.

To:  The American Association of Occupational Therapy (AOTA)

 

From: The practicing clinicians and paying students of the occupational therapy profession both in the United States and Internationally.

 

Re: Is it in the OT scope of practice to treat acute spine and lower extremity injuries and dysfunctions?

 

Official request: Please remove this article from public display on the American Occupational Therapy Association (AOTA) website for the following reasons: 

    • This article is a public display of disrespect to the occupational therapy practitioners working in settings where they competently and autonomously formulate whole-body interventions in therapeutic exercise and neuromuscular re-education to address dysfunction that is presented after applying activity analysis.
  • This article effectively truncates the occupational therapy scope of practice in favor of a global “OTs are the arms” stigma that practicing clinicians fight daily. 
  • This article is an open procomplation that AOTA believes occupational therapy is subordinate to physical therapy despite AOTA’s claims that occupational therapy is a holistic profession.
  • This article contradicts the purpose of AOTA as a public member organization that supports and advocates for the occupational therapy profession by authoring a document that other professions can use to discredit occupational therapy competencies. 
  • This article is convoluted in its execution, does not appear to be based on evidence-based practice, and utilizes the universal generalization that every program and professor is teaching the exact same curriculum. 
  • This article implies that occupational therapy practitioners are taught interventions in school for the upper body but not the lower body. This idea directly contradicts hundreds of course offerings in occupational therapy programs taught by therapists who have spent their careers in adult physical medicine and are teaching a holistic approach to rehabilitation. It discredits the thousands of therapists who have been taught the skills (or taken continuing education) to execute upper body, trunk, and lower extremity interventions based on human anatomy and physiology for direct impact on dysfunction in occupational performance. 
  • This article contradicts other AOTA and AJOT publications including the OTPF which states we treat body structures and functions. 
  • This article implies that NBCOT should re-evaluate the requirements for the occupational therapy curriculums (OT/OTA) to remove all physical medicine classes that offer training on restorative principles on the human body as the entire body — upper extremity, shoulders, spine and trunk musculature, pelvis, and lower extremities– are connected through principles of kinematic links/chains and therefore requires the practitioner remediating functional performance to have the same competency to treat each component of the human body. 

 

AOTA’S Publication to be Removed

Contested text with rationals are itemized below. 

 

Question: Is it in the OT scope of practice to treat acute spine and lower extremity injuries and dysfunctions?

 

Answer: The foundation of a profession’s scope of practice is inclusion in the educational curriculum, a history of application in practice, and language in state licensure laws/regulations that define a legal scope of practice. While occupational therapy programs include anatomy and physiology of the entire body, the focus of specific evaluation and intervention is not on addressing spine and lower extremity dysfunction. This includes range of motion, muscle testing/strengthening, sensory evaluation, gait assessment/training, and manual examination of the lower extremities and spine. The PT curriculum addresses evaluation and treatment for these conditions in depth, and PT clinical fieldwork reinforces knowledge and skills in this area. However, OTs do address functional deficits related to spinal surgery, and spine and lower extremity conditions from an occupation-based perspective. This includes functional movement required to perform ADL and IADL tasks such as bathing, dressing, and home management, as well as leisure activities that involve the spine and/or lower extremities. Close communication with PT where appropriate will ensure that the client’s needs are met effectively.

 

  • “The foundation of a profession’s scope of practice is inclusion in the educational curriculum, a history of application in practice, and language in state licensure laws/regulations that define a legal scope of practice.” 
      1. ‘Inclusion in the educational curriculum’ makes absolutely no sense. 
      2. We learn history occupational therapy in one ‘101’ class. There is no reason to learn the history of application of every diagnosis – this also doesn’t make sense. 
      3. Learning the language in state licensure is also a broad class with minor information. This response gives no information of the 35+ classes build in physical medicine and restorative health that an occupational therapy practitioner must pass with a B+ or better. Nor does it allude to the many classes (including functional application, gross anatomy, and gross human physiology that we must take with physical therapy students being required to have the same level of aptitude to pass the class). 
      4. According to  ‘The National Board for Certification in Occupational Therapy, INC : Professional Practice Standards, every occupational therapist should be equipped to execute the following items. Please note that these requirements apply to the human body in its entirety as evidenced by universal language like “anatomical, physiological, biomechanical” and corresponding requirements of competence in physiological components of healing as it applies to the entire body listed in many school curriculums. 
        1. Domain 3: Task 3 – Manage interventions for improving range of motion, strength, activity tolerance, sensation, postural control, and balance based on neuromotor status, cardiopulmonary response, and current stage of recovery or condition in order to support occupational performance.
  • “While occupational therapy programs include anatomy and physiology of the entire body, the focus of specific evaluation and intervention is not on addressing spine and lower extremity dysfunction.”
    1. This is a grotesque generalization. Through a poll which was conducted on social media. More than 60% of hundreds of practitioners have refuted this statement. The level of education a student receives is based on the program, the teacher, and the clinical placement to which the student is assigned during fieldwork. Most programs require their occupational therapy practitioners to demonstrate competence in all of the above elements of practice. During placements (especially in rural settings), occupational therapy is required to treat the entire body due to healthcare disparity. 
    2. There is absolutely no differentiation in NBCOT, ACOTE, nore the OTPF to state that an occupational therapy practitioner should not be /is not just as competent in the lower body and spine as they are competent in the upper body. To state this would be ignorant and not based in current evidence-based practice. During occupational therapy courses, like Kinesiology, every OTP is taught that the body is connected. If we are to abide by the standards of ACOTE when we are teaching postural control and neuromotor principles, we teach that everything starts with the knowledge of the spine, vertebral column alignment, and pelvic alignment. We are taught through gait and postural analysis that lower extremity function and the type of gait being executed will impact the pelvis which will impact the trunk (Spine), which will impact bilateral upper extremities. The body is completely connected and if the occupational therapy practitioner’s job is to correct functional performance, we must understand how to apply activity analysis to every ADL and IADL. 
  • Essential ADLs are AMBULATION and TRANSFERS! This requires working knowledge and competence of all components of the musculoskeletal and neuromuscular system along with the corresponding avenues of treatment! This article is telling the world that we can’t do our job, when our job is to help someone in functional performance using JUST AS MANY physical medicine strategies as strategies in the social science model. 
  • “This includes range of motion, muscle testing/strengthening, sensory evaluation, gait assessment/training, and manual examination of the lower extremities and spine.”
    1. Everything about this is completely wrong when half of America is taking functional anatomy, gross anatomy, and applied therapy techniques WITH physical therapy students. 
    2. The association that is taking the money of working occupational therapy practitioners who have spent years developing competencies and years after graduating developing competencies can not and should not ever allude that an occupational therapy practitioner does not have the skills necessary to treat every single part of the human body. 
    3. The OTPF clearly states that our domain consists of all body structures and functions. The OT framework has made clear that a licensed occupational therapist applies activity analysis to break down every occupation into its micro components and it is the job of the therapist to remediate this function. Every part of the body. Every function of the body. 
    4. It is the responsibility of AOTA to respect and hold safely the scope of the occupational therapy practitioner and promote out competence. Any article on AOTA without substantial support that is telling an occupational therapy practitioner to defer to physical therapy should be removed immediately. 
    5. These articles are read by the medical community and are robbing occupational therapy practitioners of the ability to use the education they have received. 

 

  • “The PT curriculum addresses evaluation and treatment for these conditions in depth, and PT clinical fieldwork reinforces knowledge and skills in this area.”
    1. In 2019, APTA released their ‘Physical Therapist Practice Guidelines’ which included their new scope of practice: 
      1. Biopsychosocial point of view
      2. The remediation of ADLs, IADLs, and other functional activities
      3. Their new focus on the environmental context during the therapy process
      4. Community reintegration. 
    2. AOTA allowed physical therapy to include the OT scope in their framework for which they can now be reimbursed. AOTA is allowing occupational therapy to lose respect and presence in acute care and outpatient settings. AOTA refuses to advocate on a public and professional level for the competence every occupational therapy practitioner (member or otherwise) – to make a reference that the physical therapy curriculum is superior to occupational therapy and make the assumption that a PT is being trained on these principles in fieldwork but an OT is not, is shameful. This is a generalization made in assumption and should be removed. 
    3. An occupational therapy practitioner is responsible to develop and maintain further competencies and specialities as is every medical provider, this statement takes hope for occupational therapy practitioners and gives physical therapy and management (payors) leverage to rob us of essential practice areas. 

 

  • “However, OTs do address functional deficits related to spinal surgery, and spine and lower extremity conditions from an occupation-based perspective. This includes functional movement required to perform ADL and IADL tasks such as bathing, dressing, and home management, as well as leisure activities that involve the spine and/or lower extremities.”
      1. “occupation-based interventions are defined as activities that support performance in the following areas of occupation: ADLs, instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation (AOTA, 2014)”. In order to remediate underlying dysfunctions preventing an individual from completing what is most meaningful to them, OTP’s MUST be competent in the remediation of the entire human body. 
      2. Occupational Therapy’s unique approach to therapy through client centered and holistic interventions can not reduce an individual to “occupations” that associations or governing bodies deem meaningful. 
      3. Furthermore, the entire human body functions in a kinetic chain. There is not one domain of occupation that ONLY addresses the upper body. 
      4. Functional MOVEMENT are patterns of movement that involve multiple muscles and often multiple joints. You do a disservice to practitioners and patients.
  • “Close communication with PT where appropriate will ensure that the client’s needs are met effectively.”
    1. This should be retracted and a press release should be issued apologizing for the insult and disrespect that is represented by this article. Hundreds of thousands of practitioners have spent years developing their practice areas and one article can rob them of every ounce of respect that has taken years to earn because AOTA does nothing to help create jobs and respect for therapy practitioners on the ground floor. 
    2. Any and all published documents from AOTA should be carefully reviewed as this profession is facing turmoil and it is the responsibility of AOTA to set an example for the success and future of OT Practice in the United.  States. Instead, this article has effectively silenced many occupational therapy practitioners in physical medicine settings. 

 

Sincerely, 

Owner and Lead Practitioners of Buffalo Occupational Therapy

Michelle Eliason, MS, OTR/L, CDS, CKTS & Hannah McDowell, COTA/L, NASM-CES