American Occupational Therapy Association, Inc.

Five Things Patients and Providers Should Question

Released June 4, 2018; Last reviewed 2019

  1. 1

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

    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.

  2. 2

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

    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.

  3. 3

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

    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.

  4. 4

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

    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.

  5. 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.

    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.

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.

The American Occupational Therapy Association (AOTA) is the national professional association established in 1917 to represent the interests and concerns of 213,000 occupational therapy practitioners and students of occupational therapy and to improve the quality of occupational therapy services. AOTA’s major programs and activities are directed toward assuring the quality of occupational therapy services, improving consumer access to health care services, and promoting the professional development of members. AOTA educates the public and advances the profession by providing resources, setting standards, and serving as an advocate to improve health care.

For more information about AOTA, visit

How This List Was Created

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


  1. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.

    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.

    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.

    Steinbeck, T. (1986). Purposeful activity and performance. American Journal of Occupational Therapy, 40, 529–534.

  2. 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.

    Council for Exceptional Children. (2014). Council for Exceptional Children standards for evidence-based practices in special education. Retrieved from

    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.

    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.

    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.

  3. American Occupational Therapy Association. (2012). Physical agent modalities: A position paper. American Journal of Occupational Therapy, 66(6_Suppl.), S78–S80.

    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.

    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.

  4. 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.

  5. American Occupational Therapy Association. (2013). Cognition, cognitive rehabilitation, and occupational performance. American Journal of Occupational Therapy, 67(6 Suppl.), S9–S31.

    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.

    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.

    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.