Occupational Therapy Frames of Reference: Complete Guide with Examples

Occupational therapy professionals use theory to guide their practice. A theory is the base of any profession, from which construction or modification can be done with valid reasoning. Theories are usually developed by experts in a field. In general, a theory may be a belief, policy or procedure proposed or followed as the basis of action.

Theories are not always vast and complex, but many people avoid reading theories and postulates. Theories are based on research, thought or observation of phenomena. Research-based theories are more trustworthy because they have valid reasoning and references behind them.

A frame of reference uses pieces of one or more theories and makes them practical and useful. (Kramer and Hinojosa)

Theory, model, frame of reference: what’s the difference?

Students often mix these words up. A simple way to see them is as levels, from the broadest ideas at the top to what the therapist actually does in a session at the bottom.

Frames of reference in occupational therapy

In occupational therapy, a frame of reference is used as a baseline for practical application. It uses theories to guide evaluation, assessment and their application in practice.

The frame of reference provides a structure for identifying relevant theories and then, based on this information, outlines guidelines that occupational therapists use when assessing and providing intervention.

Mosey’s structural components are used as the organising scheme for all frames of reference:

1. Theoretical base

An occupational therapist uses the theoretical base to understand the results they can expect after intervention. The theoretical base is the foundation of the entire frame of reference. It may draw from one or more theories, and includes assumptions, concepts, definitions and postulates, and the relationships between them.

2. Function–dysfunction continua

This part of a frame of reference focuses on the areas of concern. After setting a theoretical base, the therapist should be able to identify the specific areas of performance important to the individual’s skills and abilities. The functional end of the continuum represents what the therapist expects the client to be able to do (abilities), while the dysfunctional end represents disabilities. A single frame of reference usually contains several function–dysfunction continua.

Example: in the biomechanical frame, one continuum is range of motion, running from “full, pain-free movement for daily tasks” to “joint movement too limited to reach, dress or eat”.

3. Guide for evaluation

Evaluation creates the baseline for intervention. It should relate to the indicators of function and dysfunction. Specific assessment tools, scales or protocols may be used. The therapist uses tools, standardised or non-standardised, that provide an appropriate baseline of performance and help develop a meaningful plan for intervention.

4. Postulates regarding change

Postulates regarding change give the frame of reference more concrete structure. Here we see the cause and effect. They guide the therapist about the changes expected after an action, and transform the abstract material of the theoretical base into practical actions the therapist takes to facilitate change in the client.

Example: “If muscles are worked against gradually increasing resistance, strength will increase.”

5. Postulates regarding intervention

Postulates regarding intervention follow from the postulates regarding change. They describe how the occupational therapist puts theory into action. After assessment, the therapist plans the media and modalities according to the frame of reference. This step helps the therapist set client-oriented goals and use different techniques to achieve them, and guides how to use specific techniques and modalities according to the theory.

Example: “Grade a woodworking or kneading task from light to heavier resistance as the client’s strength improves.”

Occupational therapy frames of reference list

Fifteen frames of reference commonly used in occupational therapy practice are compared below. Click a name for the full guide.

OT models of practice

Models are broader than frames of reference. They describe how the person, their occupations and their environment fit together, and guide thinking across all of practice. Read our full guide to occupational therapy models.

A short history of OT theory

How to choose a frame of reference

Effective practice depends on the therapist’s ability to match the client with the most appropriate frame of reference in the context of their life. After a patient is referred to occupational therapy, the therapist does a preliminary screening and looks at the person’s needs, strengths, limitations and environment.

After understanding all of this, the therapist chooses the most appropriate method for evaluation and intervention. Sometimes one specific frame of reference is enough, but at other times one isn’t adequate for the complexity of the problems the patient presents.

How to apply frames of reference in clinical practice

Many therapists read about frames of reference but don’t know how to apply their principles in clinical practice. Frames of reference are quite theoretical, and even when a therapist understands the principles, applying them to a patient can be difficult.

A therapist must understand what they are doing and why. They also need to be able to explain this rationale to patients, observers and other professionals, which builds their confidence during therapy sessions.

Early on, a therapist may learn by trial and error if there is no senior or expert to guide them. A therapist should keep improving their knowledge of each frame of reference. They may use different frames with a single patient, but it’s crucial to know the effects and why each one is being used.

For example, a physician should not prescribe medication without knowing its possible consequences; similarly, a therapist should not use a procedure without understanding its potential effects. Based on a client’s presenting problems, the therapist selects a frame of reference to specify the changes or outcomes they want to promote.

Single vs multiple frames of reference

Young occupational therapists may not yet have the knowledge to apply multiple frames of reference to one patient. They should focus on one frame at a time and, after mastering one, add others. Some patients need one frame of reference, but many need several.

• Single frame example: for a child with sensory processing disorder, the occupational therapist may apply one frame, the sensory integration frame of reference.
• Multiple frames example: for a child with cerebral palsy, the therapist may use the developmental, neurodevelopmental and biomechanical frames of reference.

Frames of reference can be used in sequence or in parallel, according to the needs of the patient.

Frames of reference by practice setting

One client, several frames: a worked case

Mr Sharma, 64, had a stroke three weeks ago. His right arm is weak, he tires quickly, he forgets steps when dressing, and he has lost confidence. He wants to go home and return to cooking for his wife.

This is the frames used in parallel: each addresses a different problem, all serving one occupational goal, cooking at home.

Tips for students and the NBCOT exam

Summary

Occupational therapists use frames of reference to guide their practice and clinical reasoning. Every frame of reference has a specific structure, from theory to intervention. Many frames of reference are available to occupational therapy practitioners, and multiple frames can be used in sequence or in parallel. Explore each one in depth:

• Biomechanical frame of reference
• Rehabilitative frame of reference
• Developmental frame of reference
• Model of Human Occupation (MOHO)
• Psychodynamic frame of reference
• Sensory integration
• Neurodevelopmental (NDT) frame of reference
• Motor learning frame of reference
• Cognitive disability (Allen) frame of reference
• Behavioural and cognitive-behavioural frames of reference
• Acquisitional frame of reference
• Occupational adaptation
• OT models: PEO, CMOP-E, PEOP, EHP
• Kawa model

References

• Kramer P, Hinojosa J, Howe TH, eds. Frames of Reference for Pediatric Occupational Therapy. 4th ed. Wolters Kluwer.
• Mosey AC. Applied Scientific Inquiry in the Health Professions: An Epistemological Orientation. AOTA.
• Pendleton HM, Schultz-Krohn W, eds. Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction. Elsevier.
• Boyt Schell BA, Gillen G, eds. Willard and Spackman’s Occupational Therapy. Wolters Kluwer.
• Taylor RR, ed. Kielhofner’s Model of Human Occupation. 5th ed. Wolters Kluwer.
• Mosey AC. Occupational Therapy: Configuration of a Profession. Raven Press; 1981.
• Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L. The Person-Environment-Occupation Model: a transactive approach to occupational performance. Canadian Journal of Occupational Therapy. 1996;63(1):9–23.
• Dunn W, Brown C, McGuigan A. The ecology of human performance: a framework for considering the effect of context. American Journal of Occupational Therapy. 1994;48(7):595–607.
• Iwama MK. The Kawa Model: Culturally Relevant Occupational Therapy. Churchill Livingstone; 2006.
• Cole MB, Tufano R. Applied Theories in Occupational Therapy: A Practical Approach. 2nd ed. SLACK.

Written by

Deepam Pawar, OT

Deepam Pawar is an occupational therapist and co-founder of Occupational Therapy OT. He focuses on clinical frameworks, assessment, and evidence-based practice.

All articles by Deepam →

This article is for general education and is not a substitute for individualized assessment or treatment by a licensed occupational therapist. Always seek the guidance of a qualified professional for specific concerns.