Occupational Therapy
Kimberly Nemi (OTR/L, CBIS), senior-level occupational therapist at SUNY Upstate Medical University, has reviewed this page for content accuracy.
Following a concussion, your symptoms may make certain tasks and activities more difficult than they previously were; returning to work or school may exacerbate symptoms. You may find it difficult to drive to work due to dizziness, or read a screen or book due to light sensitivity or visual strain. In cases like these, seeing an occupational therapist (OT) may help. Occupational therapy is a licensed healthcare profession that helps individuals with an injury or disability to thrive in everyday activities. Occupational therapists work with patients to improve function by altering surroundings or tasks and compensating for symptoms. While physical therapists (PTs) often help with direct rehabilitation, OTs can also provide rehabilitation, such as for vision or vestibular difficulties.
Contents
Why does occupational therapy help manage a concussion?
Symptoms that may benefit from occupational therapy for concussion
How to access occupational therapy
Symptom-based strategies your OT might use
What a concussion OT session might look like
Where occupational therapy is provided
Why does occupational therapy help manage a concussion?
As a concussion can disrupt all areas of life, OTs help concussion patients return to daily activities in addition to just school, work, and sports. They approach rehabilitation from a unique perspective that considers a client’s needs in a larger context: daily activities, community, family, school, work, and beyond. OTs can be members of a multidisciplinary concussion management team, so they may work alongside a PT, psychologist, speech-language pathologist, physical medicine & rehabilitation (PM&R) physician, neuropsychologist, and neurologist.
What is occupational therapy?
Occupational therapy is a licensed healthcare field that takes a holistic approach to treatment for injury and physical and mental disability. It helps to identify activities of daily living (ADLs), a category of activity encompassing self and home care, work, participation in social or family life, and ability to pursue hobbies or interests. OTs help identify which ADLs patients are experiencing difficulties with and focus on helping them thrive. Following a concussion, an OT can identify how a concussion may have affected an individual’s ability to perform activities of daily living. OTs then develop both compensatory and rehabilitative interventions based on these symptoms and the functioning deficits they cause. They educate and coach their patients on how to use these interventions to aid in recovery and return to work and activity. Compensatory interventions help patients work around difficulties to find alternative ways of performing ADLs, while rehabilitative interventions help patients improve upon their ability to execute these activities. For instance, occupational therapy could help a concussion patient experiencing mental fatigue return to their previous level of daily activities, such as grocery shopping, cooking, and cleaning. OTs may also receive specialized training in vestibular therapy, which qualifies them to diagnose and rehabilitate vestibular problems. Look for OTs who are Certified Vestibular Therapists (Cert. VT) or have extensive training. OTs will also refer individuals to other professionals when necessary, such as a referral to a physical therapist for rehabilitation focused on eliminating exercise intolerance.
Many people confuse occupational therapy with physical therapy. While physical therapists (PTs) and OTs can both treat concussion patients, the main difference lies in their approaches to treatment. For concussions, PTs primarily address physical symptoms, such as neck pain, dizziness, vertigo, oculomotor issues, and exercise intolerance through physical rehabilitation interventions. OTs help individuals execute their everyday tasks–such as driving, cooking, reading, and cleaning–through compensatory and rehabilitative interventions that target physical, sensory, cognitive, and emotional symptoms that contribute to these ADL difficulties.
Kimberly Nemi (OTR/L, CBIS) is an OT specializing in concussion management with training in visual and vestibular issues often experienced by patients who have sustained a brain injury. We had the chance to speak with her about what an OT does for concussion patients in her clinic. Nemi described the OT role in concussion management as starting with a thorough assessment of concussion symptoms, physical, sensory, cognitive skills, followed by assessing the impact those symptoms have on patients' function. A treatment plan is developed with the patient that looks to optimize independence and safety. For example, if a patient is experiencing fatigue and sleep issues after a concussion, the Mental Fatigue Scale can be used to help determine the extent of these symptoms and tailor a plan based on the patient’s response. This plan might include education on energy conservation techniques and the use of an activity log to increase endurance for various activities over time. An activity log allows the patient to keep track of what activities may exacerbate their symptoms and for how long they can endure an activity before symptoms are exacerbated. The OT checks the activity log during follow-up appointments to assess the effectiveness of the energy conservation techniques and to ensure that endurance is indeed increasing.
However, it is important to note that, for those seeing an OT in a multidisciplinary concussion or outpatient rehabilitation clinic, some clinics will have professionals other than OTs address some of these symptoms. For instance, at one clinic, an OT might be in charge of creating dizziness-focused interventions, but an OT at another clinic may not focus on this if a vestibular physical therapist is available. Other healthcare professionals who are often part of a clinic’s multidisciplinary team–like PTs, speech-language pathologists, athletic trainers (ATs), and psychologists–are very qualified to treat these symptoms as well. Nemi notes that an OT’s responsibilities in a patient’s treatment plan depend greatly on the team, clinic, or setting, and especially on which other professionals are present.
An OT is a licensed professional with a Master’s degree or Doctorate in occupational therapy (OTD). Other certifications can be obtained as well, such as Nemi’s Certified Brain Injury Specialist (CBIS) certification. OTs are highly qualified professionals who develop individualized compensatory and rehabilitative treatment plans to help concussion patients return to school, work, and ADLs.
Symptoms that may benefit from occupational therapy for concussion
A concussion, also called a mild traumatic brain injury (mTBI), is often overlooked as a trivial injury, as many regard recovery to be quick. However, many concussion patients do not recover in a quick or linear way, and some people develop persisting symptoms that require rehabilitation. Furthermore, concussions are “invisible,” meaning that diagnosing and treating may be complicated by symptoms and signs that aren't always easy to recognize. Therefore, concussions must be taken seriously. In this page, we will use the term “concussion” to refer to this type of brain injury.
Compensatory intervention (strategies for the accommodation of impaired function) and rehabilitative intervention (exercises promoting restoration of function) are both important in occupational therapy. OTs help people better perform ADLs by addressing how to compensate for a variety of new or worsened symptoms, some of which include the following:
Physical: fatigue, pain, sleep issues, and co-occurring muscle or soft-tissue injuries like whiplash
Sensory: poor balance or sense of your body’s position in space, dizziness, and double vision or visual strain
Cognitive: mental fatigue, poor attention or memory, and executive dysfunction
Emotional: emotional lability (dysregulation), such as frequent, uncontrollable mood swings or inability to manage strong emotions; depression and anxiety
How to access occupational therapy
You can schedule an appointment with an occupational therapist through a number of different avenues. One method of scheduling a first appointment would be to get a referral. This could be done by making an appointment with your primary care provider and requesting a specialist referral. Patients could also contact a local outpatient rehabilitation center to understand intake requirements for an occupational therapy appointment. Local hospitals may also provide referrals for initial appointments. Families can also contact their child’s school guidance counselor for advice on accessing occupational therapy.
Another Resource and method of starting the journey of receiving occupational therapy would be contacting your State Occupational Therapy Association.
What a concussion OT session might look like
The occupational therapy process follows three steps:
an initial assessment
development of a set of rehabilitative and compensatory interventions
ongoing evaluation and referrals
In the initial assessment, the OT figures out how symptoms affect areas of an individual’s life. This varies greatly for concussion patients as their symptoms vary substantially. Assessments can include:
procedures, such as the administration of fatigue and sleep assessments
interviews
consultations
clinical observations
The OT develops interventions according to the initial assessment and communicates this strategy to the patient, with some services being provided by an occupational therapy assistant (OTA). Services for concussion include, but are not limited to, educating the patient on recovery and sleep hygiene, determining accommodations for work, implementing behavioral and physical interventions to address ADL difficulties, and developing strategies for return to school, work, and activity. This plan should address the short- and long-term goals and needs of the patient. The timeline for a patient’s intervention is very individualized and depends upon the symptoms, needs, and goals identified by the patient and the OT, as well as the patient’s recovery trajectory. The frequency of the sessions will be determined following the completion of the initial assessment.
The OT continues seeing the patient to track progress toward goals and modify the treatment plan as needed. As concussion symptoms can change over time, an OT typically reassesses the treatment plan every ten visits. If additional concerns are identified, the OT may refer the patient to other providers (i.e., neuropsychologist, physical therapist, speech-language pathologist, neuro-optometrist, etc.).
Because the American Occupational Therapy Association (AOTA) does not publish recommendations for which assessment tools and rehabilitation interventions OTs should use for the general population, clinicians do not agree on which assessments and interventions to utilize—so not all patients may receive the same standard of care.
Symptom-based strategies your OT might use
To address symptoms, an OT develops an intervention plan based on how symptoms affect a patient’s lifestyle. So, someone who reads and writes for a living would have a different treatment plan than someone whose main role is to deliver packages.
Cognitive Difficulties
OTs may use cognitive rehabilitation exercises with concussion patients; these exercises can stimulate the brain's ability to alter pathways and build new connections. Additionally, OTs may help patients create compensatory techniques. For example, an OT might show their patient how to effectively use a planner to help with trouble remembering plans, tasks, or other ADLs. The planner is a compensatory tool helping the patient with their memory limitation. These types of interventions help with overall life function while the difficulties or constraints remain. Some patients will need to rely on the planner less as they progress with their rehabilitation, while others may continue to find it helpful.
Fatigue
When addressing fatigue in patients, the occupational therapist may start with administering a fatigue scale to determine how symptoms are affecting the patient’s fatigue levels. OTs will ask patients about their sleep cycle and patterns as well as when and how the patient feels tired (crashing quickly and randomly, or always at the end of the day, etc.). This will help the OT determine what aspects of a patient’s lifestyle are contributing to their fatigue. The fatigue scale and information provided are used as a starting point for treatment. According to OT Kimberly Nemi, helping patients with symptoms such as fatigue is individualized and can require education, reinforcement to carryover strategies, and support.
A home program could be created for building endurance in tasks. Some fatigue concepts addressed could be balancing necessary daily activities (such as dishwashing and vacuuming) with fatigue levels, or meal planning to simplify cooking.
Pain management (non-pharmacological)
A key part of working with patients on pain management for OTs is helping patients identify their pain levels, especially pain levels, while completing activities of daily living. A sign that patients might need help with pain management (and possibly other modes of rehabilitation) is that completing ADLs often increases their pain by more than 2 points on a 10-point scale. A significant way that OTs work with patients suffering from pain is by adjusting how the activity is done. They analyze and correct posture, ergonomics, and body mechanics. Following this, OTs teach patients energy conservation strategies and monitor patient symptoms. Energy conservation strategies are small ways to help conserve patient energy, which can be very beneficial when dealing with pain.
Sleep Issues
Occupational therapists administer a sleep assessment to identify the patient's sleep patterns and determine what specific sleep issues they are having: staying asleep, falling asleep, etc. They can make suggestions to patients such as…
Creating a daily routine
Adjusting pillow/number of pillows
Changing mattress
Not drinking caffeinated drinks in the evening
Many concussion patients also suffer from neck and spine injuries such as whiplash and need cervical rehabilitation. These musculoskeletal problems can also affect sleep, so it is important to determine the cause of the sleep issues.
For additional information on ways concussions can impact sleep, visit our page on Sleep and Sleep Problems.
Driving Rehabilitation
Driving—a necessity for many people—can become a much more dangerous activity for people with concussion symptoms. OTs will identify the issues the patient is facing while driving, such as headaches, dizziness, perception issues, slower reaction time, cognitive issues, and more. Helping patients return to the road can be done through driving simulations and practice on cognitive and physical skills needed to be behind the wheel safely. Many concussion symptoms can make driving unsafe, and increase the risk of accidents. Getting into an accident while you are still in concussion recovery could prolong your recovery or potentially reinjure you.
Balance Issues
Occupational therapists will work with the patient on education and compensation surrounding balance issues, as direct rehabilitative exercises for balance would be done with a physical therapist. OTs work with patients on adaptation and modification of activities where the patient is struggling with balance and/or safety is a concern. A home safety check could be initiated to see if any part of the home should be altered to maintain the patient’s safety. OTs may also receive specialized training in vestibular therapy, which qualifies them to diagnose and rehabilitate vestibular problems. Look for OTs who are Certified Vestibular Therapists (Cert. VT) or have extensive training
Dizziness
OTs will ask patients to complete assessments to determine where their dizziness originates. The cause of the dizziness will allow the OT to select the appropriate next steps. Visual intolerance to lighting can be one cause of dizziness reported by patients. Computer screen lighting, in particular, can trigger dizziness and headaches. Occupational therapists can assess these tolerance levels and teach the patient about modifications to the device and/or the environment to help the patient with safe progression and return to this type of activity. OTs coach patients on what to do when they experience dizziness where there is a fall risk. OTs may also receive specialized training in vestibular therapy, which qualifies them to diagnose and rehabilitate vestibular problems. Look for OTs who are Certified Vestibular Therapists (Cert. VT) or have extensive training.
Where is occupational therapy provided?
You can access occupational therapy from many different locations. Appointments could be scheduled in various locations listed below. However, keep in mind that this list is not exhaustive.
Schools
Private Practices
Hospitals and Clinics
Behavioral Health offices
Mental Health Facilities
(typically related to head trauma from self-injury)
Occupational therapist qualifications
An occupational therapist is a health professional who has to complete certain degrees and requirements, just like all other healthcare workers. Occupational therapists must have a bachelor's degree, often in a related field such as health science, psychology, or biology. They also must have received a master’s degree from an accredited occupational therapy program. Following this degree, they must have completed the required licensing exams, including passing the National Board for Certification in Occupational Therapy (NBCOT) exam. Individuals can continue schooling to earn a Doctorate in Occupational Therapy (OTD) as well. Alongside going into practice, OTDs also have the opportunity to pursue careers as educators, researchers, and more. Additionally, OTs can pursue many specialty certifications.
Additionally, there are also occupational therapy assistants (OTAs), who help the occupational therapist with the implementation of different occupational therapy interventions. After an OT diagnoses and creates a treatment plan, OTAs may work with patients on exercises and education. Occupational therapy assistants must have at least an associate’s degree from an accredited OTA program.
The science behind: OT Practitioners
A 2022 study investigated how occupational therapy for adult concussion patients differs across practitioners and outpatient settings. This qualitative, descriptive study surveyed expert occupational therapy practitioners on the measures they use for symptom and performance assessment. The researchers aimed to develop a guideline for concussion occupational therapy practice in the absence of evidence-based AOTA guidelines for concussion rehabilitation. The expert practitioners exhibited similar patterns of practice, implementing the following components in the same order: baseline ability assessment, symptom management lesson, impairment-based training, and graded return-to-activity. However, the practitioners did not agree on which assessments and interventions were the most ideal. This study highlights the need for an AOTA gold standard for occupational therapy intervention and assessment for outpatient concussion rehabilitation in the general population.