Amy Marshall, Christine Myers, Doris Pierce; A Century of Therapeutic Use of the Physical Environment. Am J Occup Ther 2016;71(1):7101100030. https://doi.org/10.5014/ajot.2017.023960
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In this article, we describe the use of the objects and spaces of the physical environment by occupational therapy practitioners in the United States over the profession’s first 100 years. Using professional literature selected by decade from the years 1917 through 2016 to obtain data, we applied grounded theory methods to complete a detailed description. Team-based analysis over four coding schemes yielded a theoretical description of the profession’s therapeutic use of the physical environment. Study findings included descriptions across occupational therapy’s history of (1) treatment spaces, (2) the concepts of adapting and grading, and (3) a typology of constructive and nonconstructive applications of objects and activities by occupational therapy clients and practitioners. This extended historical perspective on trajectories of change in intervention space, the role of physical products in intervention, therapist repertoire, and the enduring role of adaptation suggests how the physical environment may be used in future practice.
As occupational therapy becomes further integrated into clients’ natural settings, practitioners will have increased opportunities to center therapeutic efforts on relatively intact occupations within the spaces of the client’s daily life. For example, the use of telerehabilitation, supported by videoconferencing and self-monitoring devices, can help older adults age in place and remain engaged in everyday occupations within their homes (Cason, 2012). In addition, technology, such as therapy ball chairs, supports students’ engagement in the classroom setting (Bagatell et al., 2010).
Therapeutic use of adapting and grading has evolved far beyond the simple adjustments in craft activities of the profession’s early years. The dedicated professional spaces of the biomechanical period provided controlled settings within which highly adaptable, measurable, and product-focused interventions addressing physical limitations were conceptually refined. Today, grading and adapting are used within a multifaceted, dynamic, and highly contextualized approach that draws on a client’s potential to foster engagement within everyday spaces. Current interventions with children with autism spectrum disorders exemplify this approach because grading of task and environment within the natural context increases generalization of functional behaviors and occupational participation (Tomchek & Koenig, 2016).
Although practitioners’ construction of objects to support client healing or function has shifted to the use of manufactured items, the clinical reasoning necessary to effectively prescribe these devices and to train clients in their use has not changed. Moreover, this aspect of practice will continue as adaptations within clients’ natural environments, particularly in postacute settings, become increasingly important.
The increasing sophistication of practitioners’ repertoires suggests the benefit of higher levels of education for both occupational therapists (i.e., clinical doctorate) and occupational therapy assistants (i.e., baccalaureate entry) so that they may cultivate the knowledge, skills, and clinical reasoning to effectively use all aspects of the physical environment on behalf of their future clients. Programs that provide higher levels of education may have more opportunities for service learning, fieldwork experiences, or capstone projects that address the complexity of clients’ needs in their homes, schools, neighborhoods, and communities through a focus on the therapeutic use or adaptation of the objects and spaces of those environments.
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