American Occupational Therapy Association, Inc.

View all recommendations from this society

July 27, 2021

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

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.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their health care provider.

How The List Was Created

(1–5) The American Occupational Therapy Association (AOTA) conducted a three-phase project to develop the final 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—dissemination of the final items. Phase I was accomplished through presentations to AOTA member and volunteer groups, a Town Hall session at AOTA Annual Conference, an online webinar and related materials, and coverage in AOTA publications. Phase I was completed with an 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.

AOTA’s disclosure and conflict of interest policy can be found at


(6-10) In 2018, The American Occupational Therapy Association (AOTA) published its first set of Choosing Wisely recommendations. Between 2018 and 2020, numerous
practice articles, clinical resources, and webinars were created to promote the recommendations and assist AOTA members with implementation efforts. In 2019,
AOTA selected two members as Choosing Wisely Champions, based on their implementation efforts in practice and education. The initial recommendations are
reviewed annually.

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 that was used for the initial recommendations. Interventions identified, but not selected for a final recommendation in the 2018 survey,
were included in an online member survey. Respondents were to select 5 out of 10 items for development of additional recommendations. This survey resulted in
999 responses that were analyzed, resulting in 7 highly ranked selections. These selections, along with a write-in suggestion identified in multiple surveys, were
then ranked by AOTA Special Interest Section (SIS) steering committees. Results from the member survey and SIS rankings were compared, and the top 5 items
were selected. A final literature review was conducted for each item, and recommendations were developed in collaboration with AOTA staff members and member
content experts.

AOTA’s disclosure and conflict of interest policy can be found at



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.