Grading Occupational Therapy Interventions

As occupational therapy practitioners, our brains are all about task analysis, the ability to completely break down an activity and view the minute details that others don’t see. It is a thought process that is ingrained into our brains starting day one of occupational therapy school.

Upgrading and downgrading interventions in a simulated scenario are much easier than with your first clinical treatments with actual patients. All of us have those moments as new therapists where we get into a comfortable groove, but then freeze when we have to unexpectedly change our treatment plan because it is too easy or difficult for the patient.

So, let’s explore some ways to grade these treatments, meaning making these changes easier or more challenging.

“Grading,” defined:

Grading occupational therapy interventions simply means increasing or decreasing the difficulty of the intervention you’ve provided based on how your patient is responding to it.

If the activity is too easy, you would grade it up to make it a greater challenge. Conversely, if it the intervention is too difficult, you will decrease the difficulty of the task. Grading interventions appropriately makes a “just-right challenge,” making it an appropriate treatment to address your patients’ goals.

Now that we have the meaning of grading defined, how can you apply this in a real-life situation?

Take a look at the following scenario:

Mark is a licensed occupational therapist who graduated last year and started his first job at a local skilled nursing facility. He evaluated Norma, an 81 year old female patient who sustained a ground level fall at home resulting in a RLE tibia fracture. The OT evaluation revealed that Norma is alert and oriented x4, was on non-weight bearing precautions for her right leg, and has had several falls over the past six months.

She lives in her private residence with her spouse and was independent in all ADL tasks. The only assistance she needed help with was grocery shopping and transport from her children who live in her same neighborhood. She occasionally used a cane to get around her home before her injury.

Three weeks of occupational therapy have gone by, which have focused on Norma’s goals to shower independently in standing and to increase her standing balance so she can go back to cooking meals for herself and her husband. Her primary physician has recently changed her orders to weight-bearing as tolerated on the right leg. Now that she can use both of her lower extremities in standing tasks, Norma is breezing through the OT interventions.

So, how can Mark change the interventions to make them more challenging?

The following few factors should be considered when upgrading/downgrading interventions to optimize the patient’s therapeutic benefit:

Medical Precautions and Vitals:

Regularly check with nursing staff or medical records to see if the patient had any recent medical precautions placed or lifted. Precautions lifted such as NPO orders (no food by mouth), sponge-baths only, weight-bearing status, and fall precautions (alarms, one-on-one care, etc.) usually indicate room for upgrading treatments.

Let’s say Mark decides to conduct a showering task with Norma after he just learned that her weight-bearing precautions have been updated.

Beforehand, Norma’s vitals (heart rate, oxygen saturation, and respiratory rate) registered as normal with showering activity. Additionally, she was using a shower chair and required Minimum Assist for sit-to-stand transfers.

Now that she is allowed to weight-bear on both feet, Mark may consider upgrading the showering task to standing with the assist of a grab bar. He would need to keep track of her vitals to make sure her body can tolerate the upgrade. If her vitals are abnormal, he would incorporate sitting rest breaks and gradually reduce them over time until they are regulated again.

Pain Levels:

Active pain warrants a downgrade for an activity instantly, and with Norma’s healing fracture you can bet she will still feel some pain with weight-bearing. Mark would have to keep track of what her pain levels are on a subject scale of 1 to 10: at rest and with activity, incorporate rest breaks and adaptive strategies (shower chairs, wheelchairs, etc.) as necessary and then remove those aids when the pain comes down with activity. As the pain in her right leg subsides, it will become easier for Norma to stand in the shower.

Current AE and DME use:

Possible medical equipment being used for the showering task could include a shower chair, grab bars, a wheelchair, a walker, a quad cane, and a reacher to name a few. If Norma is alright with the possibility of returning home with equipment in order to complete her showers, then the goal would be changed to “Modified Independent” and the equipment viewed as adaptive strategies.

If that’s not the case, then adding and taking away equipment could be viewed as a method of grading. For instance, Norma may have been using a wheelchair to get in and out of the bathroom. Mark could upgrade the task to using a walker instead, and then gradually move her to a cane with the help of her physical therapist.

Physical Assist Levels: 

If the patient is beginning to approach “stand-by assist” while completing the task, then it is time for the therapist to make it more challenging. If the patient is starting to require more hands-on assist or is stagnating at moderate or maximum assist, then the task is too hard and needs to be down-graded.

Cognitive Assist Levels:

Cognitive assist includes any kind of cueing (verbal, tactile, visual) that the therapist needs to provide in order for the patient to succeed in the task. This is commonly seen when working with patients with brain injury, stroke, or dementia.

The therapist would keep track of the number and type of visual cues provided for task completion, and then with time start to reduce the cues if the patient can complete the task safely. If the patient requires an increase in cueing or stagnates at a certain number of cues, then the task is too hard and needs to be downgraded.

Documentation of Changes:

Any form of upgrading and downgrading tasks should be thoroughly documented in the daily treatment notes. If anything, downgrading tasks should be efficiently backed up with evidence to support the change. Therapists know that insurance companies like to see functional progress and maintenance of functional participation in order to justify coverage of services.

Red flags start to raise if the patient appears to be back-tracking on the treatment plan. If goals or tasks have to be downgraded (and it happens), justify it with reasons pertaining to preserving the patient’s health and to follow written orders from primary physicians.

When you grade the task appropriately, your patients will likely view the intervention as challenging but not impossible or too simple. This makes them work for their success, which makes therapy more appealing to come back to over and over again until treatment is finished and their functional goals have been satisfactorily met.

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We hope this post gave you some easy to follow examples on how you can easily grade your interventions in a real life scenario.

Do you you have any examples that helped you get a grasp on grading your occupational therapy interventions? Please share them in the comments below!

This post was originally published on October 22, 2017 and updated on February 2, 2022.