Models Of Practice

Model of Human Occupation (MOHO)

The MOHO is a comprehensive ecological model of practice known in OT. It suggests that various factors, including volition, performance capacity, habituation, and the environment, impact occupation. High-intensity training in OT aims to capture these essential concepts described in the MOHO to improve understanding of patients' relationship with meaningful occupation. 

Volition 

Volition can be thought of as the motivation or drive that fuels a person's engagement in an occupation. Use context, props, and goals that can be achieved during each session. The aim is to increase meaningful engagement with occupations that are important to the patient. Context can be included through the narrative description of why the intervention is valuable. For example, although a patient may be performing overground walking, the OT can increase salience by providing context: "We are going to walk the distance from the mailbox and back." Or, "We are going to practice getting onto the floor so you can return to playing with your grandkids." Props may be helpful to increase motivation and salience during the training session (e.g., using a grocery cart). Lastly, goals should be set during each session that drives motivation. These should be achievable and can be used as self-competition. These are just examples, and it is recommended that the OT be creative and include contexts that may hold value to each patient's unique situation.

Habituation

Habituation involves the everyday habits, roles, routines, and rituals that makeup one's identity. Habituation can act as either a strength or a barrier to stroke recovery, depending on the nature of the patient's lifestyle. Similar to the saying that "old habits die hard," it may be incredibly challenging when an OT is attempting to increase the "buy-in" for HIT. Still, the patient may have long-term sedentary or self-limiting behaviors to minimize engagement and participation. Although there is no guarantee that a patient will be engaged in therapy and HIT, an OT can help patients make progress to recovery by logically reiterating the patient's goals and desire to get better and increase function. This strategy is only effective if the patient is able to express their own goals and reason through the disconnect with the help of patient education from the OT. Use the Volition Tool to drive patient engagement. Remember that there is no guarantee that every patient will have the buy-in for HIT, and ultimately, OTs would benefit from honoring patient autonomy and decision-making.

Performance Capacity

Performance capacity can be thought of as a person's potential based on the range of current abilities. Again, depending on multiple psychological factors, including personality, performance capacity can be either a strength or a barrier. An OT can use the goal reiteration strategy, the Transtheoretical Model of Change, and therapeutic modes to reduce the obstacles and increase buy-in for HIT. This may be especially helpful when a patient has a poor perception of their own performance capacity. The OT should use objective measures and observations for evaluation and during training sessions to identify performance capacity. For example, although the patient can safely participate in aerobic activity for 75-85% of the age-predicted heart rate max (Kim et al., 2019), they may demonstrate reduced activity tolerance due to other elements of MOHO, such as habituation and poor volition. Or they may have low activity tolerance due to knee or ankle pain. The OT should not provide OT-based HIT in a way that would cause injury to the patient. Protect the joints with ankle foot orthotics (AFOs), knee braces, and slings when needed, but also challenge the patient based on their performance capacity.        

Environment

The environment plays a crucial role in occupational engagement and performance. The OT should always consider the possibility that a patient may feel as though they have been stripped of their natural environment when hospitalized. An inpatient rehab facility possesses multiple environmental support and barriers depending on the occupation. In some ways, the setting provides extra environmental assistance (e.g., hospital beds, grab bars), while at other times, it can be detrimental (i.e., poor sleeping environment). Although the effects on salience may vary, OTs can try to increase environmental context during interventions to simulate the patient's actual occupational experiences more accurately. This can be thought of as manipulating the environment for the patient's gain. With OT-based HIT, the environment can be manipulated as a facilitator or error augmenter using the skill acquisition chart.    

Considerations. It is recommended to use a strength-based approach when barriers are identified. For instance, if a patient has poor volition/engagement in therapy but has good performance capacity with endurance, use that to help the patient make functional gains during OT-based high-intensity functional mobility training. The same goes for the reverse: if a patient is motivated and goal-oriented but has poor activity tolerance, use the strength-based approach for setting achievable, within-session goals to drive intrinsic and extrinsic motivation.        

Motor Learning Theory 

Motor Learning Theory is well-established and has been helpful for guidance and informed decisions during rehabilitation (Magill, 2011). It suggests that motor learning occurs through practice, requiring more cognitive load with skill acquisition compared to mastered or autonomous motor performance. High-intensity OT aims to reduce unnecessary demands on cognition during skill acquisition, especially with skills that can be practiced with high dosage and repetition, such as functional mobility. Skills that require more cognitive demands are recommended for intervention as patients progress through rehab. Motor learning strategies such as error-based learning, meaning, feedback, knowledge of performance, and results are emphasized throughout OT-based HIT to increase functional recovery and complement the current evidence on HIT.