American Journal of Occupational Therapy

Each issue of the 2017 volume of the American Journal of Occupational Therapy will feature a special Centennial Topics section containing two to four articles related to a specific theme. The goal is to acknowledge occupational therapy’s history while focusing on the future of the profession. The Centennial Topics section is intended to help occupational therapy professionals in all aspects of the profession take stock of how far the profession has come and to spark interest in the many exciting paths for the future development of the field.

One in four individuals living in the United States has multiple chronic conditions (MCCs), and the already high prevalence of MCCs continues to grow. This population has high rates of health care utilization yet poor outcomes, leading to elevated concerns about fragmented, low-quality care provided within the current health care system. Several national initiatives endeavor to improve care for the population with MCCs, and occupational therapy is uniquely positioned to contribute to these efforts for more efficient, effective, client-centered management of care. By integrating findings from the literature with current policy and practice, we aim to highlight the potential role for occupational therapy in managing MCCs within the evolving health care system.

OBJECTIVE. More is known about the experience of occupational therapists than the experience of patients during the profession’s early years. We examined soldiers’ experiences of occupational therapy in American Base Hospital 9 in France during World War I through analysis of a 53-line poem by Corporal Frank Wren contained in the unpublished memoir of occupational therapy reconstruction aide Lena Hitchcock.

METHOD. Historical documentary research methods and thematic analysis were used to analyze the poem, the memoir, and the hospital’s published history.

RESULTS. The poem describes the activities engaged in during occupational therapy, equipment used, and the context of therapy. It articulates positive dimensions of the experience of engaging in activities, including emotional benefits, diversion, and orthopedic benefits.

CONCLUSION. Previous historical research has identified core philosophical premises about the use of occupational therapy; in this article, the enactment of these principles is established through the analysis of a soldier’s account of receiving occupational therapy.

Helen Willard (1894–1980) and Clare Spackman (1909–1992) paved the way for modern and future occupational therapy. This article validates the need for historical research in occupational therapy and presents a historical study on how the personal and professional collaboration of Willard and Spackman influenced occupational therapy. Data were gathered from archival documents, private papers, and 10 oral histories with colleagues, students, family, and friends. We used text analysis with triangulation to develop themes to reconstruct a proximity of the historical story. Two major themes that describe Willard’s and Spackman’s influence on occupational therapy are (1) Enduring Legacies and (2) Sacred Solitude and Chosen Gatherings. Subthemes within Enduring Legacies include Guiding Practice, Leaders in Service, and Educational Leadership. These women strongly influenced practitioners worldwide while maintaining the sacredness of their private lives. Their example can serve as a model for current and future occupational therapy practitioners and leaders.

In this article, we describe the use of the objects and spaces of the physical environment by occupational therapy practitioners in the United States over the profession’s first 100 years. Using professional literature selected by decade from the years 1917 through 2016 to obtain data, we applied grounded theory methods to complete a detailed description. Team-based analysis over four coding schemes yielded a theoretical description of the profession’s therapeutic use of the physical environment. Study findings included descriptions across occupational therapy’s history of (1) treatment spaces, (2) the concepts of adapting and grading, and (3) a typology of constructive and nonconstructive applications of objects and activities by occupational therapy clients and practitioners. This extended historical perspective on trajectories of change in intervention space, the role of physical products in intervention, therapist repertoire, and the enduring role of adaptation suggests how the physical environment may be used in future practice.

At 99 years old, occupational therapy is a global health care profession with a growing orientation toward justice. Because much of the occupational justice discourse has developed outside the United States, parallels between the profession’s ethos and its current focus on justice must be examined more closely in this country. Although occupational therapy practitioners in the United States are better equipped than their predecessors with language and theories that explicitly emphasize justice, the potential for bringing that focus to bear depends on practitioners’ willingness to think differently about their practices. We argue that a focus on justice can be naturally integrated with curriculum standards by emphasizing the link between cultural humility, client-centeredness, and embodied habits of “seeking out unknown others.” Outside formal education, practitioners can be encouraged to think of justice as something that already intersects with practice, not something that practitioners must choose whether to take up.

Evidence-based practice (EBP) is a widely endorsed concept, but many occupational therapy practitioners would like to be more informed and supported in its full implementation. They need information on the evolving definitions and concepts of EBP, encouragement to develop and adopt EBP models that link to occupational therapy’s professional values, and methods that translate evidence into answers for clinical questions. This column discusses these needs and makes recommendations to the American Occupational Therapy Association for addressing them.

Musculoskeletal conditions are the second greatest cause of disability worldwide, and chronic musculoskeletal conditions affect nearly the same percentage of the general population as chronic circulatory and respiratory conditions combined. Moreover, people with musculoskeletal conditions experience a significant decline in independence with daily activities and occupational performance, key areas targeted by occupational therapy interventions. This special issue of the American Journal of Occupational Therapy provides comprehensive summaries of evidence for the care of common musculoskeletal conditions, highlights important implications that support evidence-informed practice, and proposes ways to advance the practice of occupational therapy to improve the lives of people with musculoskeletal conditions.

Occupational therapy practitioners are key health care providers for people with musculoskeletal disorders of the distal upper extremity. It is imperative that practitioners understand the most effective and efficient means for remediating impairments and supporting clients in progressing to independence in purposeful occupations. This systematic review provides an update to a previous review by summarizing articles published between 2006 and July 2014 related to the focused question, What is the evidence for the effect of occupational therapy interventions on functional outcomes for adults with musculoskeletal disorders of the forearm, wrist, and hand? A total of 59 articles were reviewed. Evidence for interventions was synthesized by condition within bone, joint, and general hand disorders; peripheral nerve disorders; and tendon disorders. The strongest evidence supports postsurgical early active motion protocols and splinting for various conditions. Very few studies have examined occupation-based interventions. Implications for occupational therapy practice and research are provided.

People with musculoskeletal disorders of the shoulder commonly experience pain, decreased strength, and restricted range of motion (ROM) that limit participation in meaningful occupational activities. The purpose of this systematic review was to evaluate the current evidence for interventions within the occupational therapy scope of practice that address pain reduction and increase participation in functional activities. Seventy-six studies were reviewed for this study—67 of Level I evidence, 7 of Level II evidence, and 2 of Level III evidence. Strong evidence was found that ROM, strengthening exercises, and joint mobilizations can improve function and decrease pain. The evidence to support physical modalities is moderate to mixed, depending on the shoulder disorder. Occupational therapy practitioners can use this evidence to guide daily clinical decision making.

Lower-extremity (LE) musculoskeletal disorders (MSDs) can have a major impact on the ability to carry out daily activities. The effectiveness of interventions must be examined to enable occupational therapy practitioners to deliver the most appropriate services. This systematic review examined the literature published between 1995 and July 2014 that investigated the effectiveness of occupational therapy interventions for LE MSDs. Forty-three articles met the criteria and were reviewed. Occupational therapy interventions varied on the basis of population subgroup: hip fracture, LE joint replacement, LE amputation or limb loss, and nonsurgical osteoarthritis and pain. The results indicate an overall strong role for occupational therapy in treating clients with LE MSDs. Activity pacing is an effective intervention for nonsurgical LE MSDs, and multidisciplinary rehabilitation is effective for LE joint replacement and amputation. Further research on specific occupational therapy interventions in this important area is needed.

OBJECTIVE. This systematic review addresses the effectiveness of occupational therapy–related interventions for adults with fibromyalgia.

METHOD. We examined the literature published between January 2000 and June 2014. A total of 322 abstracts from five databases were reviewed. Forty-two Level I studies met the inclusion criteria. Studies were evaluated primarily with regard to the following outcomes: daily activities, pain, depressive symptoms, fatigue, and sleep.

RESULTS. Strong evidence was found for interventions categorized for this review as cognitive–behavioral interventions; relaxation and stress management; emotional disclosure; physical activity; and multidisciplinary interventions for improving daily living, pain, depressive symptoms, and fatigue. There was limited to no evidence for self-management, and few interventions resulted in better sleep.

CONCLUSION. Although the evidence supports interventions within the scope of occupational therapy practice for people with fibromyalgia, few interventions were occupation based.

OBJECTIVE. We reviewed the efficacy of occupational therapy–related interventions for adults with rheumatoid arthritis.

METHOD. We examined 51 Level I studies (19 physical activity, 32 psychoeducational) published 2000–2014 and identified from five databases. Interventions that focused solely on the upper or lower extremities were not included.

RESULTS. Findings related to key outcomes (activities of daily living, ability, pain, fatigue, depression, self-efficacy, disease symptoms) are presented. Strong evidence supports the use of aerobic exercise, resistive exercise, and aquatic therapy. Mixed to limited evidence supports dynamic exercise, Tai Chi, and yoga. Among the psychoeducation interventions, strong evidence supports the use of patient education, self-management, cognitive–behavioral approaches, multidisciplinary approaches, and joint protection, and limited or mixed evidence supports the use of assistive technology and emotional disclosure.

CONCLUSION. The evidence supports interventions within the scope of occupational therapy practice for rheumatoid arthritis, but few interventions were occupation based.

OBJECTIVES. The objectives of this study were to investigate whether people with rheumatoid arthritis (RA) require greater muscle loads to equal the grip strength of healthy adults and to find the optimal grip distance for people with RA using carpometacarpal and metacarpophalangeal immobilization orthoses as measured by electromyography of the forearm muscles.

METHOD. A 2 × 2 (Group × Orthosis) experiment and a 2 × 3 (Orthosis × Grasp Distance) factorial were conducted. Grip strength and muscle load were measured.

RESULTS. Grip strength was significantly lower, and muscle load was greater, in 18 participants with RA than in 18 healthy adults. No effect of orthosis use on grip strength and muscle load was found. Muscle load was lower for the 42.25-mm diameter dynamometer handle than for handles with larger diameters.

CONCLUSION. People with RA require more muscle load than healthy adults to produce the same exertion, and 42.25 mm is recommended for people with RA as the optimal grasp distance.

OBJECTIVE. We evaluated whether a joint-protection strategy changes the mechanics of opening a sealed jar.

METHOD. Thirty-one adult women with hand osteoarthritis attempted to open a “sealed” jar instrument when using and not using nonskid material. Grip force, torque, success, and pain were recorded for each trial.

RESULTS. Participants used less grip force when twisting with their left hand. The greatest torque and success, yet the least amount of grip force across time, and pain was noted when the left hand turned the lid, the jar was held vertically, the right hand supported the base, and nonskid material was used.

CONCLUSION. Women with hand osteoarthritis should be educated to consider the hand they use and their approach when opening sealed jars. Use of nonskid material without additional reasoning may increase load on arthritic joints, pain, and dysfunction. Additional research on task kinematics and the kinetics of the stabilizing hand is needed.

Little is known about injury prevention in recycling workers; therefore, in this study, I aimed to identify physical and psychosocial risk factors for employees involved in single-stream recycling and to explore strategies for prevention and wellness. Fifteen participants who were either recycling workers or supervisors located throughout seven locations on an urban university campus participated. A mixed-methods research design was used to obtain data through a variety of standardized work environment and health questionnaires and semistructured interviews. Approximately 80% of participants expressed satisfaction with their jobs; 50% reported having a musculoskeletal injury; and 33% reported a lack of support from coworkers or supervisors, which created stress and anxiety. Additional risk factors included poor body mechanics, equipment issues, poor social interactions, and lack of supervisor knowledge for prevention. Occupational therapy practitioners are well situated to support preventive interventions that address the combined physical and psychosocial needs of recycling workers.

Work-related musculoskeletal disorders are a significant burden; however, no consensus has been reached on how to maximize occupational rehabilitation programs for people with these disorders, and the impact of simulating work tasks as a mode of intervention has not been well examined. In this retrospective cohort study, the authors used logistic regression to identify client and program factors predicting success for 95 clients in a general occupational rehabilitation program and 71 clients in a comprehensive occupational rehabilitation program. The final predictive model for general rehabilitation included gender, number of sessions completed, and performance of work simulation activities. Maximum hours per session was the only significant predictor of success in the comprehensive rehabilitation program. This study identifies new factors associated with success in occupational rehabilitation, specifically highlighting the importance of intensity (i.e., session length and number of sessions) of therapy and occupation-based activities for this population.

OBJECTIVE. We sought to understand the wide range of problems that patients with upper-extremity peripheral nerve disorders experience and to identify predictors of disability and quality of life (QOL).

METHOD. Data from standardized assessments of disability and QOL, physical examination results, and intake surveys from 627 patients were analyzed using descriptive and inferential statistics. We compared results between groups and built multivariate models measuring disability, work disability, and physical and mental QOL.

RESULTS. The sample demonstrated substantial disability and even greater work disability, which both closely correlated with poorer QOL. Work status was integral in predicting disability. Common predictors across models included problems with sleep and intimate relationships, deficits in work and household performance, and higher pain.

CONCLUSION. To decrease disability and improve QOL, occupational therapy practitioners should help patients with upper-extremity peripheral nerve disorders identify strategies to maintain meaningful work and household roles, intimate relationships, and sleep, while continuing to address pain.

OBJECTIVE. We sought to identify outcome instruments used in rehabilitation of the hand and upper extremity; to determine their alignment with the constructs of the International Classification of Functioning, Disability and Health (ICF) and the Occupational Therapy Practice Framework: Domain and Process; and to report gaps in the constructs measured by outcome instruments as a basis for future research.

METHOD. We searched CINAHL, MEDLINE, OTseeker, and the Cochrane Central Register of Controlled Trials using scoping review methodology and evaluated outcome instruments for concordance with the ICF and the Framework.

RESULTS. We identified 18 outcome instruments for analysis. The findings pertain to occupational therapists’ focus on body functions, body structures, client factors, and activities of daily living; a gap in practice patterns in use of instruments; and overestimation of the degree to which instruments used are occupationally based.

CONCLUSION. Occupational therapy practitioners should use outcome instruments that embody conceptual frameworks for classifying function and activity.

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s (AOTA’s) Evidence-Based Practice Project. In this Evidence Connection article, we describe a case report of an adolescent with autism spectrum disorder. The occupational therapy assessment and treatment processes for school, home, community, and transition settings are described. Findings from the systematic reviews on this topic were published in the September/October 2015 issue of the American Journal of Occupational Therapy and in AOTA’s Occupational Therapy Practice Guidelines for Individuals With Autism Spectrum Disorder. Each article in this series summarizes the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical decision making.