Data about the ways in which hospital routine affects performance can guide occupational therapists in advocating for balanced programs of activity and rest for older rehabilitation patients.

Practitioners of occupational therapy in the early 1900s selected therapeutic activities with an intuitive understanding of their characteristics and operations. The term activity analysis and the methodology for breaking down and examining tasks scientifically, however, were borrowed from industry during World War I. Methods originally used in time and motion study of jobs were applied to vocational retraining and therapeutic crafts; later, they were applied to a broader range of activities. The most systematic early use of activity analysis was in occupational therapy for physical dysfunction, particularly in military hospitals. Development of the concept was gradual until the 1970s, when the delineation of theoretical frames of reference for practice led to important changes. Today, activity analysis is viewed as a multifaceted process that involves both generic and specific components.

In this pilot study, qualitative methodology was used to examine the clinical reasoning of four experienced occupational therapists as they presented and modified therapeutic activities to treat patients with spinal cord injuries. The therapists demonstrated the multi-layered thinking discovered in previous research, but hierarchical structuring of knowledge emerged as an unexpectedly dominant theme in their reasoning. Examples of hierarchical thinking about therapeutic activity included creating mental files of therapy tasks and materials sequenced from elementary to advanced and determining the level of difficulty at which to present an activity in order to build the patient's skills in a stepwise manner. The therapists reported that they learned to make decisions about the use of activities in treatment by observing skilled clinicians and by treating patients.

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This paper discusses the relationship of a theoretical frame of reference to the implementation of a work-oriented program. Three frames of reference in occupational therapy are reviewed, and work-related theories and approaches available to therapists are categorized under each. Examples of the application of various frames of reference are given through an analysis of work programs described in the occupational therapy literature. We recommend that therapists select and apply frames of reference systematically when developing work programs to facilitate the development of a body of knowledge in this area.