THE ISSUE IS

Bottom-Up or Top-Down Evaluation:

Is One Better Than the Other?

Gwen Weinstock-Zlotnick,
Jim Hinojosa

particular tasks define each of the roles . . . and political beliefs at the time. This move-
T he Occupational Therapy Practice Frame-
work: Domain and Process (Framework;
American Occupational Therapy Associa-
whether he or she can now do those tasks,
and probable reasons for an inability to do
ment, which encouraged patients to engage
in activities, is credited as the philosophical
tion [AOTA], 2002) specifies that all occu- so” (Trombly, 1993, p. 253). In the top- roots of occupational therapy (Bockhoven,
pational therapy evaluation must begin down approach, the foundational factors 1971). Adolph Meyer built on those princi-
with an occupational therapy profile and an (performance skills, performance patterns, ples with value placed on time, work, and
analysis of occupational performance context, activity demands, and client fac- activities that promote self-fulfillment
(AOTA, 2002). This document requires tors) are considered later. (Christiansen & Baum, 1997). Occupa-
that a top-down approach to evaluation be The bottom-up approach considers tions and later “habit training” embodied
used wherein the therapist always begins by foundational factors first to obtain an the early philosophy of occupational thera-
examining the client’s occupational perfor- understanding of the client’s limitations, py (Mosey, 1986). The popular societal
mance, grounded in a client-centered real disabilities, and strengths. “A bottom- beliefs regarding the indelible connection
approach. In this paper, we question the up approach to assessment and treatment between a person’s value and his or her
soundness of the AOTA official position focuses on the deficits of components of work as well as the danger of “idle hands”
that occupational therapy evaluation should function, such as strength, range of motion, likely supported or even shaped the early
always be based on a top-down approach. balance, and so on, which are believed to be philosophy of occupational therapy (Mosey,
After surveying the evolution of each prerequisites to successful occupational per- 1986, p. 25). This era can be described as
approach and examining their relative formance or functioning” (Trombly, 1993, using a modified top-down approach,
strengths and ability to document effective- p. 253). An assumption inherent in the bot- where intervention focused primarily on
ness, we suggest that clients’ needs may be tom-up approach is that acquisition or re- occupations, with remediation of perfor-
better served by a therapist determining acquisition of motor, cognitive, and psy- mance skills being an occasional, but wel-
which evaluation approach would be most chological skills will ultimately result in come by-product.
appropriate to the situation through the use successful performance of activities of daily In the early 1900s, medicine focused
of a screening tool. living. on treating acute conditions. After World
Although the focus of this paper is on War I, immunological and surgical practices
the top-down versus bottom-up approach, advanced; however, the Depression over-
Three Approaches To Evaluation it should be noted that some therapists use shadowed serious growth in the field of
and Treatment a third approach to evaluation by assessing rehabilitation (Mosey, 1986). Injuries suf-
“A top-down assessment . . . starts with the client’s context first. The initial focus of fered during World War II, followed by the
inquiry into role competency and meaning- evaluation is the examination of the person successful use of antibiotics presented a need
fulness . . . [and] further determines which relative to his or her disability status, and supportive climate for the rehabilitative
lifestyle, age, and stage of life as well as set- professions. Intervention at this time
Gwen Weinstock-Zlotnick, MA, OTR/L, CHT, is Doctoral ting and environment (Hinojosa & focused on physical components, as that was
Candidate, Department of Occupational Therapy, New York Kramer, 1998; Ideishi, 2003). what the medical team valued. Many occu-
University, New York, New York. Correspondence: 545 pational therapists embraced the reduction-
West 236th Street, Apt. 5I, Riverdale, New York 10463; ist medical model and to varying degrees
[email protected] Historical Perspective abandoned the holistic approach of occupa-
Jim Hinojosa, PhD, OT, FAOTA, is Professor, Department In the early 19th century, the moral treat- tions and activities (Christiansen & Baum,
of Occupational Therapy, New York University, New York, ment movement was noted in several men- 1997; Mosey, 1986). This series of events
New York. tal hospitals, influenced in part, by religious ushered in the use of a bottom-up approach.

594 September/October 2004, Volume 58, Number 5

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 In the 1960s, in a national environ- common language for health professionals. Occupational Therapy Association in 1994,
ment of social and political change during The disease-impairment-disability-handicap was intended to replace its predecessor. An
which many traditional paradigms were model was of bottom-up orientation and an important initiative in this version was the
challenged, some occupational therapists important beginning in the conceptualiza- introduction of performance contexts. The
began to question the appropriateness of tion of disability on a global scale. three resulting categories, performance
the medical model. As therapists sought to Significant revisions were made to the areas, performance components, and per-
define the domain of concern, different ICIDH in 2001 to encompass a more holis- formance contexts, are organized laterally,
philosophical camps emerged (Mosey, tic approach to health and wellness as well not hierarchically, suggesting equal impor-
1986). The use of frames of reference to as to include context as a relevant factor to tance among them and potential for incor-
support treatment was prevalent (e.g., function and disability. The resulting porating a bottom-up approach. Given
Ayres, 1972; Ayres & Robbins, 1979; International Classification of Functioning, examples are resolved using a bottom-up
King, 1974; Mosey, 1970, 1981) along Disability, and Health (ICF), much like the approach. However, the following state-
with pragmatic problem solving approach- ICIDH, aims to maintain the common lan- ment, “This document is not meant to
es (Schell & Cervero, 1993)1 very much guage for describing issues relevant to limit those in the field, formulating theories
embodying a bottom-up approach. In the health and allow for worldwide comparison or frames of reference, who may wish to
1970s, Mary Reilly and Elizabeth Yerxa of data and comprehensive coding (WHO, combine or refine particular constructs. It is
both argued that the profession needed to 2001). This version’s paradigm of health, also not meant to limit those who would
distance itself from dependency on the wellness, and context, embodies popular like to conceptualize the profession’s
medical model and began to promote occu- global concerns about function and dis- domain of concern in a different manner”
pations as the primary focus of intervention ability while still retaining a bottom-up (AOTA, 1994, p. 1) reflects the presence of
(Reilly, 1971; Yerxa, 1967). They proposed orientation. new ideas and constructs for problem anal-
the development of a comprehensive theo- Similar trends are mirrored by revi- ysis. This was indeed the case as occupation
ry for occupational therapy wherein there sions in the American Occupational based models had been developed but not
would be no need to rely on theories from Therapy Association’s Uniform Termin- accepted as a standard.
other disciplines, unlike the frame of refer- ology documents, specifically editions two A dramatic change in approach is evi-
ence model, thereby providing the ultimate through four. The first version, the dent the Framework (AOTA, 2002).
professional identity. This focus on occupa- “Occupational Therapy Product Output Described as filling a “need to reaffirm and
tions embodies the top-down approach. Reporting System and Uniform Termin- clarify what occupational therapy practice
During the past decade, the development ology for Reporting Occupational Therapy is all about” (Youngstrom, 2002, p. 607),
of occupational science has created an Services” document was published in 1979 this newest version of a uniform terminol-
increased emphasis of occupations as the to establish a uniform system for reporting ogy asserts occupation-based practice at the
primary concern of occupational therapy occupational therapy services in hospitals as core of assessment and intervention.
and the top-down approach as the “best” was mandated by the 1977 Medicare- Concepts such as performance patterns
method of evaluation. Medicaid Anti-Fraud and Abuse Amend- and activity demands are introduced
ments (AOTA, 1989). (AOTA, 2002), mirroring popular, top-
A second edition of the Uniform down models. Labels are better aligned
Changes in World Health Terminology was published in 1989 intent with terms in the ICF.
Organization (WHO) on defining occupational performance areas The evolution of the occupational
Classifications—Influences and components, and not replacing its first therapy uniform terminology has a forma-
on Uniform Terminology edition (AOTA, 1989). Occupational per- tive impact on occupational therapy pro-
In 1980, the WHO published the formance areas and components are orga- grams and their students. These defining
International Classification of Impairments, nized laterally, with the areas ordered as “I” documents are presented as the domain of
Disabilities, and Handicaps (ICIDH) as its and the components ordered as “II.” The concern of the profession. The most recent
first classification of disability to serve as a only description of their relationship is, version will ensure the proliferation of
“Performance components refer to the occupation-based concepts, even in schools
functional abilities required for occupa- with a strong bottom-up tradition.
1
An article entitled, “Assistive Devices for
tional performance . . . “ (AOTA, 1989,
Activities of Daily Living” by Helen Hopkins, p. 812). The lack of a hierarchical organi-
published in a 1960 American Journal of zation and the very ordering of the two Supporting Evidence—
Occupational Therapy exemplifies the use of concepts in the above statement leave
Which Approach Works?
pragmatic reasoning. In it, the author describes much leeway for the support of a bottom- Therapists evaluate to obtain data necessary
the process by which assistive devices are select-
up approach, which was indeed popular at for understanding the client and for plan-
ed and fabricated for individuals with functional
limitations, using knowledge about a client’s the time. ning appropriate interventions (Hinojosa
abilities and difficulties, along with the types and The third edition of the Uniform & Kramer, 1998). The way that a therapist
costs of materials available. Terminology, published by the American organizes and conducts an evaluation will
The American Journal of Occupational Therapy 595
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 determine the interventions the therapist rationalize continued reimbursement for Standardized, efficient tools are needed to
selects. Thus, the focus of an evaluation our services. accurately measure the effectiveness of
determines the goals and outcome of treat- When guided by a bottom-up interventions. In a description of occupa-
ment. Good outcomes indicate that the inter- approach, a therapist can measure changes tion-based curriculum, Yerxa (1998) makes
vention facilitated goal accomplishment. in performance skills with confidence by only one concession for the need of a bal-
Ultimately, client satisfaction with the level using a standardized assessment, operating ance between the study of occupations and
of functional performance, engagement in under the assumption that skills will gener- medical knowledge. Does the top-down
desired occupations, and objective determi- alize in to functional gains. Numerous approach provide that balance? Moreover, is
nation of safety while doing so, is of assessment tools have been developed and just a balance enough?
paramount importance and should be standardized to measure performance skills. Foundational factors in the bottom-up
included in the goals of therapy. These goals Two examples are the use of a dynamome- approach keep the therapist grounded in
are compatible with both the top-down and ter to assess grip strength and the Semmes- the very intricacies of physical, psychologi-
bottom-up approach to evaluation. Weinstein monofilaments to assess pressure cal, and cognitive function. When a client is
Some therapists argue that the top- sensitivity (Jones, 1989). The assured relia- assessed using a bottom-up approach, the
down approach and the focus on the bility and validity of those tools enables therapist’s focus is in the detailing of the
client’s occupation naturally leads to posi- practitioners to measure change in perfor- progress that is made. For example, subtle
tive client satisfaction outcomes. Even if mance skills as they relate to therapeutic changes in edema would be measured,
true, is client satisfaction adequate to sup- intervention. While component based recorded, and addressed even if its very
port the efficacy of an intervention? While assessments can provide valid information presence did not interfere with occupation-
client satisfaction is highly important, it about specific changes in client’s perfor- al performance. However, its timely control
may reflect spurious factors, such as the mance on specific tasks, they do not pro- may very well have prevented future func-
affability of the treating therapist. vide evidence about whether the person can tional limitations. The risk in using a bot-
Moreover, client satisfaction is subjective perform occupations and whether the inter- tom-up approach lies if and when the prac-
wherein integral points, such as safety, may ventions relate to the person’s life. titioner fails to connect the foundational
not have been considered. Thus, client sat- To better determine the impact factors to occupational performance.
isfaction alone is important but not ade- approach has on successful outcomes, an
quate for establishing the efficacy of an experimental design with a random sam-
intervention. When examining top-down ple, stratified for different diagnoses, is Considering the Bigger Picture
occupation-based goals, we are challenged indicated, using approach as an indepen- Occupations were the prevalent assump-
due to the dearth of valid and reliable tools dent variable and one standardized assess- tions during the inception of occupational
to measure occupations. Tackling the ment tool for measurement. Without such therapy. The changing philosophical
philosophical question as to whether occu- a comprehensive design, comparison of the assumptions of leaders of the profession
pations can really be measured, Law writes bottom-up and top-down approaches is such as Reilly and Mosey have affected
that occupations can be assessed in a variety rough at best. those of the profession. Finally, social
of ways, namely through informal inter- change in the 1960s, when many prevalent
views, a narrative or life history, metaphor, paradigms were challenged, provided a fer-
semistructured interviews, and health or Inherent Challenges tile environment for philosophical innova-
functional status questionnaires (1998).
in Each Approach tion. These changes in philosophical
Many of the above methods are highly sub- The resurgence of occupations as a prima- assumptions, influenced as they were, have
jective and not standardized. The ry focus of the profession is significant and contributed to the alternating rise and fall of
Canadian Occupational Performance positive. This very special and unique the bottom-up and top-down approaches.
Measure (COPM) (Law et al., 1998) is a aspect of occupational therapy has taken a Over the years and throughout the lit-
semistructured interview that has demon- backseat for many years, much to our col- erature, the discourse regarding both
strated strong test–retest reliability and lective loss. However, top-down approach- approaches has included strong, differing
responsiveness to change (Law, 1998), but es centered in occupations do present opinions. A virtual chasm has resulted
is lengthy to administer. The Self-Identified some challenges if not limitations. between the two schools of thought with
Goals Assessment (SIGA) (Melville, Baltic, Occupation-based practice does not the top-down proponents currently enjoy-
Bettcher, & Nelson, 2002) designed for use address time-based priorities such as a ing greater popularity supported by the
in subacute rehabilitation in nursing homes burn, which requires immediate concen- Framework (AOTA, 2002). Despite indi-
has yet to be standardized. The difficulty in tration on the injury even prior to assess- vidual preferences for one approach over
effectively and efficiently assessing changes ment of occupations. In some cases, exclu- the other, it is the ultimate goal of thera-
that result from therapeutic interventions sive use of occupation-based practice can peutic intervention to encompass both
undermines the validity of what we do. A be detrimental to the client. poles of the component–function continu-
direct relationship between intervention Assessment of occupation-based inter- um, wherein, both the “top” and “bottom”
and result needs to be demonstrated to vention still has room for growth. of an individual’s functional limitations are
596 September/October 2004, Volume 58, Number 5
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 Bottom-Up Approach Top-Down Approach

Models/Theories Incorporating Each Approach • Frames of Reference (Mosey, 1970, 1986) • Occupational Science (Clark et al., 1991)
(The following include some examples of the • Sensory Integration (Ayres, 1972) • Model of Human Occupation (Kielhofner, 1997)
given category. There are many other models not • Neurodevelopmental (Bobath, 1979) • Occupational Behavior (Reilly, 1962)
included) • Movement Therapy (Brunnstrom, 1966, 1970) • Client-Centered Occupational Therapy (Law,
• Proprioceptive Neuromuscular Facilitation 1998)
(PNF) (Voss, Ionta, & Myers, 1985) • Activities Health Model (Cynkin & Robinson,
• Motor Relearning (Carr & Shepherd, 2003) 1990)
• The Person-Environment-Occupational
Performance Model (Christiansen & Baum,
1997)
• Occupational Adaptation (Schkade & Schultz,
1992; Schultz & Schkade, 1992)
• Task-Oriented Approach (Bass-Haugen &
Mathiowetz, 2002)
• Occupational Therapy Intervention Process
Model (Fisher, 1998)

Unique Strengths • Easily incorporated with all clients, even those: • Is most synonymous with the roots of the
without insight, unable to articulate occupa- profession.
tions, without family to do so, nor for whom • Provides occupational therapists with knowl-
the process of learning to express desired edge of our supposed area of expertise—
occupations would be meaningful (Law, 1998). occupations so that we can best address them
• Compatible with the biomedical team philoso- (Christiansen & Baum, 1997).
phy (Law, 1998). • Focuses the occupational therapist on the
• Appropriate for time sensitive physical disabili- holistic.
ty, in which immediate and/or focused interven- • Identifies clients with occupational dysfunction,
tion is integral (i.e., fracture or burn). but not necessarily medical needs or disease, a
• Often directed by applied scientific inquiry, category of clients often missed with other
appropriate and ready for clinical use. models (Rogers, 1982).
• Engenders theoretical autonomy.

Limitations • Frames of Reference utilize theory from other • There have been difficulties noted in assess-
disciplines, never becoming fully independent ment and implementation of some models in
and self-sufficient. this approach (Law, 1998).
• Some models in this approach embody basic
science—not readily applicable for use.

Figure 1. Comparison of bottom-up and top-down approach

reached and successfully achieved or at least ing discussion between the two schools of The one constant throughout our collective
addressed. Both have advantages that are thought is a disagreement on how best to evolution is the focus of occupational ther-
critical for occupational therapy evaluation organize the dilemmas presented by a par- apy: the goal that clients reenter society,
and intervention (see Figure 1). ticular client(s) to plan a course of treat- whatever that may mean in a given decade
In Educating the Reflective Practitioner, ment to obtain the best results. Attaching a or century. In the early years of occupation-
Schon (1987) describes how various disci- label to this concept facilitates its conceptu- al therapy the promotion of occupations
plines set or frame problems that they alization by the general population of occu- and adaptive habits was reflective of the
encounter. For the purposes of this discus- pational therapists. Moreover, after experi- societal norms of that time period—the
sion, we have labeled and defined the con- encing the expressions of a sharp divide in concept of “clean habits” (Mosey, 1986)
cept of problem framing as a cognitive pro- the literature, it is our hope that uniting and the arts and crafts movement. The
cess by which a health care practitioner both approaches under a common label can answers to existential questions of what it
mentally structures the limitations experi- soften the lines of demarcation, promote means to be productive, spiritual, and ful-
enced by a client, incurred by a functional understanding, and lead to the develop- filled vary from one generation to the next;
difficulty or medical dilemma, into a work- ment of a unified, integrated, and more thereby changing the definition of success-
able configuration to facilitate appropriate effective approach. ful, societal reentry from generation to gen-
intervention. We believe that differing Another element to appreciate is that eration and reflecting relevant social, politi-
opinions regarding the bottom-up and top- occupational therapy embodies a profession cal, and religious trends.
down approaches are essentially different of change tempered by constancy. Changes Occupational therapists are the ulti-
modes of problem framing based on differ- have occurred in the settings we work in, mate adaptors; we have flourished as a pro-
ing philosophical assumptions. The ongo- the tools we use, and the clients we treat. fession because of our ability to incorporate
The American Journal of Occupational Therapy 597
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 social change and assimilate the challenges the spirit face imminent harm and hinder- References
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Acknowledgments Clark, F. A., Parham, D., Carlson, M. E., Frank,
flawed. It is time that clients are not sub- Much appreciation to Dr. Mary Donohue G., Jackson, J., Pierce, D., et al. (1991).
Occupational science: Academic innova-
jected to the changing climates of contem- for planting seeds of curiosity about
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or contextual; in a truly “client-centered” Segal for her insightful comments on an Occupational therapy and activities health:
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screening examines health circumstance in and Phyllis Mirenberg for their guidance in Fisher, A. G. (1998). 1998 Eleanor Clarke Slagle
which structures of the body or aspects of the early stages of writing this paper. lecture: Uniting practice and theory in an

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