The PEO Model and Brain Injury: How to Use OT Theory to Achieve Best Results!

Approaching care for brain injury patients is, in one word, intimidating. Figuring out how to approach consideration for all of the contextual factors that will influence recovery for this patient population is a daunting undertaking to say the least.  

We know that modifying these factors in some capacity is almost always necessary during brain injury recovery, but how do we go about approaching this when there is just so much to consider? 

An Overview of the PEO Model

If you haven’t considered the PEO model since the day you passed your boards, don’t sweat it! I want to bring it back to your consciousness & assure you that this client-centered model is a lifesaver when it comes to approaching intervention for the beloved brain injury population.

Let me start with a refresher – the PEO model posits that occupational performance is the result of interactions between the person (P), the environment (E) and the occupation itself (O). 

The Person is complex, dynamic, intrinsically motivated and always developing. Think of your past patients — every one of them has been motivated by different words, emotions, and interested in different goals and accomplishments. 

The Person factor, especially with our brain injury population, is helpful for keeping client-centered care at the forefront of treatment while simultaneously acknowledging how quickly these personal factors can change throughout the injury-recovery continuum.  

The Environment is inclusive of social, physical and geopolitical factors–cues, demands, rules and norms are informed by the patient’s environments. Environmental considerations are paramount to ensuring our patient’s safety, providing controlled sensory enrichment, reestablishing or developing appropriate behaviors that are environment-specific and more.

The Occupation includes meaningful tasks, actions and engagements that are relevant to life maintenance, wellbeing, pleasure and productivity. Our patients’ best performance occurs when there is balance between these three factors — conversely, dysfunction is then the result of an imbalance.

Imbalance may look like a patient that is unable to safely navigate their environment due to lack of accessibility, a patient that cannot complete an occupation because it requires high level sequencing, a patient that typically enjoys crafts that now is unable to participate in crafting. The imbalance can be restored by modifying any of the three factors in order to facilitate occupational performance. Nothing too out there, right? 

Returning to our brain injury patients, the need for modifications in order to promote occupational success is nothing entirely new — there are even guidelines for doing so available for clinician reference (for free). Mild TBIs (mTBI, also known as concussions) are not excluded from this need for modifications, either! 

A PEO Example with an mTBI case:

Kailey is a 20 y/o college student who sustained an mTBI during a collegiate soccer game. She reports symptoms including some grogginess, headaches, photosensitivity & hyperacusis. Following her injury, she finds herself unable to tolerate sitting in class for prolonged periods of time due to the fluorescent lights, struggling with loud discussions and overall decreased ability to maintain focus for the duration of her classes. 

She finds it difficult to tolerate looking at handouts and exams printed on white paper, and has headaches when a professor shows a Powerpoint without turning the room lights off. At this point in her recovery, she is most concerned with being able to maintain her participation and grades in classes so she can get into OT school next year.

Analyzing Different PEO Factors 

Personal factors include Kailey’s age, involvement in collegiate soccer, status as an mTBI patient, interest in OT school and prioritization of returning to classes.  

Environmental factors include the university and classrooms Kailey goes to, the social demands of physical attendance and participation in classroom discussions, and the understanding that her getting into OT school is contingent upon good grades and participation in undergraduate coursework. Environmental factors also include the norms of utilizing white paper for handouts and exams, leaving the lights on during Powerpoint presentations, and using the standard fluorescent lights that are installed in each classroom.  

Occupational factors would include Kaileys’ new limited tolerance of the social and physical activities that are necessary for her engagement and success in education.  Being able to quickly identify these factors should give you an idea at-a-glance of where the occupational dysfunction may be occurring — her personal and environmental factors are no longer harmonious and will need to be addressed. Some standard and practical concussion treatment methods will be beneficial to Kailey here, including requesting professors to print examinations and handouts on green/yellow/blue paper to decrease the brightness and reduce her sensitivity. 

Other accommodations, like permitting Kailey to Zoom into class when she is feeling fatigued or there is an expectation of a loud discussion, may also help her maintain participation while decreasing the effect of symptoms. Advocacy and education will further help account for the environmental and social norms of the educational environment that Kailey must navigate while recovering.

Patients with more severe brain injuries will show similar patterns of occupational dysfunction as well — with an increase in severity of symptoms, the need to modify the three factors will also increase. 

For our case study above, there were some simple methods for environmental modifications that helped accommodate for the personal factors interfering with occupational performance; but how does utilizing the PEO model with our more severe brain injury patients make life easier?

PEO Model With a Severe TBI Case Study:

Michael is an 63 y/o man who sustained a severe TBI post fall at his job as a mechanic. His symptoms include confusion, memory impairment, decreased strength and endurance, and fatigue. Michael was admitted to an inpatient rehab facility for rehabilitation prior to returning home.

Post injury, he has had difficulty with completing basic ADLs, and is requiring maximal visual/verbal/tactile cueing to complete tasks such as grooming, bathing, and self-care. For mobility and transfers, he requires moderate assistance for truncal control and balance.

Michael and his caregivers have set goals for him to be able to complete BADL tasks with minimal cueing, to be able to transfer himself with contact guard assist, and to return to his home with assistance from his wife. 

Personal factors in this case include Michael’s age, his status as a male living with his wife; his experience as a person with severe TBI, and his profession as a mechanic.

Environmental factors may include the facility he is in for rehabilitation – which includes his room, therapy gym, and common areas. It also can be extended to include the clinicians he interacts with on a daily basis, the new medical professionals he meets daily that have different cognitive expectations of him, and the other patients with whom he shares a room and common space with.

Environmental factors that should be taken into consideration for Michael here could include the constantly noisy and busy hallways and rooms; fluorescent lighting; flickering televisions in shared spaces, and interruptions of clinical staff for checks.

Occupational factors would include Michael’s best abilities to function at present – which require maximal verbal, visual and tactile cueing to complete BADL tasks; his strength and endurance deficits which impair his occupations such as mobility; and his cognitive and social interaction deficits.

In this specific instance, we are able to utilize an existing protocol to manage environmental factors. The Post-Traumatic Amnesia Protocol created by Moss Rehab outlines specific measures to be taken by the interdisciplinary care team to manage stimuli and continuously assess the person-environment fit for optimal engagement – supporting the person and also providing a structured frame for the health care professional.

I highly suggest you check out the entire protocol to see how the person’s environment can facilitate the occupational performance of the person, but one example is in the reference guide as to how each team member can approach the person in a supportive manner – they are instructed to introduce themselves with name and purpose; provide information; focus questions on the here and now; and keep it simple.

The staff member should: not assume that the person will remember them; not ask the individual to recall information; and not quiz them on any ‘assumed’ knowledge. This sets the social-cognitive environment up for greater success.

Compensatory approaches to care also modify the environment to support the occupational performance of the person-think of passive medical equipment such as bed rails/shower chairs; strategic placement of grooming utensils, and easy pull-on clothes as opposed to buttons and enclosures. 

Personal factors can be integrated into care such as folding therapeutic activities that speak to the person’s intrinsic personhood. In this example, using tools or parts as a way to work on strength endurance or cognition so as to speak to Michael’s background as a mechanic may be supportive to function. 

This approach to evaluation and intervention provides a solid framework that we can base occupational therapy upon, as well as helping us appreciate the nuance between these interwoven areas.

Too often, and owing to higher productivity expectations, decreased resources, or time crunches, practitioners can fall into a reactive approach to therapy. Stepping back and making space to apply our theory specific frameworks to cases is grounding for OTs. 

Occupational therapists (as we all know!) have a unique viewpoint on the way that person, environment and occupation can support or inhibit each other, and bearing this model in mind ensures we can truly practice in a client-centered way. 

About the Author

Spenser Bassett, OTD OTR/L graduated from the University of Findlay with her Doctorate in Occupational Therapy in 2022. She currently works in subacute rehab & long-term care, and is ARC Seminars’ Associate & Social Media Developer.

Spenser is passionate about promoting diversity in rehab spaces & empowering rehab professionals to succeed beyond classroom walls.