 1 and the Appendix illustrate the wide range of occupational therapy intervention strategies with potential relevance to persons, groups, and populations with, or at risk of developing, chronic conditions.
Examples of Person-, Group-, and Population-Level Intervention Strategies in the Three-Tier Model for Chronic Conditions
Footnotes
Copyright © 2022 by the American Occupational Therapy Association, Inc.
Case Examples of Occupational Therapy Intervention for Chronic Conditions
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• Quitting smoking—feels “out of breath” during all activities/occupations that require physical exertion ∘ Importance 10/10 ∘ Performance 1/10 ∘ Satisfaction 1/10 • Emotional regulation—“pops off” at others when his feelings and point of view are not validated ∘ Importance 8/10 ∘ Performance 5/10 ∘ Satisfaction 4/10 • Making friends—Alex has difficulty making meaningful connections with others and sometimes misinterprets their social cues. ∘ Importance 10/10 ∘ Performance 5/10 ∘ Satisfaction 5/10 Alex’s high ACES score indicates that complex trauma has played a significant role in his development, in particular in regard to strategies to manage his chronic stress (smoking, use of movement, and avoidance of touch and auditory input). Alex seems highly motivated to engage in self-development, although does state that he is “nervous” about his ability to quit smoking. Both person and group occupational therapy intervention are recommended to develop social support and emotion regulation strategies and improve health behaviors related to smoking and physical conditioning. |
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A trauma-sensitive and recovery-oriented approach was used with Alex to promote justice, voice, and choice for him. Alex engaged in 1:1 daily sessions with the OT practitioner to develop mindfulness strategies, including body-based work such as deep breathing, body scans, and simple chair yoga techniques to decrease stress response and enable emotional regulation. Alex agreed to participate in a smoking cessation group based on harm reduction. To support his efforts, he and the OT practitioner developed a sensory toolbox for him to enhance interoception and use when emotionally escalating. Energy conservation techniques were identified and mastered by Alex to accommodate the decreased respiratory function secondary to smoking. Alex is hopeful that he will not need these techniques if he is successful with smoking cessation. Through the smoking cessation group, Alex developed several relationships and exchanged information with members to enhance his community support system. Last, Alex engaged in exercise routines within tolerable limits 5 days/week on the unit and wants to continue to include these exercises in his daily routine upon discharge. Outpatient OT and social work were recommended to follow up with Alex’s desire to be more independent in his living situation. |
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The COPM was readministered, with positive change scores in all identified areas of importance noted as follows: (1) quitting smoking +5 performance, +6 satisfaction; (2) emotional regulation +2 performance, +3 satisfaction; and (3) making friends +2 performance, +2 satisfaction. Alex identified a variety of desired outcomes as a result of participating in the OT evaluation process. Health and wellness, which he has struggled with for many years and which resulted in a chronic condition (COPD), was addressed through a smoking cessation group and a regular exercise routine, as was preventing further complications secondary to the COPD. By the end of his 3-week hospitalization, Alex had cut his cigarette consumption by half and had not missed a day of exercising while on the unit. A desire to make friends resulted in improved social participation and role competence as a friend. Finally, quality of life was greatly improved as Alex physically felt better because of the exercise program and decrease in cigarette smoking. He also reported fewer positive symptoms associated with his diagnosis of schizoaffective disorder. |
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American Occupational Therapy Association. (2018). Adults with serious mental illness.
https://www.aota.org/∼/media/Corporate/Files/Secure/Practice/CCL/Mental%20Health/MH_MiniCAT_Exercise.pdf
D’Amico, M. L., Jaffe, L. E., & Gardner, J. A. (2018). Evidence for interventions to improve and maintain occupational performance and participation for people with serious mental illness: A systematic review. American Journal of Occupational Therapy, 72, 7205190020. https://doi.org/10.5014/ajot.2018.033332 Griffin Lannigan, E., & Noyes, S. (2019). Occupational therapy interventions for adults living with serious mental illness. American Journal of Occupational Therapy, 73, 1–5. https://doi.org.une.idm.oclc.org/10.5014/ajot.2019.735001 Kaldenberg, J., Newman, R., & Emmert, C. (2020). Self-management interventions for social and leisure participation among community-dwelling adults with chronic conditions: Systematic review of related literature from 1995–2018. American Occupational Therapy Association. Kalmakis, K. A., & Chandler, G. E. (2015). Health consequences of adverse childhood experiences: A systematic review. Journal of the American Association of Nurse Practitioners, 27, 457–465. https://doi.org.une.idm.oclc.org/10.1002/2327-6924.12215 Pfeiffer, B., Brusilovskiy, E., Bauer, J., & Salzer, M. S. (2014). Sensory processing, participation, and recovery in adults with serious mental illnesses. Psychiatric Rehabilitation Journal, 37, 289–296. https://doi.org.une.idm.oclc.org/10.1037/prj0000099 |
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• Meal preparation: Finding healthy breakfasts and lunches that can be prepared quickly to take to school (Importance 8/10, Performance 6/10, Satisfaction 5/10) • Physical activity: Engaging in at least 20 min of moderate physical activity at least 5 ×/week (Importance 7/10, Performance 4/10, Satisfaction 3/10) • Taking medications: Establishing a consistent routine for taking daily medications (Importance 10/10, Performance 7/10, Satisfaction 6/10) The findings of Ale’s evaluation indicated that she has difficulty consistently performing health management occupations relevant to effectively managing her diabetes. She is motivated to improve her performance on these tasks to minimize the risk of developing complications, and she has good support from her family to enact lifestyle changes. Ale and her family would benefit from OT services to implement consistent routines for taking medications and engaging in physical activity and education on meal preparation strategies to improve the nutritional quality of their meals and incorporate preparation of healthy meals into their weekday routines. |
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Ale, her mother, and her brothers attended weekly group sessions for 16 weeks to address goals related to meal preparation, physical activity, and taking medications. To address meal preparation, the dietician reviewed healthy eating patterns for people with diabetes, while the OTA coached Ale and her family in identifying healthy meals that could be prepared quickly for weekday breakfasts and lunches to take to school. In some cases, this meant adapting meals they already enjoyed to meet nutritional goals (e.g., eating whole rather than refined grains, adjusting portion sizes, or substituting leafy for starchy vegetables) and in other cases trying new recipes to find ones that the family enjoyed. The OT, drawing on Ale’s interest in art, involved her in creating illustrations for a family cookbook that included recipes, meal plans, and grocery lists to facilitate ongoing carryover of meal preparation at home. To address physical activity, the OTA reviewed strategies to incorporate physical activity into the family’s daily routines and developed a plan with the family to incorporate more activity into their day. Over several weeks, Ale gradually increased her physical activity through walking to school each morning instead of getting a ride, doing body weight exercises while watching television in the evening, and going dancing with her friends more often on weekends. To address taking medications, the OT provided education on habit formation and the strategy of chaining with an existing habitual activity. Ale and her mother (who also takes diabetes medications) identified packing school lunches as a strong habit and an activity they did together. They placed their medications in the kitchen next to the lunch supplies as a cue to take their medication at that time, and they supported one another with reminders to take their medication until it became a habit. |
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Ale and her family derived several measurable benefits from the OT program. Ale addressed her goals of improving her medication routines, healthy eating, and physical activity. By the time of discharge, she was taking her medication consistently at least 6/7 days/week, had increased her physical activity to an average of 20 min/day, and was preparing breakfasts and lunches 5/7 days/week that were consistent with her nutritional goals. Her COPM scores reflected +2 Performance/+3 Satisfaction for meal preparation, +4 Performance/+2 Satisfaction for physical activity, and +1 Performance/+2 Satisfaction for taking medications. Similarly, her scores on the DSMQ subscales increased an average of 1.7 points, reflecting a clinically meaningful change. In addition, because Ale’s blood sugar levels were lower, she was experiencing decreased fatigue, more energy, and better sleep because of decreased nocturia. Ale’s mother also started taking her diabetes medications more consistently and reported preparing healthier meals for the family at mealtimes. Last, Ale’s family expressed increased knowledge about how to manage diabetes and less anxiety about the possibility of developing diabetes complications. All of these changes increased the family’s overall well-being. |
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Cahill, S. M., Polo, K. M., Egan, B. E., & Marasti, N. (2016). Interventions to promote diabetes self-management in children and youth: A scoping review. American Journal of Occupational Therapy, 70, 7005180020. https://doi.org/10.5014/ajot.2016.021618
Fritz, H. (2014). The influence of daily routines on engaging in diabetes self-management. Scandinavian Journal of Occupational Therapy, 21, 232–240. https://doi.org/10.3109/11038128.2013.868033 Pyatak, E. A., Carandang, K., Vigen, C. L., Blanchard, J., Diaz, J., Concha-Chavez, A., . . . Peters, A. L. (2018). Occupational therapy intervention improves glycemic control and quality of life among young adults with diabetes: The Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) randomized controlled trial. Diabetes Care, 41, 696–704. https://doi.org/10.2337/dc17-1634 Pyatak, E., King, M., Vigen, C. L., Salazar, E., Diaz, J., Niemiec, S. L. S., . . . Shukla, J. (2019). Addressing diabetes in primary care: Hybrid effectiveness–implementation study of Lifestyle Redesign® occupational therapy. American Journal of Occupational Therapy, 73, 7305185020. https://doi.org/10.5014/ajot.2019.037317 Sokol-McKay, D. A. (2011). Occupational therapy’s role in diabetes self-management [Fact sheet]. American Occupational Therapy Association. http://www.aota.org/Consumers/Professionals/WhatIsOT/HW/Facts/Diabetes.aspx Thompson, M. (2014). Occupations, habits, and routines: Perspectives from persons with diabetes. Scandinavian Journal of Occupational Therapy, 21, 153–160. https://doi.org/10.3109/11038128.2013.851278 |
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Robert’s occupational therapy evaluation indicated limitations in several areas of functioning, including self-care, home management, community integration, and leisure. His current reliance on opiates as a first-line treatment of pain, depressive symptoms, and limited self-efficacy in coping with pain contribute to his current limited level of functioning. Robert is motivated to participate in treatment to develop pain coping strategies that enable his performance of self-care and increased engagement in activities outside the home. Occupational therapy services are indicated to address ADL and IADL performance and satisfaction, increase pain management skills, and improve community integration. |
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Robert attended a chronic pain clinic 1×/week for 12 weeks. Robert’s list of concerns related to his chronic pain were varied and numerous, and in collaborating with Robert the following areas of concern were prioritized: (1) learn strategies to minimize pain during daily routines, including self-care; (2) develop relaxation and coping strategies to increase sense of control over and competency with pain management; (3) identify potential low or unpaid work opportunities; and (4) develop a support system. The therapist used a coaching model to support Robert in acquisition of pain management strategies. Coaching was used to support development of competency and perception of control over the pain and situation. Strategies included chunking tasks to embed rest breaks, body mechanics training, and a home assessment to modify/adapt the environment to adhere to ergonomic principles. The therapist used mindfulness activities, such as body scans, breathing techniques, and noncontact therapeutic touch to support Robert in developing a repertoire of techniques he could use to manage the pain without the use of prescription medications. The therapist and Robert collaboratively developed a plan to reestablish a volunteer work routine at a local community garden for those living in a food desert, which addressed his interest of being outside and creating meaningful social support and human connections. Finally, the therapist worked with Robert to establish a plan for networking, which included a local chronic pain support group. Robert also explored social skills related to asserting himself to get his social and emotional needs met. |
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Robert’s quality of life was significantly improved following participation in occupational therapy via the chronic pain clinic. He learned many new strategies to decrease and manage pain and reported that he no longer relies on prescription opiates as a first line of defense against the pain. Robert’s score on the PSEQ increased 14 points, indicating a clinically meaningful improvement in his ability to manage pain. Using proper body mechanics and principles of ergonomics also improved Robert’s occupational performance related to self-care skills, such as bathing and dressing. Robert’s newfound ability to self-manage much of the pain increased his well-being and sense of hope about his future, which contributed to a decrease in depressive symptoms—his BDI 2 score decreased to 15, indicating mild depressive symptoms. Robert has been consistent in attending his volunteer position at the local community garden, and his role competence regarding his perception of his worker role was enhanced. Robert’s attendance at the local support group was initially sporadic. The occupational therapy practitioner suggested that he volunteer to lead the group 1×/mo, which has increased his attendance and participation in the group significantly. His leadership in this area and connection with others who are experiencing similar challenges has also contributed to his sense of well-being. |
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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
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Note. ADL = activities of daily living; IADL = instrumental activities of daily living; OT = occupational therapy/therapist; OTA = occupational therapy assistant.