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.) |
Case Study: Top-Down vs Bottom-Up in Action
A patient with a Traumatic Brain Injury (TBI) presents with overall deconditioning (weakness, low energy) and increased tone affecting the right side of their body.
Patient Goals:
- Improve strength and endurance to use stairs independently without fatigue.
- Regain independence in Basic Activities of Daily Living (BADLs).
Approach Comparison:
- Bottom-Up: Focuses on foundational skills such as improving muscle strength and endurance. Example interventions include:
- Strengthening exercises:
- Wrist weights
- Pulleys
- Strengthening exercises:
- Bottom-Up: Focuses on foundational skills such as improving muscle strength and endurance. Example interventions include:
- Top-Down: Addresses performance and participation in activities using adaptations and techniques. Example interventions include:
- Instruction in adaptive techniques:
- Energy conservation methods
- Adaptive equipment:
- Reacher, tub bench
- Assistive technology:
- Speech-to-text typing
- Environmental adaptations:
- Grab rails by the stairs
- Instruction in adaptive techniques:
In practice, a blended approach may be used to address both foundational skills and functional goals simultaneously.
Assessments: Bottom-Up vs Top-Down
Using the same case study, here are examples of assessments for each approach:
- Bottom-Up Assessments:
- Goniometer measurements
- Manual muscle tests
- Top-Down Assessments:
- Activities of Daily Living Checklist/Observation
- Kohlman Evaluation of Living Skills
Advantages
Bottom-Up Approach:
- Suitable for all patients, including those unable to communicate or make decisions.
- Aligns with the biomedical model used in hospitals and clinics.
- Facilitates easy data collection for tracking outcomes.
Top-Down Approach:
- Provides a holistic view of the patient.
- Reflects the core principles of occupational therapy as a profession
When to Use Each Approach
The choice between a bottom-up or top-down approach often depends on the frame of reference (FOR) or model being used:
- When to Use Bottom-Up:
- The biomechanical FOR requires a bottom-up approach, focusing on foundational skills.
- When to Use Top-Down:
- The Occupational Adaptation Model encourages a top-down approach, especially for clients with progressive diseases or permanent disabilities.
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What is the bottom-up approach in occupational therapy?
The bottom-up approach in occupational therapy focuses on enhancing foundational skills to address impairments. It is a restorative method aiming to improve functional skills needed for meaningful activities.
How does the top-down approach differ from the bottom-up approach?
The top-down approach is a compensatory method that emphasizes adapting activities to maximize patient independence, focusing on participation in daily activities rather than improving underlying skills.
When should a therapist use the bottom-up approach?
Therapists use the bottom-up approach in biomechanical frames, especially suitable for patients who are unable to communicate and when simplified data collection is needed, aligning with hospitals’ biomedical models.
What assessments are associated with the top-down approach?
Top-down assessments in occupational therapy include evaluating Activities of Daily Living (ADL) checklists and the Kohlman Evaluation of Living Skills to focus on patient independence and participation.
What are the advantages of the top-down approach in occupational therapy?
The top-down approach offers a holistic viewpoint, foundational to occupational therapy principles, and is particularly useful in occupational adaptation models, especially for patients with progressive diseases.
