Intervention
The intervention hierarchy
Occupations first, then purposeful activity, then preparatory methods that enable performance. Every session should justify itself by its link to a client goal. "Skilled" does not mean "complex" - it means the intervention requires therapist training and is individualized to this client.
Core tools
Activity analysis and grading (up: less cueing, more steps, added resistance; down: more support, simpler task, seated position). Adaptation and compensation versus remediation. Motor learning: practice variability, whole versus part task, blocked versus random practice, faded feedback. Neurological approaches include task-specific training, constraint-induced movement, NDT handling, and PNF patterns. Physical agents require knowing indications and contraindications - no heat over acute inflammation, no electrical stimulation across the heart or over the carotid sinus, and pregnancy precautions.
Monitoring and modifying
Vital signs, pain, dizziness, fatigue, skin, and cognition drive in-the-moment decisions. If a patient reports chest pain, becomes suddenly short of breath, or turns acutely confused, stop, position safely, and report. Fatigue is managed with rest breaks and energy conservation, not by pushing through.
Worked example: A client with COPD wants to dress independently but desaturates when standing. Don't abandon dressing training; grade it - seated dressing at bedside with rest breaks and energy conservation, progressing toward standing dressing with standby assist as tolerance improves, then document and report to the OT.
Trap: options that jump to adaptive equipment before trying grading, or that have the COTA change the plan of care without consulting the OT.