What is Top Down vs Bottom Up in Occupational Therapy?

Have you heard about the top down vs bottom up occupational therapy approaches? Are you in OT school trying to figure out these two approaches? You may also find yourself wondering which is the best approach to use and wondering what exactly is the difference between the two. Not to worry, we’ve got you covered!

Whenever we treat patients as occupational therapy practitioners, we are using one of these approaches, even if we are not aware of it. This article will outline what the two approaches are, and the difference between them, examples of outcome measures for each approach, and which approach we recommend.

The Top Down Approach:

The top down approach in occupational therapy assesses and treats the patients’ engagement in meaningful activities with their context in mind. In this approach, you identify what is important to the person, and take note of why there is occupational dysfunction within their different occupational performance areas.

These include activities of daily living, instrumental activities of daily living, sleep and rest, work or education, leisure, social participation. Some consider it a more task specific approach.

The top down approach also takes into consideration the patient’s habits, roles, and routines and it is incorporated into therapy. It also provides an opportunity to form a stronger therapeutic relationship with your patient and their family.

Examples of Top Down Assessments:

Canadian Occupational Performance Measure

Barthel Index

Top Down Intervention Example:

The therapy intervention is designed to specifically target performance within a functional activity. For example, working on lower body dressing in the session as a means to improve the person’s overall independence in dressing.

top down approach

The Bottom Up Approach:

The bottom up approach in occupational therapy focuses more on performance skills and client factors. It focuses more on the impairment that is contributing to decreased function and independence in a task. It emphasizes the body’s structure and function. Examples of this include: range of motion, muscle strength, and cognitive skills.

The thought behind this approach is that improving these performance skills and client factors will lead to improved performance within meaningful activities. This is a more medical approach, and some consider it an impairment focused approach.

Organizations and payors often request results from assessments that are bottom up. Many hospitals are more in line with the biomedical model, so the bottom up approach often feels like it fits better in these settings, however, it does have its limitations. It is, however, easier to measure client factors and performance skills in the bottom up approach (like tracking increasing upper body strength or an increased range of motion in a joint over time).

Examples of Bottom Up Assessments:

Oxford Muscle Strength Scale

Goniometer readings of range of motion

Montreal Cognitive Assessment (MOCA)

Bottom Up Intervention Example:

The therapy treatment is designed to target the impairment. An example is working on exercises to strengthen a hemiparetic upper limb.

bottom up approach

Examples of Top Down vs Bottom Up Approaches:

Case One:

A 30-year-old mother suffered a traumatic brain injury, which has affected her memory in many domestic tasks.

Top Down: Using cooking as an activity to target her memory, and teach her external and internal compensatory techniques that she can use while cooking. Taking into consideration her context, you note that she has 3 young children who try to play with her while cooking and cause a lot of external distraction, so you also address with the father that he plays with them in a separate room while his wife cooks to help her better
focus in the quiet environment.

Bottom Up: Targeting the memory impairment with paper based and verbal tasks.

Case Two:

A 15-year-old boy burned his right hand, and presents with reduced range in his fingers now.

Top Down: Considering how this is impacting on his schooling, analyzing what tasks he does at school, and using these activities to improve his range. Taking note that he is nervous about returning back to school and addressing anxiety with techniques he can use at school to help him cope.

Bottom Up: Focusing on his passive and active range of motion in his fingers, teaching edema management principles, strengthening exercises, and scar massage when appropriate.

Case Three:

A 3-year-old child screams every time it’s bath time and hates getting dressed afterwards.

Top Down: Assessing and treating the child while in the bath, providing accommodations, changing the environment, and using a behavioral approach while the child is bathing. Identifying what is done before or after bath time that may be contributing to this behavior.  Observing how the caregiver is doing bath time and making suggestions of changes to the caregiver.

Bottom Up: Sensory regulation and emotion regulation are targeted separately to this task.

So, which approach is “better”?

Using a blend of both approaches can be useful. As occupational therapists, it is always of the utmost importance that we assess and treat patients holistically. We have to be aware of all of the contributing factors to occupational dysfunction.

Through this, we are able to set meaningful goals with our patients, which will lead to improved independence in activities that are important to them. This does not mean, however, that we must focus solely on using activities, teaching compensatory strategies, or using assistive devices or adaptive equipment to improve independence in a task.

Let’s use this example of upper body dressing: John is a 54-year-old male who has had a stroke. As a result of this, he has hemiparesis (weakness) in his right upper limb, and a very weak grasp and pinch. He has identified that he wants to be able to dress himself independently in the morning.

If one were to use the top down approach only, it would involve using dressing as an activity to improve his independence in upper body dressing, while teaching him one handed compensatory strategies. If one were to use the bottom up approach only, it would involve doing right upper limb strengthening exercises in the session (weights and pegs) and hoping that this would carry over into him being able to use his right upper limb to assist him in putting on his top. A blend of both approaches will help us set client-centered goals, while still targeting underlying impairments that are contributing to dysfunction.

It is important to note that a bottom up approach on its own will not necessarily translate into improved performance in an activity. For example, doing arm exercises will successfully strengthen the upper limb, but doing that in isolation does not mean it will automatically result in independence in upper body dressing. We always need to tie it back in with the functional task.

A study done in 2013 on motor skills assessment of children concluded that a combination of top down and bottom up approaches are best to utilize (1), and we believe using a blend of both approaches can be beneficial to all clients and diagnoses.

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We hope you now can better understand what these two approaches are, the differences between them and examples of them, as well as examples of outcome measures for each approach.

Using a combination of both approaches is ideal in keeping your therapy client-centered and holistic, but also targeting underlying impairments that are contributing to occupational dysfunction. What is certain is that it is important to always keep the goal of the meaningful task in mind and to have that in the forefront of your mind while treating.

We would love to hear your thoughts about the top down vs bottom up occupational therapy approaches in the comments below. 

If this article was helpful for you, please don’t hesitate to share it with anyone who you think it would benefit. 

Reference:

1) Kennedy. A, Brown. T, Stagnitti. K, “Top down and bottom up approaches to motor skill assessment of children: Are child report and parent-report perceptions predictive of children’s performance-based assessment results?”, Scandinavian Journal of Occupational Therapy, Volume 20, 2013, 45-53.

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