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Bottom Up vs Top Down Approach

The term “bottom up” and “top down” refer to the approach occupational therapists take when evaluating and treating patients. This chart will focus on the definitions and differences between these two approaches.

Bottom Up Approach: The occupational therapist evaluates the foundational components of function and develops the treatment plan based on deficits in these components.
Top Down Approach: The occupational therapist evaluates the patient’s functional status in relation to his or her daily occupations and develops the treatment plan based on the patient’s ability to participate in those occupations.


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.)

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