Introduction to Grading Occupational Therapy Interventions

Definition of Grading

The dictionary definition of gradation is the process of advancing something step by step; as in a gradual process.

In occupational therapy, a reference of my old lecture notes defines gradation (Reed and Sanderson, 1990) as an intervention technique that categorizes tasks into degrees of difficulty or complexity.

In the simplest of terms, gradation, or “grading” increasing or decreasing the difficulty of an intervention based on how the client responds or performs. This is an ongoing process and you may continue to grade up, down, or a combination of up and down to present the client with the “just right challenge”.

Purpose of Gradation

  • To select an activity that is at the client’s functional ability (otherwise they will get discouraged or give up; too easy and they get bored and are not fully engaged).
  • To meet the client’s needs.
  • To promote client success.
  • Engagement in meaningful occupations.

Before you Grade

  • Collaborate with the client to determine meaningful occupations.
  • Determine and set client’s goals.
  • Consider the client’s strengths and weaknesses.
  • Choose a frame of reference or theory or framework, e.g., P-E-O.
  • Refer/develop the client’s occupational profile.
  • Consider the environment (distractions, familiarity).
  • Refer to the Occupational Therapy Practice Framework (OTPF) table for the Domain and Process and their respective component parts, e.g., client contexts, habits, roles, routines, etc.
  • Plan and gather appropriate materials and supplies.
  • Be aware of the client’s personal knowledge and attitudes toward the activity.

“A client who has difficulty performing effectively in one context may be successful when the natural environment has human-made modifications or if the client uses applicable products and technology.”[1]American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. … Reference List

Get Grading (or Functional)

  • Choose an anticipated graded level and try it with the client.
  • Prepare to- and grade up or down as needed.

Areas to Grade

  • Sensory (e.g., light touch, tactile, pain, stereognosis)
  • Motor (e.g., ROM, strength, strength, endurance)
  • Cognitive & Perceptual (e.g., alertness, attention, arousal, on-task activity)
  • Psychosocial (e.g., self-control, time management, social interactions)

Grading Considerations

  • Goals
  • Demand (least, moderate, most)
  • Therapeutic impact
  • Assistive technology
  • Physical vs virtual vs mental imagery
  • Measurement of outcomes
  • Objective documentation

Similar Terminology

  • Graded-activity (GA)
  • Graded Exposure (GEXP)

“Both interventions have several features in common: they aim to restore functionality by decreasing patient disability and increasing patient education as well as setting feasible goals of specific behaviors. The main differences between treatments are that GA aims to achieve this target by positively reinforcing patient activity levels[2]Leeuw M Goossens MEJB van Breukelen GJP et al. . Exposure in vivo versus operant graded activity in chronic low back pain patients: Results of a randomized controlled trial . Pain 2008 ; 138 : 192 … Reference List, while the GEXP approach encourages a confrontation response by exposing patients to specific situations of which they are fearful during rehabilitation.[3]George SZ Zeppieri G . Physical therapy utilization of graded exposure for patients with low back pain . J Orthop Sports Phys Ther 2009 ; 39 : 496 – 505 .

Summary

No matter which setting or population occupational therapy practitioners work with, they are constantly grading the activity to meet the clients’ needs. Too easy and activity may be boring and not challenge the client. Too difficult and the client may get discouraged and become disengaged and give-up.

References

References
1 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
2 Leeuw M Goossens MEJB van Breukelen GJP et al. . Exposure in vivo versus operant graded activity in chronic low back pain patients: Results of a randomized controlled trial . Pain 2008 ; 138 : 192 – 207 .
3 George SZ Zeppieri G . Physical therapy utilization of graded exposure for patients with low back pain . J Orthop Sports Phys Ther 2009 ; 39 : 496 – 505 .