Occupational science and therapy

This essay will attempt an explanation of occupational science and its’ value for the Occupational Therapy profession in viewing occupational experiences, looking at the core skill of activity/occupation analyses in professional practice, and how this applies to the process of occupational analysis with a chosen personal occupational performance to discuss the ‘form, function and meaning’ of a personal experience and will conclude with an evaluation of how an understanding of activity analysis will inform the development of professional practice.

Occupational science is the study of occupation and the influences that shape occupation. Occupational science researchers seek to develop knowledge on; humans as occupational beings, the form, function and meaning of human occupation, the relationship between human occupation and health and the contextual influences on occupation. Although occupational science is an interdisciplinary field of enquiry, its central focus on occupation means that it can inform the practice of Occupational Therapy (Clark et al 1991). Just over 10 years ago, occupational science announced its arrival on the agenda for occupational therapy in the 21st century (Yerxa et al 1989). The first decade has highlighted the obstacles to the vision. These include the lay understanding of the value of activities and participation, which masks the complexity of occupation. Occupational science aims to add to the knowledge of occupational therapy and provide a foundation.

Occupation is an amazingly common yet also very complex phenomenon. It is ever-present, it relates to everything individuals do. Defining, studying and understanding occupation is extremely difficult, hence the role of occupational science in opening up opportunities for methodical research and study. Occupation has largely been taught in subjects applied to the medical model or have been of a purely practical nature. While subjects of that kind are important, they give more belief to knowledge external to occupational therapy. The simplest definition of occupational science, then, is that it is the rigorous study of humans as occupational beings (Yerxa et al 1989).

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The founders of the world’s first Occupational Therapy Society recognised that the profession needed such a science; that it was one of the keys to the continuing development of the profession. Occupational scientists study people’s occupational natures across a broad spectrum of concern, that is, they explore any other perspective, philosophy or idea from the point of view of the human need for occupation (Wilcock 1991). So, for example, they reconsider, research and advise on politics, spirituality, education, social structures, science and technology, the media, work, growth, development and creativity, and health from an occupational perspective. If they are thorough, that will encompass reductionist as well as holistic perspectives and exploratory methods. Occupation crosses so many boundaries that there are hardly any areas of study which could not contribute to what is essentially a new way of looking at the world and its peoples. It is a new perspective which has much to offer in the next century.

Occupation is the dynamic relationship between the occupational form and occupational performance. (Nelson 1996). Many people see the term occupation as a job one does. However, the meaning of occupation is seen in a much wider context by an Occupational Therapist. A human being can be engaged in a wide range of occupations: leisure, self-care or educational activities are just a few examples of occupation. (Richards 2003). Wu and Lin (2010) stated that the occupational form was the

“…objective pre-existing structure or environmental context that elicits or guides subsequent human performance”.

The occupational form consists of objective features. These may include materials, human context and socio-cultural dimensions. Occupational performance is the active voluntary human doing of the occupational form. (Kramer et al 2003). Townsend et al (2007) states that occupation has an effect on health and well-being. Occupation creates structure and organizes time. Occupation brings meaning to life, culturally and personally. Occupations are individual. People value different occupations.

Occupational therapy has, as one of its roots or foundations, the need and use of activities to achieve the goals set. The origin of this activity orientation can be traced back to one of the founding fathers, Dr Adolph Meyer, who held that therapeutic activity:

…”was a pleasure in achievement, a real pleasure in the use and activity of one’s hands and muscles, and a happy appreciation of time”… (Lamorot, Coffey & Hersch 2001)

In trying to choose the appropriate task for a client in order to achieve the most effective intervention, several factors should be considered. Activities should be goal directed and should always have a specific reason or purpose for their use. They are not chosen to fill idle time. Typically, therapists validate their choices of activity by relating that activity to address a deficit in a performance area or performance component according to the framework. Activities should also have some level of interest or significance to the client. This may be in the form of being an important step in assisting the client to reach a larger goal in the future or to have a relationship to their required life roles. (Finlay 2004)

Many activities require mental and/or physical involvement, meaning that the client can be part of the selection process; the client may determine a chosen task or activity before actually performing the task chosen. When selecting an activity age and developmental appropriateness must be considered. There also be the potential to break the activity into various grades of complexity or competence in order to grade participants of different ages and abilities.

Identify the activity to demonstrate activity awareness:

Out of the activities of daily living and under the term self care, the activity I chose to focus on was brushing my teeth. Looking at my ability to obtain and use cleaning supplies for good oral hygiene which could include toothpaste, mouthwash, or dental floss.

Task analysis comprising at least 15 steps

Have correct tools for task

Usually performed in the bathroom

Pick up tooth brush

Turn cold tap on

Rinse brush

Turn cold tap off

Pick up toothpaste

Undo lid

Squeeze paste onto tooth brush

Close lid

Clean teeth

Spit and rinse mouth with cold water (no 4 & 6)

Dry face

Place toothbrush back in rack

Place paste back in rack

Squeeze toothpaste onto brush

Slight shoulder flexion, horizontal abduction, elbow flexion, wrist neutral, fingers flexed

Raise toothbrush to mouth

Elbow flexion, forearm neutral, wrist flexed, fingers flexed

Brush teeth up and down

Elbow flexion, forearm neutral, wrist flexion and extension, fingers flexed

Rinse toothbrush

Shoulder flexion, elbow extension, forearm pronated, wrist ulnar and radial deviation, finger flexion

Demand Analysis: Adapted from Hersch, Lamport & Coffey’s (2005) Activity Analysis for Expected Performance

Part 1

PERFORMANCE SKILLS

Component

Description

How required?

A. MOTOR SKILLS

1.

Posture

Stabilises, aligns, positions

To maintain an upright position when the body’s equilibrium and balance is challenged. Stabilising the trunk and keeping the position in a safe and controlled manner when completing the activity

2

Mobility

Walks, reaches, bends

To move the body to enable me to complete the task, without stumbling or scuffing my feet and also having the ability to successfully reach for an object with my arm, and bending my body to orient myself to the task

3

Coordination

Coordinates, manipulates, flows

I can utilize more than one body part in relationship to the task object or activity

4

Strength & effort

Moves, transports, lifts, calibrates, grips

The amount of muscle power utilised to resist movement or the power to move objects, including the ability to move against gravity. Also using the proper grip or pinch techniques to grasp objects and consider the force placed on an object during the task

5

Energy

Endures, paces

To be able to perform task without tiring

B. PROCESS SKILLS

1

Energy

Endures, paces

To be able to perform task without tiring

2

Knowledge

Chooses, uses, handles, heeds, inquires

My ability to select, utilise and protect appropriate tools and materials related to the task

3

Temporal organisation

Initiates, continues, sequences, terminates

My ability to plan, organise and carry out the steps involved in a task in the proper sequential order and discontinue at the proper time

4

Organising space & Objects

Searches/locates, gathers, organises, restores, navigates

To gather necessary equipment, and organise the task space and supplies, the positioning of the tools in a logical and organised manner for successful completion, then be able to clean and return tools to appropriate places. Also includes the movement of my body around any environmental object.

5

Adaptation

Notices/responds, accommodates, adjusts, benefits

I have the ability to recognise a problem and accommodate or modify the task in response i.e. running out of toothpaste

C. Communication/Interaction Skills

1

Physicality

Contacts, gazes, gestures, manoeuvres, orients, postures

To use my body and to move my body into the correct position

2

Information exchange

Articulates, asserts, asks, engages, expresses, modulates, shares, speaks, sustains)

To engage in meaningful conversation, to give and receive information i.e. showing another person the steps required to clean their teeth

3

Relations

Collaborates, conforms, focuses, relates, respects

Having the ability to interact with others, and to bond, or form connections, or maintain appropriate relationships

PART 2

CLIENT FACTORS

Component

Description

How required?

A

Body Function Categories

1

Mental Functions – Affective, cognitive & perceptual

a

Global

Consciousness, orientation, sleep, temperament & personality, energy & drive

I was alert and able to respond to environmental stimuli, able to identify person, place and time (orientated x3), had previously had quality sleep which will affect my ability to participate in daily occupation, I had emotional stability and motivation to do task.

b

Specific

Attention, memory, perceptual thought, higher level cognition, language, calculation, motor planning, psychomotor, emotional, experience of self & time

I was able to focus on the task for a period of time, and recall the information related to the task, was able to recognise sensory input, had clear thought, use personal judgement and manage time.

2

Sensory Functions & Pain

a

Seeing

I could see and utilise all visual fields

b

Hearing / Vestibular

I could respond to sounds i.e. water running

c

Other

Taste, smell, proprioception, touch, discrimination

Taste the toothpaste, touch sensitivity when squeezing toothpaste or cleaning teeth, responding to temperature i.e. the water when rinsing my mouth.

d

Pain

To know if something is wrong – sore gums and distinguish between sharp or dull pain

3

Neuromusculoskeletal & movement related functions

a

Joints & bones

Mobility, stability

To maintain an upright position, anatomically predicted joint movements.

b

Muscle

Power, tone endurance

When using arms to perform cleaning action and maintaining strength

c

Movement

Motor reflex, reactions, voluntary, involuntary, gait

My individual walking pattern

d

Cardiovascular

Haematological, immunological, respiratory

Blood pressure

e

Voice

& Speech

f

Digestive

Metabolic, endocrine

g

Genitourinary

Reproductive

h

Skin

Hair, nails

B

Body structure Categories

1

Nervous system

2

Eye

Ear & related structures

3

Voice

And speech

4

Cardiovascular

Immunological, respiratory

5

Digestive

6

Genitourinary

Reproductive

7

Movement

8

Skin

& Related structures

Section 4: Analysing Performance Patterns and Contexts

Part 1 Performance Patterns

A

Habits

Useful – positive and support completion of daily task.

Impoverished – Not routine, need to work on

Dominating – Compulsive and overpowering habits i.e. excessive hand washing

B

Routines

Daily activities that happen regularly within my daily performance

C

Roles

Tasks or behaviours that meet social requirements of accepted normal behaviour – fresh breath

Part 2 : Performance Contexts

A

Cultural

Refers to the expectations of a society, considering customs and behavioural patterns, regardless of cultural setting, state and national legislation will affect funding of basic programs including education, employment, and transportation. Consequently these will impact upon the availability of services to those in need. Every effort should be made to protect the personal rights of the individual.

B

Physical

Can include factors that may affect the individual’s ability to function within a specific environment such as the outdoor physical terrain; the indoor surroundings including furniture, rugs, and pets; and the need for specific tools to cope with each setting.

C

Social

considers the evaluation of the social support system, in each case noting the availability and expectations of a variety of caregivers, spouses, other family members, friends, community health aides and support groups.

D

Personal

looks at individual attributes or factors that are not related to an individual’s current physical health condition. These can include factors such as an individual’s age, extent of education and social or economic status.

E

Spiritual

A component of an individual’s life that motivates or sustains each person through life’s gifts, challenges, problems and solutions.

F

Temporal

Refers to the time aspect of occupational performance, such as the time of day or stage in an individual’s life.

G

Virtual

Considers an individual’s use of technology and tools such as computers or radios for communication.

There are specific skills and qualities that are typically incorporated to complete a functional skill, Performance skills include motor skills – the skills that are utilised to interact with the environment and the tasks or objects within the environment; which include posture, mobility, coordination, strength and effort and energy, process skills – that are used to maintain the actions required to complete daily living skills; and consist of energy, knowledge, temporal organisation, organising space and objects and adaptation, and communication/interaction skills – which is the competency to explain and describe individual needs and ideas to others in a socially accepted manner and include; physicality, information exchange and relations.

Performance patterns or habits are behaviours engaged when completing everyday tasks. These habits can vary from simple day to day routines to complex patterns used to function within an individual’s daily occupations and include; useful, impoverished, dominating, routine and roles. Other outside factors that can influence or impact upon an individual’s functioning are also considered and occupational Therapists must keep these contexts in mind when choosing the appropriate intervention programme and therapeutic activities, these take account of; Cultural, Physical, Social, Personal, Spiritual, Temporal and Virtual.

Activity demands are specific components of an activity that are necessary for completion of an activity or task. Included in the category are the objects used and their properties, physical space demands, social requirements, sequencing, and timing of an activity. Also included are specific body requirements or underlying body functions required to complete the task successfully.

Individual client factors that may impact on an individual’s performance in areas of occupation are also considered. In looking at client factors it is necessary to be aware of body functions – the physiological and psychological function – and structures and link this knowledge to the functions and structures clearly identified as needed to complete an occupation or activity, namely mental functions, sensory functions and pain, voice and speech functions, functions of the cardiovascular, haematological, immunological and respiratory systems, functions of the digestive, metabolic and endocrine system, genitourinary and reproductive functions, neuromusculoskeletal and movement related functions, the functions of the skin and related structures and finally body structures.

Molineux (2007) suggests that an individual’s functioning is represented at two levels; at the level of body structures and functions, and at an occupational level of what the person is capable of doing (activities) and what they actually do in their current environment (participation). There is not automatically a progression from impairment of body functions and structures to limitations or problems in participation in activity. Ill health or impairment are understood to affect body structures and functions but may not always result in activity limitations or affect participation.

Occupational form is explained by Christiansen and Baum (1997) as the objective context of occupation which it is vital to comprehend in the analysis of the effect of a transition. This analysis includes environment, time, who is involved and acts of meaning. The term function in this context is concerned with effective occupational performance in both observable and non-observable components. Meanings are personal and intrapersonal dynamics are expressed in symbolic doing, with a profound effect upon the sense of self. The degree to which the focus of interest has switched from how occupation can be used to regain health to how occupation can be understood as a means to promote good health is found within the work of Wilcock (1998).

Conclusion:

Occupational therapists must know what is inherent in an activity itself before applying it as a therapeutic tool. One way of doing this is to become familiar with the activity itself. This is activity analysis. Basically the activity in question is looked at in detail and broken down into its component parts in order to determine the individual skills necessary for the task. One effective way is to evaluate the task according to the framework. In doing so, each step in the task is evaluated and analysed to establish the fact that a performance component is utilised. Each step is treated similarly. Once a detailed analysis is completed of all steps, the therapist can decide how to adapt this task for a specific client, aiming at the individual’s recovery and return to functioning within their individual occupational roles.

Analysing the task by performance components can provide the practitioner with specific information about an activity, and how this related to a clients specific area of weakness. In looking at activity analysis the Therapist can see the range of movement (ROM) that is involved with each part of the task. One of the core beliefs of occupational therapy is the value and use of purposeful and meaningful activity, therefore activities are analysed to understand their meaning and how each component or sequence can be used therapeutically to maintain or improve occupational performance and hopefully quality of life.

Movement Analysis Schema:

A person in a wheelchair sits to stands, steps towards a couch, sits down on the couch, twists body and raises legs to lie on the couch with the back raised (Video on moodle)

Summary of: ‘Sit-to-Stand’

Joint

Starting position

Finishing position

Movement

Muscles

Type of m/work

Hip

Flexion

90o

Neutral

Extension

Hip extensors

Glut max, hamstrings

Concentric

Knee

Flexion 90o

Neutral

(extension)

Extension

Knee extensors (Quads)

Concentric

Ankle

Neutral

(Planti-

grade)

Neutral

Dorsiflexion

↓

↓

Plantarflexion

Plantarflexors

(Gastroc, soleus)

Plantar flexors

(gastroc, soleus)

Eccentric

Concentric

Shoulder

Rotracted & elevated

Neutral

Extension

Levator Scapulae, Pectoralis minor, Trapezius, Rhomboideus major,

Concentric

elbow

Flexion

Neutral

Extension

Pectoralis major, Latissmus dorsi, Deltoid, Teres major

Concentric

wrist

Flexion

Neutral

Extension

Brachialis, Brachoradialis, Triceps brachii, pronator teres, pronator quadratus

Concentric

Stepping:

When we take a step, the weight has to be transferred onto the supporting leg. To do this the body gets the hip abductor muscles of the supporting leg to contract isometrically. This holds the pelvis steady until the stepping leg makes contact with the floor. At this point the roles of the leg change, the stepping leg has now become the supporting leg (thus allowing the other leg to become the stepping leg). As such the new supporting leg requires the hip abductors to contract isometrically to fix the pelvis, and allows the new stepping leg to move.

Joint

Starting position

Finishing position

Movement

Muscle Group

Type of m/work

L Hip

Neutral

Stabilising

Neutral

Adduction

& Medial rotation

Hip extensors

Glut max, hamstrings

Isometric

↓

Concentric

R Hip

Neutral

Neutral

Abduction

& medial rotation & Flexion

Hip extensors

Glut max, hamstrings

Isometric

↓

Concentric

L Knee

Neutral

Neutral

Flexion

Knee extensors (Quads)

Isometric

R Knee

Flexion

Neutral

Flexion

Knee extensors (Quads)

Isometric

L Ankle

Neutral

Neutral

Plantar-flexion

↓

Dorsiflexion

Plantarflexors

(Gastroc, soleus)

Plantar flexors

(gastroc, soleus)

Concentric

R Ankle

Neutral

Neutral

Plantar-flexion

↓

Dorsiflexion

Plantarflexors

(Gastroc, soleus)

Plantar flexors

(gastroc, soleus)

Concentric

Sitting back on the couch

Joint

Starting position

Finishing position

Movement

Muscles

Type of m/work

Hip

Neutral

Flexion

90o

Flexion

Hip extensors

Glut max, hamstrings

Eccentric

Knee

Neutral

(Extension)

Flexion

90o

Flexion

Knee extensors (Quads)

Eccentric

Ankle

Neutral

Neutral

Dorsiflexion

↓

↓

Plantarflexion

Plantarflexors

(Gastroc, soleus)

Plantar flexors

(gastroc, soleus)

Eccentric

Concentric

Shoulder

Neutral

Rotracted & elevated

Flexion

Levator Scapulae, Pectoralis minor, Trapezius, Rhomboideus major

Eccentric

Elbow

Neutral

Flexion

Flexion

Pectoralis major, Latissmus dorsi, Deltoid, Teres major

Eccentric

Wrist

Neutral

Extension

Extension

Brachialis, Brachoradialis, Triceps brachii, pronator teres, pronator quadratus

Eccentric

Lying back onto the couch – lifting legs up onto couch

Joint

Starting position

Finishing position

Movement

Muscle Group

Type of m/work

L Hip

Flexion

Flexion

Adduction & Extension

Hip extensors

Glut max, hamstrings

Concentric

R Hip

Flexion

Flexion

Abduction & Extension

Hip extensors

Glut max, hamstrings

Concentric

L Knee

Flexion

Neutral

Extension

Knee

extensors (Quads)

Concentric

R Knee

Flexion

Neutral

Extension

Knee

extensors (Quads)

Concentric

L Ankle

Flexion

Neutral

Dorsiflexion

↓

↓

Plantarflexion

Plantarflexors

(Gastroc, soleus)

Plantar flexors

(gastroc, soleus)

Isometric

R Ankle

Flexion

Neutral

Dorsiflexion

↓

↓

Plantarflexion

Plantarflexors

(Gastroc, soleus)

Plantar flexors

(gastroc, soleus)

Isometric

shoulder

Rotracted & Elevated

Neutral

Flexion?

Levator Scapulae, Pectoralis minor, Trapezius, Rhomboideus major,

Eccentric

elbow

Flexion

Neutral

Flexion

Pectoralis major, Latissmus dorsi, Deltoid, Teres major

Eccentric

wrist

Flexion

Neutral

Flexion

Brachialis, Brachoradialis, Triceps brachii, pronator teres, pronator quadratus

Eccentric