OT Foundations & Theories
Core concepts, models of practice, and theoretical frameworks in occupational therapy
Table of Contents
1. Core Concepts of OT
Definition of Occupational Therapy
WFOT Definition: "Occupational therapy is a client-centered health profession concerned with promoting health and well-being through occupation. The primary goal is to enable people to participate in the activities of everyday life."
- Occupation: Daily activities that people do as individuals, families, and communities
- Purposeful Activity: Goal-directed behaviors or tasks that comprise occupations
- Meaningful Activity: Activities that hold personal or cultural significance
Philosophical Base of OT
Core Beliefs
- Humans are occupational beings
- Occupation is essential for health
- Engagement in occupation promotes well-being
- Occupational balance is important
- Humans have innate need for occupation
Occupational Justice
- Everyone deserves access to occupation
- Occupational deprivation - lack of opportunity
- Occupational imbalance - over/under engagement
- Occupational alienation - meaningless occupation
- Occupational marginalization - limited choices
Historical Foundations
| Era | Key Features |
|---|---|
| Moral Treatment (1800s) | Humane treatment through occupation; Philippe Pinel, William Tuke |
| Arts & Crafts Movement | Value of handwork and creative activity; Eleanor Clarke Slagle |
| Founding of OT (1917) | National Society for the Promotion of OT; Six founders |
| Reductionism (1940s-70s) | Medical model influence; focus on components |
| Return to Occupation (1980s+) | Occupation-based practice; client-centered approach |
2. Areas of Occupation (OTPF-4)
Activities of Daily Living (ADLs)
- Bathing/Showering
- Toileting and toilet hygiene
- Dressing
- Eating/Swallowing
- Feeding
- Functional mobility
- Personal hygiene and grooming
- Sexual activity
Instrumental ADLs (IADLs)
- Care of others/pets
- Child rearing
- Communication management
- Driving and community mobility
- Financial management
- Health management
- Home establishment and management
- Meal preparation and cleanup
- Shopping
Rest and Sleep
- Rest - quiet, effortless activity
- Sleep preparation
- Sleep participation
Education
- Formal educational participation
- Informal personal education
- Exploration of informal education needs
Work
- Employment interests and pursuits
- Employment seeking and acquisition
- Job performance
- Retirement preparation
- Volunteer exploration and participation
Play
- Play exploration
- Play participation
- Spontaneous, enjoyable activity
Leisure
- Leisure exploration
- Leisure participation
- Nonobligatory, intrinsically motivated
Social Participation
- Community participation
- Family participation
- Peer/Friend participation
3. Model of Human Occupation (MOHO)
Developer: Gary Kielhofner (1980)
Focus: Understanding motivation, pattern, and performance of occupation through dynamic interaction of person, environment, and occupation
Three Personal Components
Volition
Motivation for occupation
- Personal Causation: Sense of capacity and effectiveness
- Values: What is important and meaningful
- Interests: What brings enjoyment
Habituation
Patterns of occupation
- Habits: Automatic ways of doing things
- Roles: Social positions that organize behavior
- Provides structure and routine
Performance Capacity
Ability to perform
- Objective: Physical and mental abilities
- Subjective: Lived body experience
- Skills and underlying capacities
Environment in MOHO
Physical Environment
- Spaces - physical settings
- Objects - tools and materials
Social Environment
- Social groups - family, friends, coworkers
- Occupational forms - tasks with social meaning
MOHO Assessments
- OPHI-II: Occupational Performance History Interview
- OCAIRS: Occupational Circumstances Assessment Interview
- MOHOST: Model of Human Occupation Screening Tool
- VQ: Volitional Questionnaire
- OSA: Occupational Self Assessment
- WRI: Worker Role Interview
- ACIS: Assessment of Communication and Interaction Skills
4. Person-Environment-Occupation (PEO) Model
Developers: Law, Cooper, Strong, Stewart, Rigby & Letts (1996)
Focus: Transactive relationship between person, environment, and occupation, with occupational performance as the outcome
Three overlapping circles (Venn diagram)
P ∩ E ∩ O = Occupational Performance
Greater overlap = Better fit = Better performance
Person
- Unique being with roles, experiences
- Mind-body-spirit connection
- Attributes: cognition, physical, sensory, affective, spiritual
- Self-concept and personality
- Skills and abilities
Environment
- Physical: Natural and built
- Social: People, relationships
- Cultural: Customs, beliefs
- Institutional: Policies, laws
- Can enable or constrain
Occupation
- Self-directed, functional tasks
- Clusters of activities and tasks
- Self-maintenance, productivity, leisure
- Changes over lifespan
- Context and meaning matter
Key Concepts
- Person-Environment-Occupation Fit: Congruence between all three components
- Occupational Performance: Result of dynamic interaction; the outcome of interest
- Transactive: Continuous interaction; changes in one affect others
- Temporal: Changes across lifespan; developmental considerations
Clinical Application
The PEO model guides intervention planning. OTs can improve occupational performance by:
- Modify the person: Build skills, remediate deficits
- Modify the environment: Adapt physical/social contexts
- Modify the occupation: Grade or adapt the task
- Any combination that improves fit
5. Canadian Model of Occupational Performance and Engagement (CMOP-E)
Developer: Canadian Association of Occupational Therapists (CAOT)
Focus: Client-centered practice emphasizing spirituality as core of the person; adds "engagement" to performance
Model Structure
Nested Triangles Visualization:
Outer layer: ENVIRONMENT (Physical, Institutional, Cultural, Social)
Middle layer: OCCUPATION (Self-care, Productivity, Leisure)
Inner triangle: PERSON (Physical, Cognitive, Affective)
Core: SPIRITUALITY
Person (Inner Triangle)
- Physical: Sensory, motor, sensorimotor
- Cognitive: Thinking, reasoning, memory
- Affective: Emotions, feelings, coping
- Spirituality (Core): Will, motivation, meaning, self-determination
Occupation (Middle Layer)
- Self-care: Looking after self (ADLs)
- Productivity: Contributing to society (work, school, homemaking)
- Leisure: Enjoyment (play, hobbies, socialization)
Environment (Outer Layer)
Physical
Natural and built
Institutional
Policies, laws, economics
Cultural
Customs, beliefs, values
Social
Relationships, groups
The "E" - Engagement
Engagement goes beyond performance to include the subjective experience of occupation - involvement, commitment, and meaning. A person can be engaged without performing (contemplating, planning) or performing without full engagement.
Associated Assessment: COPM
Canadian Occupational Performance Measure
- Semi-structured interview
- Client identifies occupational performance issues
- Rates importance, performance, and satisfaction (1-10)
- Guides goal setting
- Measures outcomes (re-assess post-intervention)
6. Occupational Therapy Practice Framework (OTPF-4)
Publisher: American Occupational Therapy Association (AOTA)
Current Version: OTPF-4 (2020)
Purpose: Official document describing the domain and process of OT practice
Domain of OT
The domain describes the scope of OT practice - what OTs address:
Occupations
ADLs, IADLs, Rest/Sleep, Education, Work, Play, Leisure, Social Participation
Client Factors
Values, beliefs, spirituality; Body functions; Body structures
Performance Skills
Motor skills; Process skills; Social interaction skills
Performance Patterns
Habits, Routines, Roles, Rituals
Context
Environmental and Personal factors (ICF aligned)
OT Process
| Phase | Components |
|---|---|
| Evaluation |
|
| Intervention |
|
| Outcomes |
|
Types of OT Interventions
- Occupations and Activities: Client-directed, meaningful occupations
- Interventions to Support Occupations: Preparatory methods, tasks, and activities
- Education and Training: Knowledge transmission and skill development
- Advocacy: Promoting occupational justice
- Group Interventions: Using group dynamics therapeutically
- Virtual Interventions: Technology-mediated services
7. Frames of Reference
Frame of Reference (FOR): A set of interrelated concepts that guide practice in specific areas. Unlike models (broad), FORs are more specific and guide evaluation and intervention choices.
| Frame of Reference | Focus | Key Concepts |
|---|---|---|
| Biomechanical | Physical/structural | ROM, strength, endurance; intact CNS required |
| Rehabilitation/Compensatory | Adaptation | Adaptive equipment, environmental modification |
| Neurodevelopmental (NDT) | Movement quality | Normal movement patterns, handling techniques |
| Motor Control/Learning | Skill acquisition | Practice, feedback, task-oriented approach |
| Sensory Integration | Sensory processing | Integration of vestibular, proprioceptive, tactile input |
| Cognitive-Behavioral | Thoughts and behaviors | Cognitive restructuring, behavioral strategies |
| Cognitive Disabilities (Allen) | Cognitive levels | ACL levels 1-6, task environment matching |
| Developmental | Sequential development | Milestones, developmental sequence |
Allen Cognitive Levels (ACL)
| Level | Name | Characteristics |
|---|---|---|
| 1 | Automatic Actions | Reflexive, minimal awareness |
| 2 | Postural Actions | Proprioceptive, gross motor |
| 3 | Manual Actions | Tactile, repetitive, object use |
| 4 | Goal-Directed Actions | Visual, completes familiar tasks with cues |
| 5 | Exploratory Actions | Trial and error learning, new situations |
| 6 | Planned Actions | Abstract reasoning, anticipates consequences |
8. Clinical Reasoning in OT
Types of Clinical Reasoning
Scientific/Procedural
Focuses on diagnosis and treatment procedures. "What is the problem and what procedures will address it?"
Narrative
Understands the client's story, life context, and meaning. "What is this person's life story?"
Interactive
Builds therapeutic relationship. "How do I connect with this person?"
Conditional
Integrates all reasoning; considers future possibilities. "What might be possible?"
Pragmatic
Considers practical constraints: time, resources, reimbursement, setting.
Ethical
Addresses moral aspects of practice. "What is the right thing to do?"
Evidence-Based Practice
Definition: Integration of best available evidence with clinical expertise and client values/preferences
Best Evidence
Research, literature, data
Clinical Expertise
Practitioner knowledge and skills
Client Values
Individual preferences, goals
Levels of Evidence
- Level I: Systematic reviews, meta-analyses, RCTs
- Level II: Two or more group studies (non-randomized)
- Level III: One group studies (non-randomized)
- Level IV: Single subject designs, case series
- Level V: Case reports, expert opinion
Key Takeaways for the Board Exam
- ✓OTPF-4 has 9 areas of occupation (OTPF-3 had 8)
- ✓MOHO: Volition (motivation), Habituation (patterns), Performance Capacity
- ✓PEO: Three circles (P, E, O) - overlap = occupational performance
- ✓CMOP-E: Spirituality at core; "E" means engagement beyond performance
- ✓COPM: Client-centered assessment with CMOP-E; rates importance, performance, satisfaction
- ✓Allen Cognitive Levels: 1-6 scale; Level 4 = goal-directed with cues
- ✓Biomechanical FOR: Requires intact CNS; focuses on ROM, strength, endurance
- ✓OT Process: Evaluation → Intervention → Outcomes