Occupational therapy

Occupational therapy works on the activities that occupy a day — washing, dressing, cooking, working, driving, managing money, caring for children. Where physiotherapy asks whether the arm can move, occupational therapy asks whether you can do up a button, and those are different questions with different answers.

It works in three ways: restoring the ability, teaching a different method, or changing the environment and equipment. Often all three at once.

Upper limb function for daily tasks. Personal care and independence training. Cognitive and perceptual rehabilitation applied to real activities. Splinting to prevent contracture and support function. Home assessment and adaptation. Wheelchair and seating assessment. Return to work and to driving.

For families it also covers training in how to help without taking over, which is a genuine skill and one of the most useful things a carer can be taught.

After stroke and brain injury, in spinal cord injury, in multiple sclerosis and Parkinson's disease, in rheumatoid arthritis and hand conditions, in children with cerebral palsy and developmental difficulties, and in older adults losing independence.

It is the discipline most often left out of a rehabilitation package, and its absence is why patients are sometimes discharged walking well and still unable to manage at home.

By activities completed independently, using standardised measures of daily function and by the patient's own goals, recorded at the start.

Discharge planning starts at admission, not at the end. What matters is what happens in the patient's own kitchen, and planning for that from day one changes what the programme trains.

What someone can do in a therapy gym predicts what they can do at home poorly. Step heights, bathroom layout, chair height, door widths and the route they actually walk most determine independence.

Where a home visit is not possible — which is the case for most international patients — we work from photographs, measurements and a detailed description, and the discharge document states what needs changing.

A device is recommended when it makes a specific task possible or safe, and it is trained rather than handed over. Equipment issued without training is the most commonly abandoned intervention in rehabilitation.

We also say when equipment is not the answer — when what looks like a need for a device is actually a need for strength that can still be trained back.

Occupational therapy works on the tasks of daily life — dressing, cooking, writing, managing medication — rather than on muscles in isolation. Where an ability cannot be fully restored, it adapts the task or the environment so the person can still do it.

'Occupation' here means how a person occupies their day. It covers self-care and leisure as much as work, and the goal is participation rather than strength.

The distinction matters practically because patients frequently decline occupational therapy on the assumption that it is about returning to a job they have no intention of returning to, and miss the part of rehabilitation most directly concerned with living at home.

Three strategies, used in that order. Restore the ability if it is recoverable. Adapt the method if it is not — a different way to fasten a shirt. Change the environment if neither works — a different shirt, or a rail in a different place.

The adaptation route is often treated as giving up, and it is usually what restores independence fastest. Independence achieved with a device or a different technique is still independence, and it can be worked on alongside restoration rather than instead of it.

After a stroke or brain injury the barrier to living independently is usually a specific set of tasks, not a general level of strength. Physiotherapy addresses movement; occupational therapy addresses whether the movement is usable for something that matters. A Cochrane review of nine trials found low-quality evidence that occupational therapy aimed at daily activities after stroke improves performance of those activities and reduces the risk of deterioration in them 1.

It is also the discipline most often left out of a package, particularly in short international programmes where physiotherapy dominates the timetable. Ask specifically whether it is included and how many hours, because its absence is rarely stated.