The OT documentation system that includes the taxonomy described here is comparable to the format used by all SCIRehab disciplines (14
). As shown in , the OT first describes each therapy session in terms of type (individual or group), co-treatment with other disciplines (if applicable), the extent of the patient directing care, and patient and family involvement. Factors that may limit the session (eg, orthostasis or behavioral issues) are identified. The OT then identifies time spent on assessment and 1 or more of the identified 26 OT-specific activities in which the patient participated during the session. Patient assistance needs () may contribute to activity selection; to contain the assessment and treatment “taxonomy” portions of the documentation and show the intervention details associated with each activity individually. Intensity is measured by the amount of time spent per activity.
OT Activities and Session Variables
Options for the Level of Assistance and Education Only Descriptors
Education Not Covered by Other Activity Areas (Described in –)
Many of the 26 OT activity categories are supplemented by information about the assistance a patient requires to perform the activity. lists the adapted Functional Independence Measure (FIM) (15
) options for level of assistance (LOA) used in the OT activity descriptions. The use of adapted FIM descriptors to rate assistance needs consistently by all disciplines is described in the article by Gassaway et al (14
). In the SCIRehab OT documentation, a finer delineation of assistance needs is obtained than would be captured with standard FIM application. Assistance needs are associated with specific OT activity components in the OT taxonomy rather than FIM items defined per the FIM manual (16
). For example, a person with tetraplegia may improve significantly in a component of lower body dressing, such as donning pants. This improvement in donning pants is noted in the OT taxonomy but may not be reflected in the single FIM score for the lower body dressing item, which also includes assistance needed for donning shoes and socks. If functional work (eg, transfers, activity of daily living [ADL] training) is reviewed with the patient and/or family without the patient actually performing or practicing the task, there is no assistance needed. Thus, also contains “education only” options.
Assessment and each of the 26 activities included in the OT taxonomy are contained in to and described below. Although much treatment work is discipline specific (eg, OT activity of daily living training and physical therapy [PT] gait training), other treatments are initiated by one or both disciplines depending on facility practices. Both OTs and PTs work on transfer training and bed mobility. At some facilities, OTs are responsible for the majority of wheelchair (WC) evaluation and prescription, whereas at other facilities, this is a PT responsibility. Thus, OTs worked with PTs to establish consistent treatment intervention descriptions for those interventions that are a component of each discipline; the PT and OT taxonomy categories for bed mobility training, transfers, WC mobility, equipment evaluation/prescription, and respiratory management follow similar frameworks (17
). During analysis, this consistency will allow researchers to examine the impact of WC mobility training or transfer training, for example, regardless of the discipline providing the training. In addition, consistent descriptions provide a common frame of reference to clinicians when they discuss development and use of their taxonomies within facilities and to aid in interpretation of findings.
The OT documentation process first indicates areas of patient assessment and time spent performing the assessment. Because of the high prevalence of shoulder pain among patients with SCI (18
), shoulder function is the only assessment topic that is defined further in this documentation. The indication for the shoulder assessment (chronic/acute pain or pain prevention) and the findings of the assessment (subluxation, positive impingement test, pectoralis tightness, decreased shoulder musculature, scapular elevation and scapular protraction/winging) are included ().
Activities of Daily Living
The next 7 OT activities come under the general rubric of self-care tasks or ADLs. For these activities, the OT assumes the role of a skills teacher (coach) and therapy consists of demonstrating the skill, teaching component or simplified steps, and teaching and rehearsing the entire sequence. Once a patient knows the basics, the OT helps the patient become more efficient at the skill through repeated practice.
depicts the taxonomy information for OT work on self-feeding skills. It incorporates the main pieces of equipment used at the 6 SCIRehab centers to facilitate the self-feeding process and whether the patient practices this task in a (wheel) chair or in bed. Self-feeding in an upright, supported position, such as the WC, may lead to greater independence with the task than when a less supportive surface (eg, a hospital bed) is used. A variety of adaptive equipment for self-feeding is available; the OT taxonomy incorporates the main pieces of equipment used at the 6 SCIRehab centers.
Grooming, like self-feeding, may be facilitated by position (in bed, WC, or standing; ). The OT taxonomy includes this position along with the specific grooming tasks (eg, face washing, hair combing) worked on during the session, the type of equipment used with each task, and the amount of assistance need for each task, because a different level of assistance may be needed for each aspect of grooming. For patients with less severe injuries who are able to work on “all grooming tasks,” LOA is associated with the full task.
Bathing information captured is similar to self-feeding and grooming information (). However, designation of equipment needed for task completion is limited to none, prefabricated adaptive equipment, or custom adaptive equipment because adaptive equipment used during bathing varies greatly between centers, especially the custom equipment.
combines details for upper and lower body dressing; however, they are separate in the OT taxonomy because the equipment used, clothing type, and amount of assistance needed to complete each task often is different. Documentation for both upper and lower body dressing includes the surface where the task occurs, patient position, and adaptive equipment used. Lower body dressing also includes type of clothing donned or doffed during the session.
Toileting: Clothing Management and Hygiene
The OT taxonomy includes as separate activities toileting, bladder management, and bowel management, but in they are combined. Toileting includes the patient's ability to manage clothing and hygiene, similar to the FIM toileting item. As shown in , the only information captured for toileting is type of equipment (bed, commode type, tub bench with cut-out) used and assistance needs.
Bowel and Bladder Management, Toileting: Clothing Management, and Hygienea
Protocols for teaching bowel and bladder management vary significantly among SCIRehab centers. Nurses at some centers address all teaching needs regarding bowel/bladder management. Some other centers use collaborative efforts of nursing and OT. The remaining centers divide the task based on the patient's level of injury; nursing works with patients with paraplegia, whereas OTs focus on patients with tetraplegia. The SCIRehab centers also vary in how OTs assist patients with upper motor neuron deficits to get consistent bowel results. shows taxonomy options for surface, whether training involves a simulation (common before actual performance of the technique is attempted) or an actual performance of bowel management, and techniques and adaptive equipment used for bowel management. Not included in the OT taxonomy are techniques such as drinking a hot beverage before attempts to elicit a bowel movement. However, the time of the treatment session is documented in the SCIRehab study so that bowel management technique training can be associated with mealtimes (eg, rectal clear after breakfast or lunch).
Between-center variation also is seen for bladder management, and the OT taxonomy allows tracking of such differences. Some centers use a sterile closed technique (prelubricated catheter in a clear collection bag with an introducer tip on 1 end that allows the catheter to be touched less), others use a sterile open system (separately packaged catheters and lubrication), and others use clean (soap and water, no gloves) techniques for catheterization. In addition to the variations in technique used, centers also vary in the type of adaptive equipment used in bladder management and catheterization types for patients with tetraplegia (intermittent catheterization, indwelling [suprapubic] catheter, leg bag, or external collectors).
Communication and Assistive Technology
The OT taxonomy includes 3 types of communication activities: writing, page turning, and phone use. It also includes 2 types of assistive technology: computer access and electronic aids for daily living (EADLs)/call system. Equipment lists include various types of writing devices, splints, and telephones. Generic categories for phone types are included so that rapidly changing technology will fit into these categories over time. In addition, devices to assist with upper extremity function (eg, mobile arm support and overhead sling) are included for assistive technology. combines details for communication and assistive technology activities; however, they are separate in the OT taxonomy.
Communication and Assistive Technology
Home Management Skills
The OT taxonomy includes time spent on teaching instrumental ADLs (IADLs) such as childcare, cleaning, laundry, and meal preparation (). All patients engage in some IADLs; however, focus on a particular skill may vary by age, sex, and stage of life.
Bed mobility is a skill that is inherent in the completion of many ADL tasks (eg, lower body dressing), transfers out of bed, and correct positioning in bed for skin protection and comfort (). The PT and OT taxonomies follow a similar framework for bed mobility training (17
It is common to work on just 1 or 2 elements of bed mobility (positioning, rolling, supine-to-sit, and/or scooting) during an OT treatment session. Capturing level of assistance and other details about each bed mobility component describes independence differences that would not be apparent using standard documentation formats such as the FIM. Rolling on a treatment mat or in a hospital bed using railings often is easier than on a standard bed. Learning positioning on a large treatment mat is different than learning positioning in the confined space of a hospital bed. Thus, the taxonomy includes the surface on which bed mobility components are performed. As with many OT activities, adaptive equipment facilitates task completion.
OTs and PTs worked together to dissect transfer components and develop a common definition of transfers, including surfaces involved and type of transfer (). Because therapists intuitively think about a transfer as 1 action back-and-forth between 2 surfaces (eg, getting into and out of a car is considered 1 action) a transfer was defined as a back-and-forth action between 2 surfaces. The PT and OT taxonomies incorporate the same definition of “transfer” and follow a similar framework (17
A unique transfer training detail included only in the OT taxonomy, however, is whether a transfer is performed dressed or undressed. It is common to have an OT treatment session where tasks such as toilet or bathing transfers are performed with clothing on for the purpose of training; however, in real life, this transfer would most likely be performed undressed. Many individuals require increased assistance when transfers are performed undressed, because they are more prone to stick to the surface or are unable to slide across the transfer board as they may have become accustomed to doing when clothed. Performing transfers with vs without clothing also may have an impact on skin integrity.
The OT taxonomy category named “therapeutic activities” may be a bit confusing, because all activities conducted during OT sessions are considered therapeutic (). This all-encompassing category of therapeutic activities includes 10 OT treatments that do not fit easily into any of the other identified OT activities, including edema management, breathing exercise, visual/perceptual training, and cognitive retraining. Selection of “tenodesis training” or “practice of fine motor activities” prompts for additional information about pinch type and splint use.
The OT taxonomy includes 14 categories for strengthening and increasing endurance; some are common across sites and others are used at some, but not all sites (eg, Motomed; Video Simulation; Playstation EyeToy [Trademark of Sony Computer Entertainment, Europe]; Wii [Nintendo of America, Inc., Redmond, WA]; and yoga; ). When applicable, the OT taxonomy captures information about body position, involved body part, and direction of movement (eg, flexion, extension, protraction) for each of the 14 categories. Position is especially important when using “basic/low-tech equipment” or “no equipment,” because progressing from supine to sitting or from a WC to short sit (unsupported) can represent improvement in strength and balance.
Range of Motion/Stretching
Information about the type of range of motion (ROM) or stretching provided to specific body parts is captured (). “Intervention” includes the type of range of motion treatment delivered or treatments, such as manual/orthopedic treatment and thermal agents that are common adjuncts to range of motion and stretching.
A patient's balance performance can differ significantly depending on her/his body position and the amount of movement involved (). Thus, movement is categorized as static or dynamic and includes the body position from which balance is addressed.
The OT taxonomy seeks to classify and quantify application of specific modalities used with patients with SCI. lists the types of modalities included and the indication for use and the anatomic location of application. Modalities can be used for various reasons; for example, Kinesiotape can be used for pain management, neuromuscular re-education, or for edema management.
Teaching WC mobility is a crucial OT intervention in SCI rehabilitation to enable environmental exploration and to perform daily tasks at home. Like the skills of bed mobility and transfers, WC mobility skill training falls under other disciplines' scope of practice as well (17
). The OT and PT taxonomies capture important attributes of these cross-disciplinary skills as applicable to that discipline. combines details for power and manual WC mobility training; however, documentation for each is separate in the OT taxonomy.
Wheelchair Mobility—Manual and Power
The OT taxonomy includes various manual and power WC mobility skills and skill-specific details; there is some overlap of skill by chair type. Level of independence and surface type is tracked separately for individual skills including propulsion, ramps, and wheelies.
Adaptive equipment often is used with both manual and power WC mobility training to increase the patient's independence. For example, a patient may be unable to propel a manual chair without having a tubing wrap on the wheels.
Management of doors, elevators, and curbs is important for community mobility in either type of chair. Additionally, 2 skills unique to the power chair (WC management and power functions) are included, because patients need to be able to manage seating functions and to position their drive controls properly or to direct someone else in doing so.
Community Reintegration Outings
Community outings help to reintegrate the patient into the community. The OT taxonomy includes the location of the outing and descriptions of the integral role that OTs have in showing the newly injured patient how to cross a street in a WC, navigate curbs, manage money, perform catheterization in a community bathroom (especially the first time), and deal with the stigma or other emotional issues that come with community exposure (). Therapeutic recreation and PT also include details of community outings in their respective taxonomies.
The following 4 activities are combined into a single table ().
SCI centers follow skin care programs to prevent pressure ulcers. OTs, like their colleagues in other disciplines, adhere to pressure relief programs and are involved in procurement of appropriate equipment. Activities and specific therapy interventions included in the skin management section of the OT taxonomy mirror the activities in the PT taxonomy (17
Evaluations for ordering of WCs, transfer devices, and equipment for bed, bathing, and toileting are the primary responsibility of OTs in some centers and of PTs in other facilities. Thus, this activity is included in both the OT and PT taxonomies (17
Adaptive equipment evaluation focuses on identifying a patient's functional deficits (eg, decreased muscle strength, ROM, or fine motor skills) and determining the most appropriate piece of adaptive equipment to optimize independence.
Throughout the course of rehabilitation, splints and casts may be used in therapy to promote function, for contracture management, or for maintenance of a functional hand position (). Fabrication of the most commonly used splints is included in the OT taxonomy. The process of splinting and casting may continue throughout the rehabilitation process as patient function changes. Often, it is necessary to adapt existing splints to improve their functional use; this is termed “adaptation to prior” in the OT taxonomy.
OT practice in respiratory management varies greatly among centers, as does respiratory management by PT. The airway management section of both taxonomies includes documentation of chest physical therapy, respiratory exercises, suctioning, and coughing interventions only and an indication of whether the therapist educated the patient and/or family on components of respiratory management.
Education Not Covered By Other Activity Area
Education is an integral component of training in every functional activity and not included separately in the OT taxonomy (). As stated earlier, if the patient does not practice the functional task, the OT includes this education in the appropriate functional task activity (–) by selecting an education only option in the level of assistance field (if the functional task is not practiced, there is no assistance needed) in . For example, the OT reviews transfers techniques with the patient but the patient does not perform the transfer. Because this is education about a functional task that is included in the OT taxonomy, it is recorded in the transfer activity, and the level of assistance is documented as patient education only.
However, much OT education also is provided in the absence of functional task work, and thus, is included separately in the OT taxonomy. As presented in , the OT taxonomy includes topics that may be reviewed with a patient in an education-only session (eg, home modifications needed for optimal home independence) or during a functional work session with a different focus (eg, during tenodesis training the therapist educates the patient or family on transportation issues). If the education overlaps with a different functional activity, the therapist documents “yes—overlaps with functional work” so that minutes spent on the education do not “double count” minutes spent on the functional work.