For starters, what is activity tolerance?
When we think about activity tolerance in relation to occupational therapy, we are referring to tolerance to activities of daily living. Therefore, in this instance, activity tolerance is an individual’s ability to tolerate completing activities of daily living.
Decreased activity tolerance is one of the main limitations of patients in adult rehab settings. This can be a major challenge to patients, and it is an important deficit to address as occupational therapists.
If you’re like me, you might sometimes feel like you’re in a treatment rut for activity tolerance interventions. If this is the case, then this post is for you!
Focus on Function
As stated above, many of our patients are limited by decreased activity tolerance and endurance during ADL tasks. This is especially common following lengthy hospital stays or significant illness, injury, or surgery.
You are likely familiar with the UBE for activity tolerance, which unfortunately isn’t the most functional or exciting intervention. For this post, I’m going to keep the activity tolerance intervention ideas as functional as possible. This also helps to keep things engaging and interesting for your patients.
The best place to start is to simply ask your patients what they’re most interested in and begin by incorporating those activities into your therapy sessions. From there, you can start adding the ideas in this post for retraining which will certainly depend on your patient’s level of function. They can all be graded up or down based on your patient’s needs. Quick tip: Check for any additional precautions if the patient has any cardiac or pulmonary limitations, for example.
If your patient has very poor activity tolerance, self care tasks can take a great deal of energy. Just working on ADLs can address endurance and tolerance during daily tasks.
If you notice your patient struggling with even a shortened ADL session, you’ll know to start with something simpler.
Here are some ideas that you can grade up or down depending on the needs of your patient:
- Sitting edge of bed during bathing and/or dressing
- Standing at the sink for grooming tasks
- Working on toilet transfers or bedside commode transfers
- Completing a full morning ADL routine including showering, toileting and dressing
I-ADLs are generally more challenging than basic ADLs, so be sure your patient is able to tolerate their basic self-care first. After they’ve got the basic ADLs down, you can try progressing to I-ADLs.
Here are my favorite Instrumental ADL interventions:
- Simple meal preparation task (including retrieving the food items, dishes, and washing the dishes when done).
- Completing a full laundry task from washing, to drying, to folding the clothing.
- Hanging clean clothes up in a closet and/or putting them into low drawers.
- Making the bed from start to finish: stripping the fitted sheet, retrieving the linens, putting on new fitted sheet. This one is hard!
- Cleaning up and organizing their room.
- Sweeping, vacuuming, or mopping. One OT from the Geriatrics Treatments Facebook group recommended having the patient mop up shaving cream or wipe shaving cream/dry erase marker from windows.
I love functional mobility tasks for activity tolerance because they really are challenging. These interventions are also great for overall strengthening and increasing the patients’ mobility and balance needed for self-care tasks.
Here are some examples:
- Bed Mobility. If the patient is in the acute setting and cannot tolerate higher level mobility, working on rolling bed-level as well as completing supine to side lying to sitting edge of bed for ADLs is a great way to work up to more advanced functional mobility.
- Bathroom transfer training, such as toilet sit to stands with multiple repetitions. Stepping in/out of the tub or shower several times depending on what the patient has at home is also great for endurance.
- Wheelchair mobility off the unit into the community or to/from the gym. This one you just have to be careful with as Physical Therapy addresses this in their FIMs (in the inpatient rehab setting) so I like to document this as community re-entry wheelchair-level to the gift shop (as an example) if the patient will be going home in a wheelchair. Self-propelling takes a lot of effort but really works wonders on endurance and strength.
- Community re-entry tasks help with ambulating around the unit and strengthen skills like route planning and dynamic standing balance. As well, patients can retrieve empty grocery containers at high and low surfaces to simulate grocery shopping. Community re-entry to actual grocery stores, ambulating around obstacles, and over uneven terrain outdoors is also great if you’re able to do this at your facility.
These activities are not only great for activity tolerance retraining but are also the more fun interventions, in my experience.
- Dancing. If your patient previously enjoyed dancing, this is a great intervention to not only address endurance but also dynamic balance. You can incorporate several patients and a favorite Pandora station and get the rehab party started. (This may not be appropriate for everyone!)
- Nintendo Wii. The Wii has multiple activities that can really encourage moving and also strengthening. Check out how to use the Wii for OT treatments here.
- Traditional sports, such as bowling, table tennis, kickball, volleyball, soccer, etc. are fantastic for increasing activity tolerance through physical activity.
Measuring Activity Tolerance for Documentation:
It’s always super important to keep in mind that you should be measuring activity tolerance for proper documentation. This can be done in several ways:
- Utilize the Borg Rating of Perceived Exertion Scale (this is the most common). This measures the level of intensity of physical activity, ranging from no exertion at all to maximal exertion (Borg, 1998).
- Utilize the MET Chart to approximate the energy cost of activities, working your way up from light to moderate (as an example).
- You can also document how many minutes your patient is able to complete each activity to show progress with how long the activity (self-care tasks, for example) is tolerated.
- Document the difficulty of the activity and the progression each session that you’re addressing activity tolerance.
Final Thoughts for Activity Tolerance Interventions:
Start slow! And base your speed on the patient’s current level. Monitor their vitals if they appear symptomatic. You can then grade the activities up or down based on how they are tolerating the activity. Immediately stop the activity if the patient appears to be struggling or in any distress.
Keep interventions as client-centered as possible. For example, a patient who has never done laundry before and who won’t be doing it after discharge probably won’t love that activity.
Educate the patient on energy conservation techniques during the interventions. Some good examples are pacing, pursed lip breathing, or diaphragmatic breathing when applicable.
And there you have my personal favorite functional activity tolerance interventions. What are some of your favorite activity tolerance interventions that you would add to the list?