Occupational therapy
Occupational therapy refers to the use of meaningful occupation to assist people who have difficulty in achieving healthy and balanced life; and to enable an inclusive society so that all people can participate to their potential in daily occupations of life. Occupational therapists work with a variety of individuals who have difficulty accessing or performing meaningful occupations.
Most commonly, Occupational Therapists work with disabled people to enable them to maximize their skills and abilities.  
Occupational therapy gives people the "skills for the job of living" necessary for living meaningful and satisfying lives.
Services typically include:
- Customized treatment programs to improve one's ability to perform daily activities.
- Comprehensive home and job site evaluations with adaptation recommendations.
- Performance skills assessments and treatment.
- Adaptive equipment recommendations and usage training.
- Guidance to family members and caregivers.

# History of Occupational Therapy in Aotearoa/New Zealand
The early use of occupation to support, treat and rehabilitate people in Aotearoa New Zealand is evident in services for returned soldiers after World War 1 ((Hobcroft 1949)).  There are glimpses in mental health services during the 1930's too (Skilton 1981).  However the first qualified occupational therapist Margaret Buchanan arrived in New Zealand in 1941 (Buchanan 1941).  Initially employed in the then Auckland Mental Hospital she was rapidly involved not only in the development of occupational therapy services there, but also the development of the first training programmes and advice to government.  Initially those trained had previous health or education backgrounds (Skilton 1981).  A formal two year training programme was established by 1940 (NZNJ 1940), and state registration provided for in the Occupational Therapy Act 1949 (New Zealand Occupational Therapy Registration Board 1950) Insert a web link here to the board . From its early services in mental health and returned serviceman settings occupational therapy expanded into general rehabilitation, work with children with disabilities and services for the elderly (Wilson 2004) p88.  Educational programmes moved from the health sector to the education sector in 1971 (New Zealand Occupational Therapy Registration Board 1970b 17th July)and Bachelors programmes emerged in the 1990's.  An advanced diploma in occupational therapy was first made available in 1989 (Packer 1991) but not until the review of the Education Act was it possible for masters degree programmes to be made available as they are now through both schools . Insert web links here to the two schools   The first New Zealand occupational therapist to complete a PhD in the country in a programme related to occupational therapy was Linda Robertson who completed her PhD in 1994 (NZJOT 1996).    The development of distance education technology has enabled large numbers of therapists to participate in distance post-graduate education.
An association formed in 1948 (New Zealand Registered Occupational Therapists Association 1949) Insert a web link here to the association provides a bi-annual conference, representation at government levels, a journal and a monthly newsletter.

# History of Occupational Therapy in the United States of America
Occupational therapy began as a profession in the United States in 1917 with the founding of the Society for the Promotion of Occupational Therapy (now, The American Occupational Therapy Association, Inc.). The creation of the society was impelled by a belief in the curative properties of human occupation (or everyday purposeful activity). It had previously been employed as part of the moral treatment movement in the large state supported institutions for mental illness that were widespread in the United States. Occupational therapy has played a prominent role in epidemics, providing treatment for patients with tuberculosis, polio, and HIV/AIDS. In 1975, following the enactment of legislation known as the Education for All Handicapped Children Act (PL 94-142), thousands of occupational therapists were employed by public schools to provide therapeutic services (known as related services) to enable children with disabilities to participate in regular school settings.  Originally, therapists from approved training programs were certified, or registered by the American Occupational Therapy Association. A baccalaureate degree was required for certification beginning in the 1940s. Fifty years later, accredited programs were required to be at the Master's degree level. The 1990s saw the evolution of doctoral programs in occupational therapy. Educational programs in occupational therapy are now accredited by the Accreditation Council for Occupational Therapy Education, and national certification is granted under the auspices of the National Board for Certification in Occupational Therapy.  More recently, a new discipline within occupational therapy has opened up known as occupational science.  Many students in 5-year masters program now receive their undergraduate degree in this discipline and go on to receive a Masters degree in occupational therapy during their 5th year.

# Occupational Therapy Educational Requirements
Occupational therapy practitioners are skilled professionals whose education includes the study of human growth and development with specific emphasis on the physical, emotional, psychological, sociocultural, cognitive and environmental components of illness and injury.

## Occupational Therapy Education in the USA
Most registered occupational therapists (OTR) practicing in the field today possess a Bachelor of Science degree in occupational therapy. However, by 2007, all OTRs will enter the field with a Masters (M.S. or MOT) or Doctoral degree (OTD).  A certified occupational therapy assistant (COTA) generally earns an associate degree.
To become eligible for the national examination for certification, students must complete a minimum of two (three maximum) supervised clinical internships in physical disabilities, pediatrics or mental health.  Many college programs encourage students to pursue a third internship in an area of OT of their choosing. Upon successful completion of at least two internships, graduates must pass a national examination (NBCOT or National Board for Certification in Occupational Therapy). Most U.S. states also regulate occupational therapy practice (OTs must possess a license within their state).

# The Philosophy of Occupational Therapy
The philosophy of occupational therapy has evolved over the history of the profession. The philosophy articulated by the founders owed much to the ideals of romanticism  , pragmatism  and humanism which are collectively considered the fundamental ideologies of the past century.   
William Rush Dunton, the creator of the National Society for the Promotion of Occupational Therapy, now the American Occupational Therapy Association, sought to promote the ideas that occupation as a basic human need, and that occupation was therapeutic. From his statements, came some of the basic assumptions of occupational therapy, which include:
- Occupation has an effect on health and well being.
- Occupation creates structure and organizes time.
- Occupation brings meaning to life, culturally and personally.
- Occupations are individual. People value different occupations.
These have been elaborated over time to form the values which underpin the Codes of Ethics issued by each national association. However, the relevance of occupation to health and wellbeing remains the central theme. Influenced by criticism from medicine and the multitude of physical disabilities resulting from World War Two, occupational therapy adopted a more reductionistic philosophy for a time. While this approach lead to developments in technical knowledge about occupational performance, clinicians became increasingly disillusioned and re-considered these beliefs  .  As a result, client centeredness and occupation are re-emerging as dominant themes in the profession, perhaps indicating growing maturity and self confidence . . . Over the past century, the underlying philosophy of occupational therapy has evolved from being a diversion from illness, to treatment, to enablement through meaningful occupation. 
The two most commonly mentioned values are that occupation is essential for health and the concept of holism. However, there have been some dissenting voices. Mocellin in particular . . .  advocated abandoning the notion of health through occupation as obsolete in the modern world and questioned the appropriateness of advocating holism when practice rarely supports it. The values formulated by the American Association of Occupational Therapists have also been critiqued as being therapist centred and not reflecting the modern reality of multicultural practice . .

# Potential Uses of Occupational Therapy
A wide variety of people may benefit from occupational therapy, these may include people with:
- work-related injuries including lower back problems or repetitive strain injuries
- physical, cognitive or psychological limitations following a stroke, brain injury or heart attack
- rheumatoid and age-related conditions such as arthritis
- neurodegenerative movement disorders such as multiple sclerosis, amyotrophic lateral sclerosis, or Parkinson's disease
- birth injuries, learning difficulties, or developmental disabilities
- mental health difficulties Alzheimer's, schizophrenia, ADHD and post-traumatic stress
- substance abuse problems or eating disorders
- Fetal alcohol syndrome due to central nervous system damage from prenatal alcohol exposure
- obsessive compulsions, or diagnosed obsessive compulsive disorder (OCD)
- burns, spinal cord injuries, or amputations
- fractures or other injuries from falls, sports injuries, or accidents
- visual, perceptual or cognitive impairments
- developmental disabilities such as autism or cerebral palsy
- domestic abuse issues
- homelessness
- refugees and asylum seekers
- sensory processing disorders

# Areas of Occupational Therapy
Occupational therapists work in a vast array of settings, these include:

## Physical
- Orthopedics (outpatient clinics)
- Pediatrics
- Long-Term Care
- Hand therapy
- Cardiac rehabilitation
- Burn Centers
- Rehabilitation centers (TBI, Stroke (CVA), spinal cord injuries, etc.)
- Hospitals (ranging from inpatient, subacute rehab, to outpatient clinics)
- Forensic units
- Homeless Shelters
- Refugee Camps
- Community Settings
- Industrial therapy (work hardening, work conditioning, job demand analysis)

## Community
There is a current shift within the profession towards community based practice.  Essentially this vision encourages practitioners to expand into previously uncharted territory.  Thus, moving away from hospitals and rehabilitation clinics and begin working with atypical populations such as the homeless or at risk populations. This change in vision is meant to expand the capabilities and impact of the profession.  As the fundamental ideologies of occupational therapy are promoting independence, the profession is beginning to realize there are many more populations that would benefit from OT services. Occupational Therapists can continue the rehabilitation process in clients homes etc, they can assist clients with returning to previous life roles and activities.
Examples of community-based practice settings:
- Health promotion and lifestyle change
- Intermediate care
- Day centers
- Schools
- Child development centers
- People's own homes, carrying out therapy and providing equipment and adaptations
- Implementing gradual return to work programmes which include workplace and work station assessments

## Cognitive
- Stroke rehabilitation
- Traumatic brain injury
- Multiple sclerosis
- Parkinsons disease

## Mental Health
- Child and adolescent mental health services (CAMHS)
- Forensic psychiatry
- Prisons/sections
- Mental health clinics
- Psychiatric rehabilitation programs
- CSP's
- Club houses
- Early Intervention for Psychosis services

# Case Studies
Because of the wide range of services that occupational therapists provide, the following case studies will help provide insight into the role of an occupational therapist in each specific case.

## Autism syndrome
Adria is a four year old female with classic autism.  She exhibits distress from: loud noises, being in an elevator, various textures touching her skin, certain tastes and textures of foods, and being on a swing.  Sensory integration therapy can help autistic children learn to tolerate sensory inputs that would normally overload their central nervous system.  Occupational Therapists often will create Sensory Integration Therapies to help teach the child's nervous system to tolerate higher levels of sensory input.  In the case of Adria, an OT therapist came up with several therapies to address her sources of distress.  Noise therapy involved playing music that the child enjoyed at higher and higher levels.  Also, in areas of loud noises ear plugs were used to lessen noise that allowed Adria to enjoy venues, such as a circus or school assembly.  Once she associated that most loud venues are enjoyable, her need for ear plugs lessened.  Fear of movement (often experienced while in an elevator or on a swing) was approached by lying Adria on the back of a huge ball and rolling it slowly until she learned it was safe.  Often rewards helped reinforce the sensory integration therapy.  Once the ball movement was tolerated, Adria and the therapist would ride the school elevator over and over again.  Swinging on a swing was done by slowly increasing the amount of swing.  For treating Adria's aversion to textures on her skin, the therapist had Adria feel various types of textures.  Examples would be sand paper, beans in a bowl, pudding, and a variety of cloth.  A variety of foods were also used to overcome aversions to food textures. The result over the course of a year saw Adria being able to tolerate many sensory inputs without distress.

## Bipolar disorder
Robby is a 43 year old male with Bipolar disorder.  Due to his alternating episodes of mania and depression, Robby is challenged cognitively.  He has difficulty doing anything that requires more than 3 steps and often forgets the order of the steps.  He avoids social interaction, preferring to keep to himself.  With Robby's occupational therapist, he began attending a social skills group twice a week.  Additionally, the occupational therapist made a laundry checklist outlining the steps for doing laundry individually and put labels on all the buttons and dials of his washing machine.  Doing the same, repetitive activities with Robby will help him develop a routine, allowing him to gain independent living skills.

## First episode psychosis - New Zealand
Mark is a 21 year old male who is a frequent user of cannabis and alcohol. He's studying at university, and works some evenings and weekends at a Service Station. His family and flatmates have recently noticed that he has not been attending lectures, and is up all night even after working long hours. He's also started talking about how uncomfortable he is at work with the security cameras, and feels that they are watching him in particular. He's asked his manager if the footage is being shown to police or government agencies, and doesn't seem reassured by him. Due to concerns from his family when they notice he's stopped eating, and is having trouble speaking in coherent sentences, they take him to be assessed by the first presentation psychosis service (Early Intervention in Psychosis) who discover a range of psychotic symptoms including paranoia and thought disorder. With medication intially, inpatient treatment is avoided, and the occupational therapist works with him in his flat and the clinic to assist him to reduce his cannabis use (which worsens his paranoia), improve his sleep with sleep hygiene techniques, gradually return to daytime work, and assists him to work out how to structure his study timetable. Mark eventually has no symptoms, and has a plan of how to stay well and active.

## Gunshot wound
Jack was going into a convenience store one night when he encountered an armed robber attempting to get away.  In the ensuing altercation, Jack was shot in the arm.  As a result of the shooting, Jack had multiple surgeries, but still did not have full use of his arm due to his radial nerve palsy.  Jack's occupational therapist constructed a splint that would allow Jack to have more control over his arm.  Additionally, Jack's arm would now be stabilized and be positioned in a more correct posture.

## Hip replacement
Mary is a 58-year-old female who enjoys an active lifestyle.  Unfortunately, she has been slowed down recently due to osteoarthritis in the hips.  Her doctor recommended getting a bilateral hip replacement, which she did in the next few months.  One day after surgery, Mary's occupational therapist helped her get out of bed and walk towards the bathroom.  The therapist provided tips on how to get out of bed and how to walk.  Once in the bathroom, the therapist assisted Mary in completing a toilet transfer while adhering to all hip precautions.  On the second day following the surgery, the therapist once again assisted Mary in completing a toilet transfer.  Then, the therapist showed Mary how to use a wide range of adaptive equipment that would help her complete her daily tasks, such as showering (using a long-handled sponge), putting on socks (using a sock-aid), and reaching for things on the floor (using a reacher).  On the third day, Mary prepared for discharge.  She was educated in how to complete car transfers and tub/shower transfers.  Additionally, she was advised to get a tub seat.  Finally, she was advised to temporarily put away any throw rugs to lessen the risk of tripping.
===School Based

## Anterograde amnesia following hypoxic brain injury - New Zealand
Aroha is a 37 year old female admitted to a rehabilitation ward following a hypoxic brain injury as a result of an attempted suicide by carbon monoxide poisoning.  She presents with severe anterograde amnesia along with other cognitive deficits i.e reduced attention, slowed processing speed and impaired executive functioning.  Aroha is not orientated to time, place and does demonstrate any awareness of the reason for her admission, recent events and current limitations as a result of her brain injury.  The Occupational Therapist provided Aroha with a diary system which documented her daily timetable, details surrounding her admission and cognitive limitations and daily orientation information. All therapy and nursing staff assisted Aroha to refer to and write in her diary on a regular basis to record important information and therapy appointments. She was provided with a belt bag to wear around her waist which held her diary and a pen and served as a visual reminder of her diary system.  Initially Aroha required frequent (maximal) prompting to remember and initiate referring to her diary for required information however over time (6 weeks) she began to internalise these prompts and initiate using her compensatory memory aid with minimal prompting from staff.  She was orientated to time and place and demonstrated increased insight into her limitations.

## Multiple Sclerosis - New Zealand
Jenny is a forty-year-old lady with progressive multiple sclerosis. She lives alone in her own home and has a care package that includes caregivers who assist her with heavy domestic tasks such as hanging out wash and vacuuming. Jenny mobilizes using an electric wheelchair. As a community occupational therapist, intervention includes education and assistance with implementing fatigue management strategies such as using a diary to structure her day/week, pacing herself and prioritizing tasks, and facilitating the implementation of memory strategies. Other therapeutic interventions included assessment of her safely performing daily tasks such as going to the supermarket. Jenny uses her electric wheelchair to get to the supermarket however she is a safety risk and requires supervision in the community due to her impaired vision, decreased memory, ataxia, and unmanaged fatigue levels.
One of the major issues for Jenny is her neurological fatigue; performing normal daily tasks (showering, dressing, brushing teeth, etc) uses up most of the energy she has for the day, and therefore is unable to do things like talk on the phone, go to the shops, or play with her young daughter. Jenny's occupational therapist did a shower assessment, observing how she performed each task. Together, the therapist and Jenny identified 3 tasks which required the most effort: washing hair, shoes/socks, cleaning bathroom. The Occupational Therapist also educated Jenny and suggested strategies to use as minimal effort as possible e.g. changing the sequence, when to stand and when to sit, setup of the bathroom. The end result was Jenny had a lot more energy to do the things which were most improtant to her, and she accepted help for the 3 activities which fatigued her the most.

# Trivia
- April is Occupational Therapy month in the US
- It is Occupational Therapy Week in the UK at the beginning of November
- In Canada, October is recognized as Occupational Therapy month
- In Singapore, January 11th is Occupational Therapy Day.
- The first Occupational Therapy clinic was opened in Chicago IL., in 1914
- Occupational Therapy evolved out of the need for rehabilitation during World War I
- Occupational Therapy week is in October in New Zealand