Frames of Reference

The acquisitional frames of reference are a group of frames of references for occupational therapy practice that focus on the component parts and noted deficits of a person with the objective of developing or restoring those parts to full function.  It can be thought of as the process of skill acquisition to improve overall function.  Frames of reference typically classified as acquisitional include activities therapy, biomechanical, rehabilitative, and trait-factor.

References and Further Reading:

Creighton, C. (1985). Three frames of reference in work-related occupational therapy programs. American Journal of Occupational Therapy, 39(5), 331-334.

Mosey, A. (1981). Occupational therapy: Configuration of a profession. New York: Raven.

The biomechanical frame of reference addresses the physical deficits that exist in a client in order to facilitate that client’s ability to participate in meaningful activities.  Although this frame of reference has a more traditional bottom-up approach, it can still fit within a top-down approach when properly incorporated into occupational therapy practice.  In order to facilitate this, the maintained emphasis throughout the process should be on the outcome of increased participation in specific meaningful activities identified as goals by the client, rather than merely on the client factors themselves. 

A key element of the biomechanical frame of reference is that it takes a restorative approach to deficits by attempting to restore or develop skills in the client rather than compensate for the lack of ability.  This is important to note because it requires that the client have both the cognitive and physical ability to restore or develop skills in order for this approach to be effective.  It does not, however, require the level of cognitive functioning necessary in some other approaches.

Another component of the biomechanical frame of reference is its focus on the positioning of clients in order to facilitate functional activity.  By adjusting or supporting the positioning of a client with physical deficits, the biomechanical approach can prevent or delay the onset of fatigue in order for a client to fully complete an activity, or it can provide support to a particular physical component of the body, such as the trunk, in order to better facilitate more distal movements.

Possible intervention techniques in the biomechanical frame of reference include physical exercises, orthotics, physical agent modalities, and any other intervention that specifically targets an identified deficit.  However, intervention is not limited to only non-occupational activities, but can also include occupation based activities that revolve around the desired movements or exercises.

References and Further Reading:

Dodd, K., Imms, C., & Taylor, N. F. (2010). Physiotherapy and occupational therapy for people with cerebral palsy. London, England: Mac Keith Press.

Green, D. & Roberts, S. L. (2004). Kinesiology: Movement in the context of activity (2nd ed.). Maryland Heights, MO: Mosby.

Kramer, P. & Hinojosa, J. (2009). Frames of reference for pediatric occupational therapy (3rd ed.). Baltimore, MD: Lippincott, Williams & Wilkins.

Schell, B. B., Gillen, G., & Scaffa, M. E. (2014). Willard and Spackman’s occupational therapy (12th ed.). Baltimore, MD: Lippincott, Williams & Wilkins.

Cognitive Behavioral Therapy is a technique used by psychologists that influences and guides some approaches to mental health occupational therapy in the form of the Cognitive Behavioral frame of reference. This frame of reference focuses on changing the perceptions of the client, assisting the client in relearning behavioral patterns, and teaching the client new coping skills in order to improve overall quality of life. Intervention strategies may focus on a variety of strategies including talking through issues, developing relaxation techniques, or role playing difficult situations to develop solutions.

References and Further Reading:

Duncan, E. A. (2021). Foundations for practice in occupational therapy (6th ed.). New York, NY: Elsevier.

What is Cognitive Behavioral Therapy. (n.d.). Retrieved September 26, 2020, from https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral

The cognitive disabilities approach was developed by Claudia Allen and serves as a means of classifying cognitive functioning into seven numbered categories ranging from 0, or coma, to 6, or planned actions. A patient functioning in level 1, automatic actions, can respond to stimuli and withdrawals from noxious stimuli, however they require 24 hour care and are dependent or require maximum assistance to complete all self-care tasks. A patient functioning in level 2, postural actions, still requires 24 hour care, but may engage more in self-care tasks with assistance to initiate and follow through with activities. Level 3, manual actions, indicates that the patient is able to explore volitionally and attend to tasks for short periods of time, but requires 24 hour supervision for initiation, thoroughness, and safety during self-care tasks. A patient functioning at level 4, goal-directed activity, can complete familiar activities and learn new skills and activities through observation; however, they still require periodic supervision for safety and have difficulties appropriately responding and adjusting to changes from the ordinary routine. Level 5, exploratory actions, indicates that the patient is able to function with increased independence but may be impulsive and show deficits in executive functioning skills such as planning and identifying consequences. A patient functioning at level 6, planned actions, can live independently and process complex problems without assistance.

Evaluation in the cognitive disabilities approach is completed using the Allen Cognitive Level (ACL), the Routine Task Inventory (RTI), or the Cognitive Performance Test (CPT).

References and Further Reading:

Krajnik, S. (2015). Frames of reference in adult physical dysfunction: Neurological [Handout].

Smidl, S. (2014). The cognitive disabilities approach: Understanding the client’s best ability to function [PowerPoint slides].

The cognitive retraining approach is a remedial approach that focuses on retraining clients with cognitive deficits in order to overcome those deficits.  It was developed by Averbuch and Katz.  Repetition is a common focus of cognitive retraining as it facilitates the learning of new skills or ways of solving particular problems.  Areas of training include attention and concentration retraining, memory retraining, organizational skills retraining, reasoning, problem solving, decision making, and executive skills.  As the cognitive abilities in these areas improve, the idea is that the skills will become generalized and transferable to various situations in life.

References and Further Reading:

Cognitive Retraining. (n.d.). Retrieved March 9, 2015, from http://www.minddisorders.com/Br-Del/Cognitive-retraining.html

Krajnik, S. (2015). Week 2: Neurological impairments & approaches in neuro OT practice [PowerPoint slides].

Pendleton, H., & Schultz-Krohn, W. (2011). Pedretti’s occupational therapy for physical dysfunction (7th ed.). St. Louis: Mosby Elseiver.

The coping model is a frame of reference used in pediatric occupational therapy that takes an approach much like the cognitive behavioral approach in adults. The idea of the coping model is that improvements in the coping strategies of pediatric clients can result in an improvement in occupational performance. The approach focuses on grading or modifying the environment, teaching coping skills, and providing feedback to result in generalizable skills that can bring about an optimization of occupational performance.

References and Further Reading:

Case-Smith, J. & O’Brien, J.C. (2010). Occupational therapy for children, (6th ed.). St. Louis: Elsevier.

Constraint Induced Movement Therapy (CIMT) is a remedial approach that involves forcing the use of the involved limb by preventing use of the uninvolved limb.  It has been used and research in adults suffering from a variety of diagnoses including cerebrovascular accident or stroke, spinal cord injury, fractures, or traumatic brain injuries, and experimental research supports the use of CIMT as an effective treatment method when compared to a general therapy program.  In recent years, several studies have explored the effectiveness of CIMT in pediatric therapy, particularly for children with hemiplegic cerebral palsy, and found that CIMT that has been age appropriately adapted through use of a sling or restraint glove worn on the unaffected hand, proves more effective in improving bilateral use of both limbs than the control therapy treatment.

The dynamic interactional approach was developed by Toglia for use with any age clients.  Developed prior to the PEO model, this approach is based upon examining the interaction between person, setting, and occupation.  For the cognitive impairments, this addresses how the deficits caused by those impairments interact with the environmental setting and the demands of the occupation itself.  Treatment according to this approach can be either compensatory or remedial, depending on the needs, abilities, and prognosis of the client.

The ecology of human performance model was developed by Dunn, Brown, and McGuigan in 1994 and was one of three models developed around that time that placed higher priority on the importance of environment on occupational performance.  It considers the interactions between the client, referred to as person, the occupation, referred to as task, and the environment, referred to as context.  Based on this framework, the ecology of human performance model identifies five different strategies for intervention: establish/restore, adapt/modify, alter, prevent, and create.  Through these intervention strategies, the interaction between person, task, and context can be maximized, resulting in optimal occupational performance.

The information processing approach was developed by Beatrice Abreu and Joan Toglia and takes a remedial, bottom-up approach to cognitive based occupational therapy treatment.  The purpose of the approach is to improve cognitive processing of information in order to maximize functional performance.  It postulates that information processing is based on a series of steps that can be individually addressed in order to improve overall function.  The three phases of treatment with this approach are: maximize the ability of the patient to detect and respond to the environment, maximize the ability to discriminate, organize, and manipulate information from the environment, and maximize the ability to organize and manipulate internal information.

The Kawa River model was developed by Iwama in 2006 and was designed as a metaphor to be used in explaining the reasoning for aspects of occupational therapy intervention.  It is designed to be a more culturally sensitive approach that is easily understood by a variety of patients due to its reliance on the example of a river.  In this model, the river is a metaphor for life from birth to death, water is one’s energy or flow, rocks are negative circumstances in life that you must work around, driftwood is your personal assets and liabilities that can either assist you or get in your way depending on whether they clog up on the rocks or knock the rocks asside, and the walls and floor of the river are the social and physical environment and they impact the flow in the same way that the walls and floor of a real river impact its flow.

The Kawa model is applied to occupational therapy practice in six steps.  Step one is to appreciate the client in their context.  Step two is to clarify the context, identifying each component of the river metaphor and how it might be impacting flow.  Step three is to prioritize the issues that are most important to the client.  Step four is to assess the focal points of intervention by identifying what must be done with the previously identified issues in order to improve river flow.  Step five is intervention, or acting upon the plans discussed in step four.  And step six is evaluating the results.

The Model of Human Occupation, or MOHO, is a frame of reference that focuses on the interconnectedness between the person and environment during the performance of an occupation. It views individuals as the compilation of volition, habituation, and performance capacity and the environment as the dimensions of objects, space, tasks, social groups, and the larger culture, political, and economic contexts. Occupational engagement can be analyzed at the occupational participation level, the occupational performance level, or the occupational skill level. This engagement in occupations in turn leads to occupational identity and occupational competence within the realm of occupational adaptation.

In the MOHO frame of reference, therapists focus on understanding the client and their environment in order to more fully understand the importance of the occupation and provide appropriate and successful therapeutic intervention. Intervention strategies identified by the MOHO include validating, identifying, giving feedback, advising, negotiating, structuring, coaching, encouraging, and physical support.

Developed by Abreu and Peloquin, the Quadraphonic Approach combines four theories: information processing, teaching and learning, neurodevelopmental, and biomechanical.  It can be used for clients with a variety of neurological disorders such as strokes, traumatic brain injuries, brain tumors, or cerebral palsy.  The approach incorporates both a micro perspective, which looks at performance skills and client factors, and a macro perspective, which looks at functional performance and occupations.  Both remediation and compensation can be utilized as part of this approach.

The rehabilitative approach, also referred to as the rehabilitation approach, was developed by Catherine Trombly.  Its focus is on what the patient can do, rather than on what they cannot do, and it utilizes adaptation, compensation, and modification in order to facilitate the patient’s ability to participate in the desired activities.  The rehabilitative approach looks at functional problems from a top down approach and can be utilized regardless of the extent of the patient’s deficits because it does not require the restoration or development of missing skills but instead focuses on maximizing independence where the patient is now in the recovery process.  An example of the rehabilitative approach would be the use of a raised toilet seat during recovery from a hip replacement.

The sensorimotor frames of reference is a term used to describe a group of frames of references for occupational therapy practice.  These include the neurodevelopmental and proprioceptive neuromuscular facilitation frames of reference, both of which focus on the restoration of control over the lower motor neurons by facilitation of stability or movement respectively.