Bottom-Up vs Top-Down Approaches in Occupational Therapy
Occupational therapists often use two primary approaches—bottom-up and top-down—when evaluating and treating patients. These approaches differ in their focus and methodology but can also be blended for a comprehensive treatment plan.
Definitions
- Bottom-Up Approach:
The bottom-up approach focuses on addressing foundational factors first to understand the client’s limitations and strengths. The desired outcome is to acquire or restore the skills necessary to participate in meaningful occupations by addressing the cause of the problem. Goals in this approach typically target impairments and aim to improve functional skills.
Comparisons
- Top-Down Approach:
The top-down approach prioritizes maximizing the client’s existing skills and adapting activities to enable independence in occupations. Foundational factors such as performance skills and client factors are addressed later. This approach emphasizes participation in activities, often using adaptations to overcome limitations.
| Bottom Up Approach | Top Down Approach | |
| Therapeutic Method | Restorative | Compensatory |
| Desired Outcome | To acquire or restore the skills necessary to participate in occupation. | To maximize existing skills and adapt activities to allow independence in occupation. |
| Focus | Focuses on the cause of deficits in foundational skills. The evaluation and treatment plan is designed to address deficits in foundational skills, allowing for increased performance during daily activities. | Focuses on the skills necessary to participate in daily activities. The evaluation and treatment plan is designed to address participation in activity, including adaptations required to allow participation. |
| Approach to intervention | Addresses the cause of the problem. Treatment goals address the level of impairment and aim to improve functional skills. | Addresses functional performance. Treatment goals address participation in functional activity at the existing level of disability. |
| Frames of Reference examples | -Biomechanical -Neurodevelopmental Treatment (NDT) -Sensory Integration -Brunnstrom Movement Therapy -Proprioceptive Neuromuscular Facilitation (PNF) |
-Allen Cognitive Levels -Canadian Model of Occupational Performance -Model of Human Occupation (MOHO) -Occupational Adaptation |
| Advantages | -Easy to apply to all patients, even those who cannot communicate or make decisions for themselves. -Fits in well with the biomedical approach used in most hospitals and clinics. -Easy to collect and track data for outcomes analysis. -Allows for time sensitive intervention (i.e. prompt treatment of burns, splinting after tendon graft). |
-Consistent with the principles on which occupational therapy was founded as a profession. -Allows for a holistic approach. -Allows for intervention with patients who display occupational limitations but not necessarily the medical diagnoses that might underlie limitations (i.e. school based therapy). |
| Disadvantages | -Utilizes frames of references and theories from other professions. -Objective is to improve function, not necessarily to attain independence during occupation. |
-Assessments used are not always objective. -Models are not always readily applicable to treatment settings. (Lots of theory, not a lot of treatment examples or practical treatment tools.) |
