Evidence-Based Practice

Choosing Wisely®

An update on AOTA's best practice recommendations (formerly Choosing Wisely®)

From 2018 - 2021, AOTA published 10 best practice recommendations as part of the Choosing Wisely campaign. The campaign aimed to promote meaningful conversations between practitioners and clients and ensure quality health care that is efficacious and cost-effective. Choosing Wisely was a partnership between the American Board of Medicine (ABIM) Foundation and specialty societies and was active in generating clinical recommendations from 2012-23. Going forward, the ABIM Foundation is switching focus away from developing and maintaining recommendations through Choosing Wisely.

Though the recommendations will no longer be available on the Choosing Wisely website, they will be available directly through AOTA. We will continue to review the recommendations annually to ensure that they are representative of current evidence and best practices.

The development of these recommendations was a member-driven initiative and they have provided value to practitioners, consumers, and policymakers. Together with a review board of members and stakeholders, we will determine our next steps for the initiative and communicate this to AOTA members.

Implement & share the recommendations

We encourage you to not only apply the findings from the initiative to practice but also to share the recommendations. You can do this by

starting conversations with colleagues about the necessity of practice improvement,
utilizing conferences, social media, in-services, or other forums to spread the word,
and leading by example in your own practice and leadership in your workplace.

Recommendations

Purposeful activities—tasks that are part of daily routines and hold meaning, relevance, and perceived utility such as personal care, home management, school, and work—are a core premise of occupational therapy. Research shows that using purposeful activity (occupation) in interventions is an intrinsic motivator for patients. Such activities can increase attention, endurance, motor performance, pain tolerance, and engagement, resulting in better patient outcomes. Purposeful activities build on a person’s ability and lead to achievement of personal and functional goals. Conversely, non-purposeful activities do not stimulate interest or motivation, resulting in reduced patient participation and suboptimal outcomes.

Sources:

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.2014.682006

Hinojosa, J., & Blount, M. (Eds.). (2017). The texture of life: Occupations and related activities. Bethesda, MD: AOTA Press.

Hsieh, C. L., Nelson, D. L., Smith, D. A., & Peterson, C. Q. (1996). A comparison of performance in added-purpose occupations and rote exercise for dynamic standing balance in persons with hemiplegia. American Journal of Occupational Therapy, 50, 10–16. https://doi.org/10.5014/ajot.50.1.10

Lin, K., Wu, C., Tickle-Degnen, L., & Coster, W. (1997). Enhancing occupational performance through occupationally embedded exercise: A meta-analytic review. Occupational Therapy Journal of Research, 17(1), 25–47. https://doi.org/10.1177/153944929701700102

Steinbeck, T. (1986). Purposeful activity and performance. American Journal of Occupational Therapy, 40, 529–534. https://doi.org/10.5014/ajot.40.8.529
Many children and youth are affected by challenges in processing and integrating sensations that negatively affect their ability to participate in meaningful and valued occupations. Processing and integrating sensations are complex and result in individualized patterns of dysfunction that must be addressed in personalized ways. Interventions that do not target the documented patterns of dysfunction can produce ineffective or negative results. Therefore, it is imperative to assess and document specific sensory difficulties before providing sensory-based interventions such as Ayres Sensory Integration®, weighted vests, listening programs, or sensory diets.

Sources:

Bodison, S. C., & Parham, L. D. (2018). Specific sensory techniques and sensory environmental modifications for children and youth with sensory integration difficulties: A systematic review. American Journal of Occupational Therapy, 72, 7201190040. https://doi.org/10.5014/ajot.2018.029413

Council for Exceptional Children. (2014). Council for Exceptional Children standards for evidence-based practices in special education. Retrieved from http://www.cec.sped.org/~/media/Files/Standards/Evidence%20based%20Practices%20and%20Practice/EBP%20FINAL.pdf

Council for Exceptional Children. (2015). CEC’s standards for classifying the evidence base of practices in special education. Remedial and Special Education, 36, 220–234.

Pfeiffer, B., May-Benson, T. A., & Bodison, S. C. (2018). Guest Editorial—State of the science of sensory integration research with children and youth. American Journal of Occupational Therapy, 72, 7201170010. https://doi.org/10.5014/ajot.2018.721003

Schaaf, R. C., Dumont, R. L., Arbesman, M., & May-Benson, T. A. (2018). Efficacy of occupational therapy using Ayres Sensory Integration®: A systematic review. American Journal of Occupational Therapy, 72, 7201190010. https://doi.org/10.5014/ajot.2018.028431

Schaaf, R., & Mailloux, Z. (2015). Clinician’s guide for implementing Ayres Sensory Integration®: Promoting participation for children with autism. Bethesda, MD: AOTA Press.

Watling, R., Kuhanek, H., Parham, D., & Schaaf, R. (2018). Occupational therapy practice guidelines for children and youth with challenges in sensory processing and sensory integration. Bethesda, MD: AOTA Press.
The exclusive use of PAMs (e.g., superficial thermal agents, deep thermal agents, electrotherapeutic agents, mechanical devices) as a therapeutic intervention without direct application to occupational performance is not considered occupational therapy. PAMs provided with a functional component can lead to more positive health outcomes. PAMs should be integrated into a broader occupational therapy program and intervention plan in preparation for or concurrently with purposeful activities or interventions that ultimately enhance engagement in occupation.

Sources:

American Occupational Therapy Association. (2012). Physical agent modalities: A position paper. American Journal of Occupational Therapy, 66(6_Suppl.), S78–S80. https://doi.org/10.5014/ajot.2012.66S78

Bracciano, A. G. (2008). Physical agent modalities: Theory and application for the occupational therapist (2nd ed.). Thorofare, NJ: Slack.

Kim S. H., Park J. H., Jung M. Y., & Yoo, E. Y. (2016). Effects of task-oriented training as an added treatment to electromyogram-triggered neuromuscular stimulation on upper extremity function in chronic stroke patients. Occupational Therapy International, 23, 165–174. https://doi.org/10.1002/oti.1421

Nakano, J., Yamabayashi, C., Scott, A., & Reid, W. D. (2012). The effect of heat applied with stretch to increase range of motion: A systematic review. Physical Therapy in Sport, 13, 180–188. https://doi.org/10.1016/j.ptsp.2011.11.003
Use of an overhead pulley for individuals with a hemiplegic shoulder resulting from a stroke or other clinical condition is considered too aggressive and should be avoided, as it presents the highest risk of the patient developing shoulder pain. Gentler and controlled range of motion exercises and activities are preferred.

Sources:

Cotoi, A., Viana, R., Wilson, R., Chae, J., Miller, T., Foley, N., & Teasell, R. (2016). Painful hemiplegic shoulder. In R. Teasell, N. Hussein, N. Foley, & A. Cotoi (Eds.), Evidence-based review of stroke rehabilitation (17th ed., pp. 1–56). Ontario: Canadian Partnership for Stroke Rehabilitation.

Kumar, R., Metter, E. J., Mehta, A. J., & Chew, T. (1990). Shoulder pain in hemiplegia: The role of exercise. Archives of Physical Medicine and Rehabilitation, 69, 205–208.
To improve occupational performance, cognitive-based interventions should be embedded in an occupation relevant to the patient. Examples of cognitive-based interventions include awareness approaches, strategy training, task training, environmental modifications, and assistive technology. The use of cognitive-based interventions not based on occupational performance will result in suboptimal patient outcomes.

Sources:

American Occupational Therapy Association. (2013). Cognition, cognitive rehabilitation, and occupational performance. American Journal of Occupational Therapy, 67(6 Suppl.), S9–S31. http://doi.org/10.5014/ajot.2013.67S9

Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., . . . Ashman, T. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine and Rehabilitation, 92(4), 519–530. http://doi.org/10.1016/j.apmr.2010.11.015

Gillen, G., Nilsen, D. M., Attridge, J., Banakos, E., Morgan, M., Winterbottom, L., & York, W. (2015). Effectiveness of interventions to improve occupational performance of people with cognitive impairments after stroke: An evidence-based review. American Journal of Occupational Therapy, 69(1), 6901180040. http://doi.org/10.5014/ajot.2015.012138

Smallfield, S., & Heckenlaible, C. (2017). Effectiveness of occupational therapy interventions to enhance occupational performance for adults with Alzheimer’s disease and related major neurocognitive disorders: A systematic review. American Journal of Occupational Therapy, 71(5), 7105180010. http://doi.org/10.5014/ajot.2017.024752
Best practice occupational therapy relies on a practitioner’s understanding of a client’s occupational history and experiences, patterns of daily living, interests, values, and needs, as well as active partnership with the client and care partners (e.g., partners, parents, caregivers) to develop meaningful goals. As stated in the fourth edition of the Occupational Therapy Practice Framework: Domain and Process (OTPF-4), “only clients can identify the occupations that give meaning to their lives and select the goals and priorities that are important to them” (AOTA, 2020). If the client or care partners are not involved in developing the profile and identifying goals, priorities, and outcomes, full engagement in occupations may not be accomplished.

Sources:

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001 Improve your documentation with AOTA’s updated occupational profile template. (2020). American Occupational Therapy Association. https://www.aota.org/profile

Mroz, T., Pitonyak, J., Fogelberg, D., & Leland, N. (2015). Client centeredness and health reform: Key issues for occupational therapy. American Journal of Occupational Therapy, 69(5). https://doi.org/10.5014/ajot.2015.695001
Occupational therapy practitioners should provide person-centered, strengths-based interventions, and advocate for autistic persons on individual and societal levels by providing information to promote inclusivity and belonging, and to decrease stigma. Actions that are considered “restricted and repetitive behaviors” by the DSM-5 (American Psychiatric Association, 2013) may serve as meaningful activities for self-regulation, communication, or self-expression. Attempting to change or extinguish these behaviors without direct request from the individual, without understanding and incorporating the underlying meanings, or substituting other actions to meet self-regulatory reasons for the behavior commonly results in camouflaging (e.g., masking or hiding behaviors), that can result in negative self-image, depression, and an increased risk of suicidality.

Sources:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Benevides, T. W., Shore, S. M., Palmer, K., Duncan, P., Plank, A., Andresen, M.-L., …Coughlin, S. S. (2020). Listening to the autistic voice: Mental health priorities to guide research and practice in autism from a stakeholder-driven project. Autism, 24(4), 822–833. https://doi.org/10.1177/1362361320908410

Cassidy, S., Bradley, L., Shaw, R., & Baron-Cohen, S. (2018). Risk markers for suicidality in autistic adults. Molecular Autism, 9(1), 42. https://doi.org/10.1186/s13229-018-0226-4.

Cage, E., Di Monaco, J., & Newell, V. (2018). Experiences of autism acceptance and mental health in autistic adults. Journal of Autism and Developmental Disorders, 48(2), 473-484. https://pubmed.ncbi.nlm.nih.gov/29071566/

Hull, L., Petrides, K. V., Allison, C., Smith, P., Baron-Cohen, S., Lai, M. C., & Mandy, W. (2017). “Putting on my best normal”: Social camouflaging in adults with autism spectrum conditions. Journal of Autism and Developmental Disorders, 47(8), 2519–2534. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5509825

Patten Koenig, K. (2019). A strength-based frame of reference for autistic individuals. In P. Kramer, J. Hinojosa, & T. Howe (Eds.). Frames of reference for pediatric occupational therapy (4th edition). Philadelphia: Lippincott Williams & Wilkins.
Interventions designed solely to integrate retained reflexes do not promote participation in occupation, and while they may be observed in clients with difficulties in occupational performance, the presence of retained reflexes does not necessarily equate to functional impairment. If reflex integration techniques (i.e., techniques designed to integrate, or inhibit, primary motor reflexes that are retained beyond the typical developmental stage of integration) are being considered for intervention, standardized tools and assessment approaches are necessary to connect impairment to occupational performance. Intervention should focus on improving occupational participation and performance rather than solely on reflex integration.

Sources:

Stallings-Sahler, S., Reinoso, G., & Frauwirth, S. (2019). Neurodevelopmental soft signs: Implications for sensory processing and praxis assessment—Part One. AOTA CE. https://www.aota.org/-/ media/Corporate/Files/Publications/CE-Articles/CE-Article-%20September-2019.pdf

McPhillips, M., Hepper, P. G., & Mulhern, G. (2000). Effects of replicating primary-reflex movements on specific reading difficulties in children: A randomised, double-blind, controlled trial. Lancet, 355, 537–541.
Standard shoulder slings immobilize the upper extremity in a flexor pattern (i.e., a position of elbow flexion, and shoulder adduction and internal rotation). Utilizing a sling that places a person’s hemiplegic arm in this position for extended periods of time increases the risk of contractures and pain, and limits active use of the extremity, thereby decreasing opportunities for neuroplastic changes that support an organic increase in function. Education should be provided to clients and caregivers on safe positioning of the hemiplegic arm during activity and at rest.

Sources:

Gillen, G. & Nilsen, D.M. (2021). Upper extremity function and management. In Gillen, G.and Nilsen, D.M.(eds.) Stroke rehabilitation: A function based approach (5th ed.). St. Louis: Elsevier Science.

van Bladel, A., Lambrecht, G., Oostra, K. M., Vanderstraeten, G., & Cambier, D. (2017). A randomized controlled trial on the immediate and long-term effects of arm slings on shoulder subluxation in stroke patients. European Journal of Physical and Rehabilitation Medicine, 53(3), 10.
Occupational therapy practice requires consideration of contextual factors that affect a person’s ability to participate in meaningful occupations. Gait training and ambulation interventions do not necessarily consider the context of performing everyday activities. While occupational therapists can assess underlying performance skills for ambulation and gait and utilize related interventions, they must address functional mobility by considering the context in order to implement effective, evidence-based interventions that are personally meaningful to the individual.

Sources:

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Elliot, S., & Leland, N. (2018). Occupational therapy fall prevention interventions for community-dwelling older adults. American Journal of Occupational Therapy, 72(4), 7204190040. https://doi.org/ 10.5014/ajot.2018.030494

Clinical application resources

Quick references to help you start implementing the recommendations in your practice.

Recommendation 1: Occupation-Based Interventions

Recommendation 2: Sensory Integration and Processing Assessment

Recommendation 2: Sensory Integration and Processing Decision Tree

Recommendation 3: Physical Agent Modalities

Recommendation 4: Safe Interventions for Clients With a Hemiplegic Shoulder

Recommendation 5: Functional Cognition

Recommendation 6: Occupational Profile

Recommendation 7: Restrictive and Repetitive Behaviors

Recommendation 10: Functional Mobility

How was the list developed?

Initial recommendation development (published in 2018)

Led by Project Champion Glen Gillen, EdD, OTR, FAOTA, then Associate Director and Professor of Rehabilitation and Regenerative Medicine (Occupational Therapy) at Columbia University Medical Center, AOTA conducted a three-phase project to develop the initial 5 Choosing Wisely recommendations of services that occupational therapy practitioners should not provide. The phases of the project included Phase I—building member awareness and support, Phase II—soliciting member input, and Phase III—disseminating the final items.

Phase I was accomplished through presentations to AOTA member and volunteer groups, a Town Hall session at the 2017 AOTA Annual Conference, an online webinar and related materials, and coverage in AOTA publications. Phase I included an initial online member survey that resulted in 328 responses. Following the elimination of duplicate responses and items outside the scope of occupational therapy practice, the list was narrowed down to 62 items. Additional input was received from AOTA Special Interest Section volunteer leaders to rank the items based on established criteria. An extensive literature search was conducted on the highest-ranked strategies.
Phase II involved an online member survey presenting 12 items for evaluation, with a goal of picking the top 5. This survey resulted in 4,860 responses that were analyzed, resulting in the final 5 items. These items were reviewed by the AOTA Board of Directors.
Phase III included the development of a communication and dissemination plan. The first step was a Town Hall at the 2018 AOTA Annual Conference & Expo.

Additional recommendation development (published in 2021)

In 2020, AOTA initiated the process to develop additional recommendations. The process to select and refine the recommendations followed the same member survey and selection process used in 2018:

An online member survey included interventions originally identified but not selected in the 2018 survey.
Respondents selected up to 5 out of 10 items for the development of additional recommendations.
The survey received 999 responses that were analyzed, resulting in 7 highly ranked selections.
These selections, along with a write-in suggestion identified in multiple surveys, were ranked by AOTA Special Interest Section (SIS) Standing Committees.
Members of the AOTA Evidence-Based Practice team, and Program Champion Glen Gillen, EdD, OTR, FAOTA, current Professor and Director, Programs in Occupational Therapy at Columbia University, reviewed the results from the member survey, compared the SIS rankings, and selected the top 5 items.
The team conducted a final literature review for each item and developed recommendations in collaboration with AOTA staff members and member content experts.

If you have any questions or comments about the campaign, contact ebp@aota.org.

Implement & share the recommendations

1. Don’t provide intervention activities that are non-purposeful (e.g., cones, pegs, shoulder arc, arm bike).

2. Don’t provide sensory-based interventions to individual children or youth without documented assessment results of difficulties processing or integrating sensory information.

3. Don’t use physical agent modalities (PAMs) without providing purposeful and occupation-based intervention activities.

4. Don’t use pulleys for individuals with a hemiplegic shoulder.

5. Don’t provide cognitive-based interventions (e.g., paper-and-pencil tasks, table-top tasks, cognitive training software) without direct application to occupational performance.

6. Don’t initiate occupational therapy interventions without completion of the client’s occupational profile and setting collaborative goals.

7. Don’t provide interventions for autistic persons to reduce or eliminate “restricted and repetitive patterns of behavior, activities, or interests” without evaluating and understanding the meaning of the behavior to the person, as well as personal and environmental factors.

8. Don’t use reflex integration programs for individuals with delayed primary motor reflexes without clear links to occupational outcomes.

9. Don’t use slings for individuals with a hemiplegic arm that place the arm in a flexor pattern for extended periods of time.

10. Don’t provide ambulation or gait training interventions that do not directly link to functional mobility.

How was the list developed?

Initial recommendation development (published in 2018)

Additional recommendation development (published in 2021)