CENTENNIAL TOPICS
A Century of Therapeutic Use of the
Physical Environment
Amy Marshall, Christine Myers, Doris Pierce
In this article, we describe the use of the objects and spaces of the physical environment by occupational
therapy practitioners in the United States over the profession’s first 100 years. Using professional literature
selected by decade from the years 1917 through 2016 to obtain data, we applied grounded theory methods to
complete a detailed description. Team-based analysis over four coding schemes yielded a theoretical description of the profession’s therapeutic use of the physical environment. Study findings included descriptions across occupational therapy’s history of (1) treatment spaces, (2) the concepts of adapting and grading,
and (3) a typology of constructive and nonconstructive applications of objects and activities by occupational
therapy clients and practitioners. This extended historical perspective on trajectories of change in intervention
space, the role of physical products in intervention, therapist repertoire, and the enduring role of adaptation
suggests how the physical environment may be used in future practice.
Marshall, A., Myers, C., & Pierce, D. (2017). Centennial Topics—A century of therapeutic use of the physical environment.
American Journal of Occupational Therapy, 71, 7101100030. https://doi.org/10.5014/ajot.2017.023960
Amy Marshall, PhD, OTR/L, is Associate Professor,
Department of Occupational Science and Occupational
Therapy, Eastern Kentucky University, Richmond.
Christine Myers, PhD, OTR/L, is Research Assistant
Professor, Department of Occupational Therapy, University
of Florida, Gainesville.
Doris Pierce, PhD, OTR/L, FAOTA, is Endowed Chair
in Occupational Therapy, Department of Occupational
Science and Occupational Therapy, Eastern Kentucky
University, Richmond; [email protected]
T
his analysis of occupational therapy practitioners’ therapeutic use of the objects
and spaces of the physical environment offers a fresh, panoramic perspective
on the profession. The origins of occupational therapy have most often been
chronicled with an emphasis on the history of health care or the professional
meanings ascribed to occupational engagement (Metaxas, 2000). Our Physical
Environments Study complements previous histories by offering unique insights
into the origins of present-day practice.
Material Culture History of Occupational Therapy
In the Physical Environments Study, we used a material culture approach to
produce an original perspective on historical changes in the materials, objects,
and settings of practice. In paleoanthropology, researchers use an analogous
material culture approach in their analysis of artifacts across the fossil record
(Chapple & Coon, 1942). Humans pass on positive adaptations in large part
through material culture. The creation and skilled use of objects and built
spaces are survival requirements, expressions of personal or tribal identity, and a
way of making valued contributions to social groups. “Daily human life and
skills are integrally involved with material objects and constructed spaces, including tools, toys, clothing, vehicles, art, food, crops, buildings, roads,
Note. Each issue of the 2017 volume of the American Journal of Occupational Therapy features a special Centennial
Topics section containing several articles related to a specific theme; for this issue, the theme is occupational
therapy history. The goal is to help occupational therapy professionals take stock of how far the profession has
come and spark interest in the many exciting paths for the future. For more information, see the editorial in the
January/February issue, https://doi.org/10.1054/ajot.2017.711004.
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machines, books, medicines, manufactured materials, and
technology” (Pierce, Munier, & Myers, 2009, p. 274).
Reed (1986) discussed the use or disuse of objects in
practice, such as sanding blocks, and raised the question
of whether these objects were the profession’s heritage or
its extra baggage. Occupational therapy authors have also
addressed the use of purposeful activities (Breines, 1995;
Cynkin, 1979). In occupational science, the use of objects
within human occupation has been of interest (Hocking,
2009). Considering the degree to which the objects and
spaces of human occupation are used in intervention,
however, there is surprisingly little written on this topic.
Method
The purpose of this study was to describe therapeutic use of
the objects and spaces of the physical environment by occupational therapy practitioners in the United States from 1917
to 2016. A detailed theoretical description, deeply grounded in
the data, was produced (Bryant & Charmaz, 2007).
Data collection included articles and documents
from the Wilma West Library and selected articles and
chapters across historical periods of the profession from
Archives of Occupational Therapy, Occupational Therapy
and Rehabilitation, American Journal of Occupational
Therapy, and the Willard and Spackman’s Occupational
Therapy series (see Supplemental Appendix A, available
online at http://otjournal.net; navigate to this article,
and click on “Supplemental”). Publications with the greatest
degree of focus on aspects of the physical environment in
intervention were selected (Schwartz & Colman, 1988).
The total number of fully analyzed documents was 64
journal articles and 17 chapters from the Willard and
Spackman’s Occupational Therapy series.
Data analysis began immediately after data collection
started and proceeded through all study phases (see Figure 1).
Data were hand coded, and historical patterns within codes
were described in memos. All memos were critiqued through
team discussion, testing against data, and disconfirming cases. Our team-based approach strengthened trustworthiness
of findings by using multiple perspectives throughout the
research process (Guest & MacQueen, 2008).
Four distinct coding schemes emerged successively,
with 5, 10, 4, and 4 primary codes, respectively. Detailed
summary memos were produced for all codes. Comparative
analysis moved in a deliberate sequence from maximal
differences between historical periods and populations to
finer differences in the data. After theoretical saturation was
Figure 1. Grounded theory process: Team analysis using four successive coding schemes.
Note. The term Round Robin describes a team-based analysis strategy in which research tasks were initiated by one team member, and results were then reviewed
and revised by the other two team members in succession.
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reached, memos synthesizing themes crossing through the
data demonstrated that original concepts—a hallmark of
thorough grounded theory analysis—had been discovered
(Bryant & Charmaz, 2007).
A Century of Occupational Therapy
Treatment Settings
Early 20th Century
In the 1910s and 1920s, descriptions of practice settings
focused on the tenor of the space and how the use of
colors, light, and decorations could influence clients (Slagle,
1914; Tracy, 1925). This was also a time period in which
occupational therapy practitioners slowly transitioned from
transient entry into client spaces to using dedicated treatment space. Out of necessity, practitioners created a small,
mobile space of their own—the OT cart (Haas, 1928).
Spencer (1921) described moving from an open porch to
a new building, showing that occupational therapy was a
“valuable asset” (p. 60). Additional descriptions included a
shop for metal work (Kransee, 1929), an occupational
therapy department in a school for children with cerebral
palsy (Martin, 1939), and needs for more space (Lewis,
1924). From the 1910s to 1940s, practitioners also worked
in natural settings, such as tenements (Collins, 1922),
farmlands and gardens of institutions (Slagle, 1914; Tracy,
1925), and cure porches of sanatoriums (Lewis, 1924).
Mid-20th Century
By the late 1940s, references to sanatoriums and patients
with tuberculosis decreased. Treatment of patients with
mental illness was described through the 1960s. Use of
inpatient hospital and physical rehabilitation settings
remained generally constant after World War I. In the
1960s, services were characterized by patients entering
outpatient clinics from the community (Bergmann, 1977).
In the 1960s and 1970s, there was advocacy for population
and community-based services (Finn, 1972; West, 1968).
Late 20th and Early 21st Centuries
Involvement in universal design and workplace modifications
strengthened in the late 20th century (Rigby, Trentham, &
Letts, 2014). Community-based services were not described
in a meaningful way until the 1980s, such as attending
school district meetings to establish school-based practice
(Griswold, 1994; Sieg, 1975) and working in independent
living centers (Frieden & Cole, 1985; Simon, 1988).
Expansion into the community continued in the 1990s
and 2000s, with increasing focus on home space and an
expanded view of communities (Rigby et al., 2014; Scaffa,
2014). Services were provided to increasingly diverse
populations in the home, workplaces, school systems,
and neighborhoods (Fänge & Iwarsson, 2005; Gage,
Cook, & Fryday-Field, 1997). Community-based practice included establishing and maintaining occupational
therapy as an integrated service for school systems and in
home health (Mallinson, Fischer, Rogers, Ehrlich-Jones,
& Chang, 2009; Sudsawad, Trombly, Henderson, &
Tickle-Degnen, 2002). In the literature, researchers also
described supporting independence for people with disabilities outside of institutions and addressed a broader
agenda of increased community access (Fänge & Iwarsson,
2005; Rigby et al., 2014). Practitioners working in inpatient settings began thinking in terms of postdischarge
needs (Scaffa, 2014; Walker & Howland, 1991). Most
recently, technology-supported interventions have offered
new ways to access clients in their homes and communities (i.e., telerehabilitation) or provided services that
supported community participation (i.e., driving assessment with simulators; Classen, Monahan, Auten, &
Yarney, 2014; Linder et al., 2015).
History of Adapting and Grading in
Therapeutic Use of the Physical Environment
Adapting: Early 20th Century
In the early years, crafts were chosen for their level of
adaptability (Haas, 1928). Adaptation implies a one-time,
static change to objects, raw materials, environments, or
activities, often in response to the needs of a specific client
or the constraints of institutional space. The first use of
adaptations was to create interventions in institutional
settings without a dedicated workspace; for instance,
Tompkins (1926) adapted steam tables and a china closet
in a hospital dining room to create usable space. Second,
adaptations customized activities and objects, such as
chairs or looms, for new client populations, including
people who were homebound or children with cerebral
palsy (Brokaw, 1948; Collins, 1922; Martin, 1939).
Grading: Early 20th Century
In the early years, grading was used to increase complexity
and duration of an activity. Grading uses fine-tuned,
sequential changes to customize an activity to a particular
person. Scott (1923) described psychiatric hospital classes
that progressed from unraveling burlap to making Persian
knot rugs. Other uses for grading in the historical literature included requiring attention for longer periods
of time by providing increasingly difficult string work
for a child and promoting work tolerance through
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advancing from braid weaving to upright looms while
working at a progressively faster pace (Lewis, 1924).
Adapting: Mid-20th Century
By the 1950s and 1960s, occupational therapy practitioners were refining their services for populations through
adaptations to existing devices, such as surplus doublepedestal, over-bed tables (Simpson, 1965); garden layouts
and tools (Goble, 1969); and expanded typewriter keyboards (Lascelle, 1956). In the 1970s, novel devices were
developed specifically for the needs of given populations,
such as the Auto-Communication Slider for children who
were nonverbal (Bullock, Dalrymple, & Danca, 1975)
and a visual-tracking machine for visual–perceptual training (Bergmann, 1977). Adaptability of objects and materials was of primary importance, whereas certain crafts,
such as knitting, were of “doubtful value” because of their
perceived inadaptability (Spackman, 1971, p. 173).
Grading: Mid-20th Century
In the 1930s through 1950s, grading was used in increasingly varied ways, often as preparatory activities, such as
lacing on a form before lacing shoes (Martin, 1939) or
strengthening before return to work. Smith, Barrows, and
Whitney (1959) introduced a “classification of activities
into a graded series according to appeal, energy requirements, or other characteristics” (p. 16)—the earliest recognizable activity analysis system in the data. By the 1970s,
there was a surge of information on grading, usually
focused on increasing specific physiological capacities of
clients; however, the means for doing so were still supplied
by handicrafts (Spackman, 1971).
Adapting: Late 20th and Early 21st Centuries
Beginning in the 1980s, adaptations were made to increase
clients’ functional independence. For instance, modifications to home contexts included widening doorways
and installing ramps (Rigby et al., 2014). Both everyday
objects and therapist-constructed assistive devices were
altered, such as built-up handles, elastic laces, and adaptive
scissors (Cumming et al., 2001; Gillen, 2014; Malick &
Almasy, 1983). Adaptive equipment, such as therapy balls
and weighted vests, were used in classrooms (Bagatell,
Mirigliani, Patterson, Reyes, & Test, 2010), whereas
unique assistive technologies increased independence in
the community (Camp, 2001).
In the early 21st century, client education emerged as
a significant adaptive approach (Berger, 2014). For example, clients were taught compensatory strategies, such
as energy conservation or one-handed techniques (Gillen,
2014). Adaptations were made to the social environment,
such as identifying supports and barriers to job seeking
(Liu, Hollis, Warren, & Williamson, 2007). Achieving a
person–environment fit through modifications was
perceived to increase clients’ adaptive responses and to
enhance their well-being (Dooley & Hinojosa, 2004;
Kohler, 1980; Walker & Howland, 1991).
Grading: Late 20th and Early 21st Centuries
By the late 20th century, less was written about grading.
Although still component based, grading was used in
naturalistic settings, such as in a garage, where bike repair
and oil changes could be completed in various positions
and with differing levels of support (Simon, 1988). In the
grading literature, researchers discussed adding portions
of a task over time; going from a more sequestered experience to a natural setting; increasing demand or decreasing support in activities, such as number of breaks or
amount of assistance; and monitoring progression in an
activity. By the early 21st century, robot-assisted devices
mirrored the novel devices of earlier decades but with a
more advanced technological capacity to provide graded
activities without a therapist’s presence (Huang et al.,
2014; Linder et al., 2015).
History of Occupational Therapy’s
Therapeutic Use of Objects, Materials,
and Activities
This study revealed a four-square typology of constructive
or nonconstructive activities, completed by either clients
or practitioners. Each category displays historical trends.
Client Construction
Arts and crafts, heavily used in the founding years, are client
construction activities: They result in a physical product.
Initially, client construction activities were small, inexpensive, and portable, or they were created in the shops,
barns, laundries, and gardens of institutions. Yarn and
thread were the most common materials; objects included
hand tools, kitchen implements, and large equipment. The
literature was filled with step-by-step craft directions, and
clients often sold their products (Scott, 1923). In the
1940s, publications detailed craft tool inventories to furnish newly created clinics. By the 1970s, occupational
therapists were routinely using large equipment in their
clinics, such as adapted looms (Spackman, 1971). Wood,
metal, clay, and leather work were added in the 1940s
through the 1990s. There was a resurgence in client construction, especially ceramics, in the 1960s and 1970s. By
the 1980s, the aim shifted to aspects of life after discharge that focused on a physical product, such as factory
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assembly work or household and vehicle maintenance
(Malick & Almasy, 1983). A new emphasis on women’s
roles triggered the addition of kitchens to clinics during
the 1980s. Since 2000, there has been little mention of
client construction (Scaffa, 2014).
Client Nonconstruction
Client nonconstruction activities are those work, leisure,
and self-care activities that do not result in a physical
product. Objects used in client nonconstruction activities
included clothing, technology, and equipment for play,
leisure, and learning. In the 1910s and 1920s, client
nonconstruction was limited, but it did occur in games
and leisure activities; self-care; and work within institutional shops, kitchens, laundries, and gardens (Scott,
1923). In the 1930s to 1950s, no mention was found of
nonconstructive leisure activities in the sampled literature.
The 1960s saw a slight increase in client nonconstruction,
with play and leisure used again, and learning activities
added to intervention repertoires. Individualization of interventions in client nonconstruction activities increased
through the 1990s, emphasizing self-care, leisure, education, and vehicle and home maintenance occurring in, and
focused on, usual client settings beyond the clinic. Literature from the 2000s infrequently referred to specific client
nonconstruction activities, except as examples of client
education, revising client routines, or working with a client’s daily activities during therapy (Gillen, 2014).
Therapist Construction
In the therapist construction category, practitioners are
engaged in construction activities on behalf of clients and
in which clients have little active involvement. Therapist
construction activities have been of two types: (1) practitioners building, adapting, or providing therapeutic
tools, equipment, and healing devices, and (2) practitioners acting to shape the form and capacities of specific
anatomical parts of a client.
With the notable early exception of a cart for transporting supplies within institutional spaces, therapist
construction was first evident in plans for an adapted table
and chair for children with cerebral palsy (Martin, 1939).
As occupational therapy practitioners created new clinics
in the 1940s, they adapted equipment for clinical use and
began the regular custom manufacture of objects for
physical healing and improved function, such as splints
and orthotic devices (Brokaw, 1948; Gleave, 1971). In
the 1940s to 1980s, practitioners described clients’ anatomical parts as objects to be reshaped or restored by the
therapist (Anderson & Anderson, 1988; Hollis, 1983).
Therapist actions to directly create physical healing continue strongly in use today within some specialty areas.
By the 1960s, literature describing therapist construction was greater than that describing client construction. The sensory integration approach emerged in
the 1980s, for which practitioners designed specialized
equipment that was actively manipulated to produce a
therapeutic effect (Ottenbacher, 1978). Construction of
healing devices shifted in the 1980s to prescription,
provision, and fitting of premanufactured devices (Chase,
1989; Culler, 2003). Providing devices for in-home use
began to be of interest in the 1990s and is common today
in home modifications to support accessibility and safety
for older adults aging in place and to support classroom
inclusion of students with disabilities (Cumming et al.,
2001). As technology has evolved, therapist provision of
assistive devices has become highly complex, extending
to robotics, smart devices, and even animal assistance
(Camp, 2001; Huang et al., 2014).
Therapist Nonconstruction
A unique category emerged in the recent literature: In
therapist nonconstruction, practitioners complete activities
that do not produce a product and do not directly engage
clients. Objects in this category include—in general
historical order of emergence—clinic furnishings; administrative documents, client records, and assessments;
research equipment; and informational materials for patient education, advocacy, and consulting (Hsieh, Nelson,
Smith, & Peterson, 1996).
In the 1940s, practitioners showed great interest in the
creation of occupational therapy clinics. The creation of
new programs entered the literature in the 1940s as work
programs and continued through the emergence of sensory
integration treatment spaces. By the 1980s, hospital clinics
began to more closely resemble everyday life spaces.
Occupational therapy assessments emerged regularly
in the 1960s literature and continue as a strong presence in
present patterns of publication (Jacobs, 1993). The importance of patient advocacy emerged in the 1980s, and
consulting’s significance emerged in the 1990s. Educational approaches began to be mentioned in the 1980s
and continue in the present. Administrative and recordkeeping activities held some prominence in the 1980s. By
the 2000s, research was the therapist nonconstruction
activity most frequently mentioned.
Today, therapist nonconstruction activities are extensively included in the literature, primarily describing
patient education in clients’ natural settings and the
development of assessments of client function in usual
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settings—including at home, at work, in the community
—and while operating vehicles (Classen et al., 2014;
Seamon, 2014; Shotwell, 2014).
The Unfolding of Occupational Therapy’s
Spatial Vision of Intervention
Extreme Adaptability of Occupational Therapy as
a Profession
Although it was not the purpose of this study to analyze
the effects of prevailing sociopolitical contexts on intervention, it is arguable that the history of U.S. culture
and health care shaped occupational therapy practitioners’
use of the physical environment over the past century.
Occupational therapy’s central passion for occupation
emerged from the values of the Arts and Crafts Movement: Traditional skills and craftsmanship were viewed as
counteracting the dehumanizing effects of industrializing
forces (Quiroga, 1995). The profession has also demonstrated great adaptability to the influences and opportunities presented by successive cultural shifts: World Wars
I and II, the development of scientific methods and rehabilitation, the women’s and disability rights movements, and the emergence of new technologies and an
information economy (Schwartz, 2003). The addition of
kitchens to occupational therapy clinics in response to a
new cultural awareness of the unpaid work of homemakers provides a good example of how the field repeatedly transformed to match cultural change.
Occupational therapy has also repeatedly transformed practice in response to health care policy and
legislation—most notably, the Rehabilitation Movement,
Medicare and Medicaid, the Americans With Disabilities
Act of 1990 (Pub. L. 101–336), and the Patient Protection and Affordable Care Act of 2010 (Pub. L. 111–
148; Schwartz, 2003; Starr, 1982). The Education for All
Handicapped Children Act of 1975 (Pub. L. 94–142)
extended the role of occupational therapy practitioners
into school-based settings. The field’s remarkable responsiveness to the broader contexts of client services has
pushed theoretical growth and expansion of the field. At
times, however, scholars have been concerned that the
profession may have been too easily influenced, losing
focus on the value of occupation (Reilly, 1962; Yerxa,
1967).
Historical Trajectory 1: The Evolution of
Intervention Space
Across a century of data, occupational therapy’s intervention spaces evolved, from the early years of seeking
dedicated professional space within medical institutions
to the expansion of current practice into the natural
contexts of clients’ homes, schools, workplaces, and wider
communities. In the 1940s, the profession established
hospital-based clinics serving inpatients and, later, outpatients: carefully designed spaces within which the finely
graded and measurable interventions of the biomedical
approach were developed. In the later 20th century,
theoretical development pushed in-clinic interventions to
target function in the spaces to which clients would be
discharged. The reconceptualization of intervention space
as the client’s life space was greatly advanced by the
movement of occupational therapy practitioners into
school-based practice and home health. In the present
day, clinical space has so dramatically extended into
natural client spaces that home, school, and workplace
assessments and modifications—as well as adaptations of
client daily routines and social environments—are not
uncommon.
Historical Trajectory 2: The Enduring Value of
Adapting and Grading
A key concept discovered in this analysis was occupational
therapy practitioners’ enduring use of the processes of
adapting and grading. Practitioners’ thinking about this
process has become increasingly sophisticated as the
profession has matured. In the early years, adaptations
were practicalities, made to meet the needs of a given
population. Over time, adaptations took on a much
broader conceptualization in responding to individual
clients in their natural settings, including the use of an
educational approach. The development of grading followed a similar trajectory: first focusing on limited and
imprecise goals, and later being used in increasingly
varied and well-defined ways. Refinement of the principles of grading using a biomechanical perspective during
the 20th century laid the groundwork for today’s highly
individualized, client-centered practice. The ability to
design, create, modify, and problem solve for a client
under any given circumstance has become an essential
quality of occupational therapy practice.
Historical Trajectory 3: Physical Products
Occupational therapy began in a period that respected
craftsmanship: Employment in crafts and manufacturing
was not uncommon. Arts and crafts activities dominated
early practice. Client construction activities resulting in
physical products were used to address biomechanical
goals through the mid-20th century, relying heavily on
highly adaptable textile work. In the 1960s and 1970s,
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products of metal, wood, leather, and clay were common.
In the 1980s, the production of food by homemakers
attracted interest—but mainly as a way of preparing to do
the same postdischarge, and with limited interest in the
craftsmanship or product of a cooking activity. Since that
time, client construction of products during intervention
has waned considerably.
In contrast, occupational therapy practitioners’ construction of physical products has grown steadily over the
profession’s history. Early adaptations of equipment to
furnish clinics spurred the thinking behind fine adaptations of activities to reach biomechanical goals and
launched therapist construction of devices for daily living
and healing. A new form of practice emerged in which
practitioners worked directly to produce change in a
specific anatomical part—an approach that continues in
the present (Sharp, 2000). Later in the 20th century,
production of healing devices changed from therapist
construction to therapist prescription and fitting of premanufactured devices. An extensive set of clinical equipment for different settings also entered commercial
production. Today, therapist prescription of manufactured assistive technology for client use in home, school,
work, and community settings ranges from low-tech
objects to highly complex systems.
Historical Trajectory 4: Expansion of
Therapist Repertoire
Although often viewed through the rose-colored glasses of
nostalgia, the start of the profession can be generally
characterized as the broad application of arts and crafts by
intelligent and inspired volunteers. In this historical review, the degree to which the skilled repertoire of an
occupational therapy practitioner has expanded over a
century is striking. Interventions have become increasingly
tailored to the specific needs of individual clients and now
shape function within the real-life spaces of clients. Areas
of practice rooted in the provision of adaptive equipment,
healing devices, and assistive technology have grown
strong. In addition to direct intervention, the skills of
assessment, administration, client education, consulting,
and research have been added to the expected abilities of
practitioners. Today’s professional literature is dominated
by these recent expansions in the occupational therapy
practitioners’ repertoire.
Limitations
To develop a trustworthy and detailed theoretical description, in this study we used multiple corroborating
sources, a data-driven team analysis, and a carefully
constructed analytic path. It is possible, however, that the
sampled professional literature may not accurately represent occupational therapy practice or that we may have
omitted important evidence contributing to a more complete view of the use of the physical environment by occupational therapy practitioners.
Implications for Occupational
Therapy Practice
Our Physical Environments Study depicts historical
transformations in intervention space, adapting and grading, the role of physical products in interventions, and the
expansion of practitioner repertoire. The following implications suggest how these trajectories of historical change
in therapeutic use of the physical environment may unfold
into future practice:
• As occupational therapy becomes further integrated
into clients’ natural settings, practitioners will have
increased opportunities to center therapeutic efforts
on relatively intact occupations within the spaces of
the client’s daily life. For example, the use of telerehabilitation, supported by videoconferencing and selfmonitoring devices, can help older adults age in place
and remain engaged in everyday occupations within
their homes (Cason, 2012). In addition, technology,
such as therapy ball chairs, supports students’ engagement in the classroom setting (Bagatell et al., 2010).
• Therapeutic use of adapting and grading has evolved
far beyond the simple adjustments in craft activities of
the profession’s early years. The dedicated professional
spaces of the biomechanical period provided controlled
settings within which highly adaptable, measurable,
and product-focused interventions addressing physical
limitations were conceptually refined. Today, grading
and adapting are used within a multifaceted, dynamic,
and highly contextualized approach that draws on a
client’s potential to foster engagement within everyday
spaces. Current interventions with children with autism spectrum disorders exemplify this approach because grading of task and environment within the
natural context increases generalization of functional
behaviors and occupational participation (Tomchek &
Koenig, 2016).
• Although practitioners’ construction of objects to support client healing or function has shifted to the use of
manufactured items, the clinical reasoning necessary to
effectively prescribe these devices and to train clients
in their use has not changed. Moreover, this aspect of
practice will continue as adaptations within clients’
natural environments, particularly in postacute settings, become increasingly important.
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• The increasing sophistication of practitioners’ repertoires suggests the benefit of higher levels of education
for both occupational therapists (i.e., clinical doctorate) and occupational therapy assistants (i.e., baccalaureate entry) so that they may cultivate the knowledge,
skills, and clinical reasoning to effectively use all aspects of the physical environment on behalf of their
future clients. Programs that provide higher levels of
education may have more opportunities for service
learning, fieldwork experiences, or capstone projects
that address the complexity of clients’ needs in their
homes, schools, neighborhoods, and communities
through a focus on the therapeutic use or adaptation
of the objects and spaces of those environments.
The Spatial Gift
Findings of our Physical Environments Study demonstrate
that the profession of occupational therapy has, over its
history, developed a remarkable gift for creating, modifying, and applying for therapeutic effect the objects and
spaces of the physical environment. Vigilance for opportunities to exploit the physical environment to address
client needs is a hallmark of occupational therapy. This
lasting stance springs from the field’s history of continually seeking to advance into new spaces to serve new
populations, thus causing the rapid theoretical growth
necessary to respond to the unique client goals and
therapeutic potentials of the physical environment in each
new type of treatment setting. The profession’s enduring
desire to fully use the potential of physical settings, objects, and activities for the benefit of clients has evolved
into a capacity for creating and using assistive devices and
equipment, adapting and working within natural client
spaces, and intuitively comprehending how spatial context can be used to realize valued client outcomes. s
Acknowledgments
This research was completed at Eastern Kentucky University. The members of the Physical Environments Study
Team extend their appreciation to Kitty Reed for sharing
her expertise in an extended interview in 2005 at the time
this research was being conceptualized.
References
Americans With Disabilities Act of 1990, Pub. L. 101–336, 42
U.S.C. xx 12101–12213 (2000).
Anderson, L. J., & Anderson, J. M. (1988). Hand splinting for
infants in the intensive care and special care nurseries.
American Journal of Occupational Therapy, 42, 222–226.
https://doi.org/10.5014/ajot.42.4.222
Bagatell, N., Mirigliani, G., Patterson, C., Reyes, Y., & Test,
L. (2010). Effectiveness of therapy ball chairs on classroom
participation in children with autism spectrum disorders.
American Journal of Occupational Therapy, 64, 895–903.
https://doi.org/10.5014/ajot.2010.09149
Berger, S. (2014). Educating clients. In B. A. B. Schell, G.
Gillen, M. Scaffa, & E. Cohn (Eds.), Willard and
Spackman’s occupational therapy (pp. 353–363). Philadelphia: Lippincott Williams & Wilkins.
Bergmann, K. (1977). A visual tracking machine. American
Journal of Occupational Therapy, 31, 421–424.
Breines, E. B. (1995). Occupational therapy activities from clay to
computers: Theory and practice. Philadelphia: F. A. Davis.
Brokaw, E. H. (1948). Adaptation of media. American Journal
of Occupational Therapy, 2, 20–25.
Bryant, A., & Charmaz, K. (2007). The handbook of
grounded theory. London: Sage. https://doi.org/10.4135/
9781848607941
Bullock, A., Dalrymple, G. F., & Danca, J. M. (1975). Communication and the nonverbal, multihandicapped child.
American Journal of Occupational Therapy, 29, 150–152.
Camp, M. M. (2001). The use of service dogs as an adaptive
strategy: A qualitative study. American Journal of Occupational Therapy, 55, 509–517. https://doi.org/10.5014/
ajot.55.5.509
Cason, J. (2012). Telehealth opportunities in occupational
therapy through the Affordable Care Act. American Journal of Occupational Therapy, 66, 131–136. https://doi.org/
10.5014/ajot.2012.662001
Chapple, E. D., & Coon, C. S. (1942). Principles of anthropology. Ann Arbor: University of Michigan.
Chase, J. (1989). Equipment adaptations to improve workshop
performance. American Journal of Occupational Therapy,
43, 545–548. https://doi.org/10.5014/ajot.43.8.545
Classen, S., Monahan, M., Auten, B., & Yarney, A. (2014).
Evidence-based review of interventions for medically
at-risk older drivers. American Journal of Occupational
Therapy, 68, e107–e114. https://doi.org/10.5014/ajot.
2014.010975
Collins, E. L. (1922). Occupational therapy for the home
bound. Archives of Occupational Therapy, 1, 33–40.
Culler, K. H. (2003). Home management. In E. B. Crepeau,
E. S. Cohn, & B. A. B. Schell (Eds.), Willard and
Spackman’s occupational therapy (10th ed., pp. 534–541).
Philadelphia: Lippincott Williams & Wilkins.
Cumming, R. G., Thomas, M., Szonyi, G., Frampton, G.,
Salkeld, G., & Clemson, L. (2001). Adherence to occupational therapist recommendations for home modifications
for falls prevention. American Journal of Occupational Therapy, 55, 641–648. https://doi.org/10.5014/ajot.55.6.641
Cynkin, S. (1979). Occupational therapy: Toward health
through activities. Boston: Little, Brown.
Dooley, N. R., & Hinojosa, J. (2004). Improving quality of
life for persons with Alzheimer’s disease and their family
caregivers: Brief occupational therapy intervention. American Journal of Occupational Therapy, 58, 561–569.
https://doi.org/10.5014/ajot.58.5.561
Education for All Handicapped Children Act of 1975, Pub. L.
94–142, renamed the Individuals With Disabilities
7101100030p8
Downloaded From: http://ajot.aota.org/ on 02/01/2017 Terms of Use: http://AOTA.org/terms
January/February 2017, Volume 71, Number 1
Education Improvement Act, codified at 20 U.S.C. x
1400-1482.
Fänge, A., & Iwarsson, S. (2005). Changes in ADL dependence
and aspects of usability following housing adaptation—
A longitudinal perspective. American Journal of Occupational Therapy, 59, 296–304. https://doi.org/10.5014/
ajot.59.3.296
Finn, G. L. (1972). The occupational therapist in prevention
programs. American Journal of Occupational Therapy, 26,
59–66.
Frieden, L., & Cole, J. A. (1985). Independence: The ultimate
goal of rehabilitation for spinal cord–injured persons.
American Journal of Occupational Therapy, 39, 734–739.
https://doi.org/10.5014/ajot.39.11.734
Gage, M., Cook, J. V., & Fryday-Field, K. (1997). Understanding the transition to community living after discharge
from an acute care hospital: An exploratory study. American Journal of Occupational Therapy, 51, 96–103. https://
doi.org/10.5014/ajot.51.2.96
Gillen, G. (2014). Occupational therapy interventions for individuals. In B. A. B. Schell, G. Gillen, M. Scaffa, &
E. Cohn (Eds.), Willard and Spackman’s occupational therapy (pp. 322–341). Philadelphia: Lippincott Williams &
Wilkins.
Gleave, G. M. (1971). Organization and administration of
occupational therapy departments. In H. S. Willard &
C. S. Spackman (Eds.), Occupational therapy (4th ed.,
pp. 13–29). Philadelphia: Lippincott.
Goble, R. E. A. (1969). The role of the occupational therapist
in disabled living research. American Journal of Occupational Therapy, 23, 145–152.
Griswold, L. A. S. (1994). Ethnographic analysis: A study of
classroom environments. American Journal of Occupational
Therapy, 48, 397–402. https://doi.org/10.5014/ajot.48.5.
397
Guest, G., & MacQueen, K. M. (2008). Handbook for teambased qualitative research. Lanham, MD: AltaMira Press.
Haas, L. J. (1928). A portable occupational therapy unit.
Occupational Therapy and Rehabilitation, 7, 205–209.
Hocking, C. (2009). The challenge of occupation: Describing the things people do. Journal of Occupational Science, 16, 140–150. https://doi.org/10.1080/14427591.
2009.9686655
Hollis, L. I. (1983). Functional restoration—Hand rehabilitation. In H. L. Hopkins & H. D. Smith (Eds.), Willard
and Spackman’s occupational therapy (6th ed., pp.
461–478). Philadelphia: Lippincott.
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. https://doi.org/10.5014/
ajot.50.1.10
Huang, P.-C., Hsieh, Y. W., Wang, C.-M., Wu, C.-Y.,
Huang, S.-C., & Lin, K.-C. (2014). Predictors of motor,
daily function, and quality-of-life improvements after
upper-extremity robot-assisted rehabilitation in stroke.
American Journal of Occupational Therapy, 68, 325–333.
https://doi.org/10.5014/ajot.2014.010546
Jacobs, K. (1993). Work assessments and programming. In
H. L. Hopkins & H. D. Smith (Eds.), Willard and
Spackman’s occupational therapy (8th ed., pp. 226–248).
Philadelphia: Lippincott.
Kohler, E. S. (1980). The effect of activity/environment on
emotionally disturbed children. American Journal of Occupational Therapy, 34, 446–451. https://doi.org/10.5014/
ajot.34.7.446
Kransee, J. (1929). Waste metal work therapeutically applied.
Occupational Therapy and Rehabilitation, 8, 221–226.
Lascelle, K. (1956). A writing device for the severely handicapped. American Journal of Occupational Therapy, 10,
260–262.
Lewis, L. (1924). The occupational therapy department of the
Jewish Home for Consumptives. Archives of Occupational
Therapy, 3, 195–198.
Linder, S. M., Rosenfeldt, A. B., Bay, R. C., Sahu, K., Wolf,
S. L., & Alberts, J. L. (2015). Improving quality of
life and depression after stroke through telerehabilitation. American Journal of Occupational Therapy, 69,
6902290020. https://doi.org/10.5014/ajot.2015.014498
Liu, K. W. D., Hollis, V., Warren, S., & Williamson, D. L.
(2007). Supported-employment program processes and
outcomes: Experiences of people with schizophrenia.
American Journal of Occupational Therapy, 61, 543–554.
https://doi.org/10.5014/ajot.61.5.543
Malick, M. H., & Almasy, B. S. (1983). Activities of
daily living and homemaking. In H. L. Hopkins &
H. D. Smith (Eds.), Willard and Spackman’s occupational therapy (6th ed., pp. 231–250). Philadelphia:
Lippincott.
Mallinson, T., Fischer, H., Rogers, J. C., Ehrlich-Jones, L., &
Chang, R. (2009). Human occupation for public health
promotion: New directions for occupational therapy practice with persons with arthritis. American Journal of Occupational Therapy, 63, 220–226. https://doi.org/10.5014/
ajot.63.2.220
Martin, E. F. (1939). Occupational therapy in a school for
birth injuries. Occupational Therapy and Rehabilitation,
18, 185–190.
Metaxas, V. A. (2000). Eleanor Clarke Slagle and Susan E.
Tracy: Personal and professional identity and the development of occupational therapy in Progressive Era America.
Nursing History Review, 8, 39–70.
Ottenbacher, K. (1978). Identifying vestibular procession dysfunction in learning-disabled children. American Journal of
Occupational Therapy, 32, 217–221.
Patient Protection and Affordable Care Act, Pub. L. 111–148,
42 U.S.C. xx 18001–18121 (2010).
Pierce, D., Munier, V., & Myers, C. T. (2009). Informing
early intervention through an occupational science description of infant–toddler interactions with home space.
American Journal of Occupational Therapy, 63, 273–287.
https://doi.org/10.5014/ajot.63.3.273
Quiroga, V. A. M. (1995). Occupational therapy: The first
30 years. Bethesda, MD: American Occupational Therapy
Association.
Reed, K. L. (1986). Tools of practice: Heritage or baggage?
(Eleanor Clarke Slagle Lecture). American Journal of
The American Journal of Occupational Therapy
Downloaded From: http://ajot.aota.org/ on 02/01/2017 Terms of Use: http://AOTA.org/terms
7101100030p9
Occupational Therapy, 40, 597–605. https://doi.org/
10.5014/ajot.40.9.597
Reilly, M. (1962). Occupational therapy can be one of the
great ideas of 20th century medicine. American Journal
of Occupational Therapy, 16, 1–9.
Rigby, P., Trentham, B., & Letts, L. (2014). Modifying performance contexts. In B. A. B. Schell, G. Gillen, M. Scaffa, &
E. Cohn (Eds.), Willard and Spackman’s occupational therapy (pp. 364–382). Philadelphia: Lippincott Williams &
Wilkins.
Scaffa, M. E. (2014). Occupational therapy interventions for
organizations, communities, and populations. In B. A. B.
Schell, G. Gillen, M. Scaffa, & E. Cohn (Eds.), Willard
and Spackman’s occupational therapy (pp. 342–352). Philadelphia: Lippincott Williams & Wilkins.
Schwartz, K. B. (2003). The history of occupational therapy. In
E. B. Crepeau, E. S. Cohn, & B. A. Boyt Schell (Eds.),
Willard and Spackman’s occupational therapy (10th ed., pp.
5–13). Philadelphia: Lippincott Williams & Wilkins.
Schwartz, K. B., & Colman, W. (1988). Historical research
methods in occupational therapy. American Journal of
Occupational Therapy, 42, 239–244. https://doi.org/
10.5014/ajot.42.4.239
Scott, W. A. (1923). Occupational therapy in Kalamazoo State
Hospital. Archives of Occupational Therapy, 2, 447–452.
Seamon, D. (2014). Physical and virtual environments: Meaning of place and space. In B. A. B. Schell, G. Gillen, M.
Scaffa, & E. Cohn (Eds.), Willard and Spackman’s occupational therapy (pp. 202–214). Philadelphia: Lippincott
Williams & Wilkins.
Sharp, L. A. (2000). The commodification of the body and its
parts. Annual Review of Anthropology, 29, 287–328.
https://doi.org/10.1146/annurev.anthro.29.1.287
Shotwell, M. P. (2014). Evaluating clients. In B. A. B. Schell,
G. Gillen, M. Scaffa, & E. Cohn (Eds.), Willard and
Spackman’s occupational therapy (pp. 281–301). Philadelphia: Lippincott Williams & Wilkins.
Sieg, K. W. (1975). Rural health and the role of occupational
therapy. American Journal of Occupational Therapy, 29,
75–80.
Simon, K. B. (1988). Outpatient treatment for an adult with
traumatic brain injury. American Journal of Occupational
Therapy, 42, 247–251. https://doi.org/10.5014/ajot.42.4.247
Simpson, M. M. (1965). Adjustable table with changeable
inserts. American Journal of Occupational Therapy, 19, 90.
Slagle, E. C. (1914). History of the development of occupation
for the insane. Maryland Psychiatric Quarterly, 4, 14–20.
Smith, P. A., Barrows, H. S., & Whitney, J. N. (1959). Psychological attributes of occupational therapy crafts. American Journal of Occupational Therapy, 13, 16–22.
Spackman, C. S. (1971). Occupational therapy for the restoration of physical function. In H. S. Willard & C. S.
Spackman (Eds.), Occupational therapy (4th ed., pp.
151–215). Philadelphia: Lippincott.
Spencer, H. (1921). Reconstruction work with the disabled
soldiers in St. Louis. Maryland Psychiatric Quarterly, 10,
60–61.
Starr, P. (1982). The social transformation of American medicine:
The rise of a sovereign profession and the making of a vast
industry. New York: Basic Books.
Sudsawad, P., Trombly, C. A., Henderson, A., & TickleDegnen, L. (2002). Testing the effect of kinesthetic training on handwriting performance in first-grade students.
American Journal of Occupational Therapy, 56, 26–33.
https://doi.org/10.5014/ajot.56.1.26
Tomchek, S. D., & Koenig, K. P. (2016). Occupational therapy
practice guidelines for individuals with autism spectrum disorder. Bethesda, MD: AOTA Press.
Tompkins, A. L. (1926). The organization of an occupational
therapy department at the Marcy Division of the Utica
State Hospital. Occupational Therapy and Rehabilitation,
5, 419–426.
Tracy, S. E. (1925). Two practical suggestions for occupying
desperate cases. Occupational Therapy and Rehabilitation,
4, 181–183.
Walker, J. E., & Howland, J. (1991). Falls and fear of falling
among elderly persons living in the community: Occupational therapy interventions. American Journal of Occupational Therapy, 45, 119–122. https://doi.org/10.5014/
ajot.45.2.119
West, W. L. (1968). Professional responsibility in times of
change. American Journal of Occupational Therapy, 22,
9–15.
Yerxa, E. J. (1967). 1966 Eleanor Clarke Slagle lecture: Authentic occupational therapy. American Journal of Occupational Therapy, 21, 1–9.
7101100030p10
Downloaded From: http://ajot.aota.org/ on 02/01/2017 Terms of Use: http://AOTA.org/terms
January/February 2017, Volume 71, Number 1