Choosing Wisely in Occupational Therapy

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Choosing Wisely is a topic that is wise to discuss! Today, I’ve got some information to share on this initiative and ways to encourage Choosing Wisely in Occupational Therapy clinics and caseloads. Here, we’re chatting all things function and evidence…and from an occupational therapist with almost 20 years of experience, I wanted share why I believe that Choosing Wisely is the wisest option!

Choosing Wisely in occupational therapy discussion of initiative recommendations for occupational therapy professionals.

What is Choosing Wisely?

Choosing Wisely is an initiative of the ABIM Foundation (American Board of Internal Medicine) that seeks to promote conversations between clinicians and patients by helping patients choose health care options that are right for them. The Choosing Wisely initiative occurs across health professions, and aims to avoid treatments or interventions that are not supported by evidence, not a duplicate of other tests or procedures already received, free from harm, and truly necessary.

Many health care organizations have created recommendations that align with the goals of the Choosing Wisely initiative, and occupational therapy is one of those services that are participating. The occupational therapy profession is taking part in this initiative!

The occupational therapy profession is taking part in this initiative…and that’s a good thing! AOTA has created, along with practitioners in the field, a list of ways to “choose wisely” when it comes to best practice. These are ways to avoid unnecessary treatment interventions that are not guided by function. I love that these guidelines promote occupation…the foundation of our profession!

Read more about AOTA’s list of five things a practitioner should avoid, as well as how this list of how these recommendations were created.

Essentially, this initiative encourages use of evidence-based practices based on function and as a result of assessment of occupational performance. Client-centered practice is something we are trained in as occupational therapy professionals. Educating and advocating for this advancement sounds like a wise choice to me!

Occupational therapy’s Choosing Wisely Recommendations

Let’s take a closer look at the recommendations for occupational therapy practitioners according to Choosing Wisely standards:

Don’t provide intervention activities that are non-purposeful (e.g., cones, pegs, shoulder arc, arm bike).

From the perspective of an OT with close to two decades of experience, this guideline holds dear to my heart. How often have we seen in clinics or therapy rooms, the closets full of cones, pegs, stacking items, rings, and other motor activity tools? The OT closet can be a colorful place full of items like these! But when we step back and put on our occupational glasses, what exactly are we working towards with these tasks?

Occupational performance, or the activities that make up an individual’s lifestyle, span all aspects of a person’s environment. This is the basis for our profession. Using purposeful activities in our treatment sessions promote motivation and greater independence in personal goals.

I’ve been at fault in using rings/cones/pegs/etc. in my experience too. I think many of us have! But what if, before we reach for that stack of pegs, we filter our thoughts with an analysis of what we are trying to achieve with those pegs? What is the function? Probably not much!

When occupational therapists re-frame thinking to collaborate with the various people in a person’s environments, we can work together with parents, teachers, grandparents, teacher’s aides, and others to help our clients become more independent. Optimal outcomes occur when collaborations are guided by occupational performance.

Instead, as occupational therapists we are capable of digging deeper to address function and our client’s true personal goals. Now that is a a way to get off the hamster wheel of rotating non-purposeful activities from client to client and making a real difference! What a powerful and meaningful way to make a world of difference in our clients and potentially prevent burnout in ourselves as therapists!

2. Don’t provide sensory-based interventions to individual children or youth without documented assessment results of difficulties processing or integrating sensory information.

I think we’ve seen it before: Teachers in a classroom applying sensory strategies like chew-top pencils, weighted items, specialized paper, or other tools without consultation by the school-based OT. In schools with a sensory room, you may have seen paraprofessionals guiding students through sensory strategies, without so much as a consult from the OT. Maddening, isn’t it?

We’ve seen sensory-based interventions been applied by others without the documented assessment and it’s frustrating! What if, we as professionals stood up to this through advocacy and education? Taking a stand on how we hold ourselves to certain standards (completing an assessment of sensory needs AND documenting a plan to address needs) is the first step. Following through with documentation can be beneficial to so many: the child struggling with certain needs, the teacher or team member that benefits from education, and ourselves as we advance ourselves professionally.

3. Don’t use physical agent modalities (PAMs) without providing purposeful and occupation-based intervention activities.

Again, we come back to the function! Purposeful intervention strategies, driven by a desire to improve occupational performance fuels motivation and meaning to our client’s lives. How powerful is it to be a part of that in our client’s lives?

We as OTs can engage our clients in function while integrating physical agent modalities into meaningful and purposeful activity. It’s pulling out the OT lens to find the function! We as occupational therapy professionals are some of the most creative souls I know. Remaining true to the roots of our profession while incorporating modalities into interventions is just part of the puzzle!

4. Don’t use pulleys for individuals with a hemiplegic shoulder.

As pediatric OTs serving those in schools, clinics, homes, and early intervention environments, this recommendation may not always play into the day-to-day caseload. However, it all comes back to meaningful, purposeful, occupation-centered practice!

It may not be a pulley that we are contemplating in our intervention plans, but perhaps an aggressive resistive activity for the child with juvenile rheumatoid arthritis. It’s all about recognizing contraindications, being up-to-date on evidence-based recommendations, and best practice.

5. Don’t provide cognitive-based interventions (e.g., paper-and-pencil tasks, table-top tasks, cognitive training software) without direct application to occupational performance.

That coloring sheet, wordsearch, or “I Spy” paper? They may not be best practice when it comes to interventions for underlying needs. We are challenged as professionals to dig deeper and find the ability to address occupational performance through table-top activities and paper-and-pencil tasks. This is the basis for our profession. Using purposeful activities in our treatment sessions promote motivation and greater independence in personal goals.

Can we shift perspective to better assist clients in becoming actively engaged in their daily tasks? Occupational therapists are unique in that they have been trained to emphasize achievement of personal goals.

We strive to design treatment plans that are client centered, driven by the patient, and family/team centered. It’s our duty to be leaders in designing programming that is focused on function.

Are you Choosing Wisely as an OT?

It’s easy to fall back on cookie cutter interventions. However, it’s our duty to move beyond those routines and remember the roots of our profession. Some quick tips for applying the Choosing Wisely recommendations into practice can be found below.

  1. Focus on function. Identifying the factors that contribute to optimal function and addressing those needs in therapy.
  2. Discuss ideas with other therapists. Start conversations that filter out unnecessary interventions and encourage occupational performance and client-centered practice. Work with your colleagues to discuss the Choosing Wisely recommendations into your workplace.
  3. Advocate! Educating parents, teachers, administration, and others on the occupational therapy profession is always needed.
  4. Identify the factors that enable individuals with disabilities to perform self-care and other performance components in order to create systems that address these needs through activity-centered strategies. Always use that OT lens.
  5. Stay up-to-date on evidence. It’s the best way to identify best-practice techniques while implementing strategies geared toward function. These evidence-based practice appraisal sheets can help filter out information to define occupation-centered and client-appropriate evidence while guiding intervention.

What strategies to you have to add to these tips? Is Choosing Wisely a part of your daily practice? Add to the discussion in the comments below.

Choosing Wisely initiative in occupational therapy is easy to apply based on our background and training in occupation and client-centered practice.

References:

Carolyn M. Baum, Mary Law; Occupational Therapy Practice: Focusing on Occupational Performance. Am J Occup Ther 1997;51(4):277-288. doi: 10.5014/ajot.51.4.277.

Occupational performance. (n.d.) Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. (2003). Retrieved August 8 2019 from https://medical-dictionary.thefreedictionary.com/occupational+performance

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Choosing Wisely in occupational therapy is easy given the training OTs receive in client-centered practice.