Biomechanical Frame Of Reference Case Study

Analysis approaches and interventions with occupational performance

Sinae Ahn, PhD, OT1

1) Department of Occupational Therapy, Yeoju Institute of Technology, Republic of Korea

Corresponding author. Sinae Ahn, Department of Occupational Therapy, Yeoju Institute of Technology: 338 Seajong-ro, Yeoju-si, Gyeonggi-do 469-705, Republic of Korea (E-mail: moc.liamg@nsevolto)

Author information ►Article notes ►Copyright and License information ►

Received 2016 Apr 7; Accepted 2016 May 31.

Copyright 2016©by the Society of Physical Therapy Science. Published by IPEC Inc.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License.

J Phys Ther Sci. 2016 Sep; 28(9): 2681–2683.

Published online 2016 Sep 29. doi:  10.1589/jpts.28.2681


[Purpose] The purpose of this study was to analyze approaches and interventions with occupational performance in patients with stroke. [Subjects and Methods] In this study, articles published in the past 10 years were searched. The key terms used were “occupational performance AND stroke” and “occupational performance AND CVA”. A total 252 articles were identified, and 79 articles were selected. All interventions were classified according to their approaches according to 6 theories. All interventions were analyzed for frequency. [Results] Regarding the approaches, there were 25 articles for studies that provided high frequency interventions aimed at improving biomechanical approaches (31.6%). This included electrical stimulation therapy, robot therapy, and sensory stimulation training, as well as others. Analysis of the frequency of interventions revealed that the most commonly used interventions, which were used in 18 articles (22.8%), made use of the concept of constraint-induced therapy. [Conclusion] The results of this study suggest an approach for use in clinics for selecting an appropriate intervention for occupational performance.

Key words: Approach, Occupational performance, Stroke


Participation in occupational performance can improve daily life1, 2). To increase the meaningful occupational performance of stroke patients, the execution of tasks in the home and community should be assessed. Furthermore, it is important to put the loss of occupational performance in context. Interventions must be provided that take into consideration these points to enable improvements in actual occupations. Interventions should be provided in this way for the purpose of participating in actual occupational performance, and based on an understanding of its effects on occupational performance. Recently, virtual reality treatment, robot rehabilitation, mirror therapy, and mental practice have also been proposed as novel intervention methods2). These intervention methods include an approach based on various conceptual practice theories. Appropriate intervention methods can be selected according to the approach, based on the desired result. Thus, there is a need to classify and analyze the interventions provided for occupation performance. This research identified the types of interventions and the approaches of conceptual practice theories most commonly used for occupational performance in stroke patient. By doing this, it also provided information about the research trends related to occupational performance.


Through a thorough literature search, studies comparing the effects of interventions related to occupational performance in stroke patients were collected. Articles published in the past 10 years were searched in PubMed. The search terms used were “occupational performance AND stroke” and “occupational performance AND CVA”. Original articles that were published in academic journals, written in English, based on research in stroke patients, and related to occupational performance were searched. Through this method, a total of 252 articles were identified. The title and abstract of each article were checked, and full documents were checked as required. A total of 79 articles that fulfilled the inclusion and exclusion criteria were selected.

The hierarchy of levels of evidence for evidence-based practice was used to evaluate the qualitative criteria of the evidence in this study3). In addition, this study conducted frequency analysis to identify the frequency of intervention. The intervention methods used in the selected article were classified according to the 6 approaches defined by Keilhofner: the biomechanical approach, cognitive disability approach, cognitive-perceptual approach, group work approach, model of human occupation, and motor control approach4).


As a result of analyzing the qualitative characteristics of the evidence, the articles were divided into five groups: 38 articles (48.1%) were classified as randomized controlled trials (RCTs), 6 articles (7.6%) were classified as non-randomized comparative group studies, 14 articles (17.7%) were classified as non-randomized single-group studies, 7 articles (8.9%) were classified as single experimental studies, and 14 articles (17.7%) were classified as case studies; thus, the majority of studies were RCTs. The results of analyzing the frequency of intervention to find the intervention method most commonly used in the 79 articles are shown in Table 1. Eighteen articles (22.8%) used constraint-induced therapy (CIT); 8 articles (10.1%) used video feedback; 7 articles (8.9%) used Cognitive Orientation to daily Occupational Performance (CO-OP), electrical stimulation, and repetitive task therapy; 6 articles (7.6%) used the structural goal setting and client-centered approach, 4 articles (5.1%) used robot therapy, 3 articles (3.8%) used motor imagery and sensory stimulation training; and 2 articles (2.5%) used cognitive remediation therapy, computer-based training, mirror therapy, and prism glasses therapy. There was also 1 article that used interactive metronome training and 1 article that used group-based support training. The results of analyzing the intervention methods used for occupational performance according to the approaches defined by Keilhofner are shown in Table 2. There were 25 articles (31.6%) for studies that provided interventions according to the biomechanical approach. This included electrical stimulation, repeated task training, robot therapy, sensory stimulation training, interactive metronome training, and therapies involving orthoses, the pursuit rotor task, and botulism toxin injections. Twenty articles (25.3%) described provision of interventions according to the cognitive-perceptual approach. This included video feedback, motor imagery, cognitive remediation therapy, computer-based therapy, mirror therapy, and dynavision training of driving. Eighteen (22.8%) articles provided interventions according to the motor control approach. This included distributed constraint-induced therapy (dCIT), constraint-induced therapy combined with trunk restraint (CIT-TR), and modified constraint-induced movement therapy (mCIMT). Ten (12.7%) articles provided interventions based on the cognitive disability approach, in which CO-OP and compensation method training were included. Four (5.1%) articles focused on the client-centered approach and goal setting based on the model of human occupation. One (1.3%) article involved group-based support training as part of the group work approach, and 1 (1.3%) article focused on occupational rehabilitation training.

Table 1.

Frequency of therapeutic interventions used for occupation performance (N=79)

Table 2.

Analysis of therapeutic interventions according to approaches (N=79)


This research analyzed therapeutic interventions most commonly used in studies related to occupational performance in stroke patients according to the approaches of conceptual practice theories and considered a systematic method for the type and frequency of the interventions. Many studies included in the analysis were classified as RCTs according to their qualitative characteristics. RCTs have the best qualitative characteristics, with guaranteed independence of variables and randomization5). The interventions that were most commonly executed as RCT studies were CIT, video feedback, the client-centered approach, repetitive task training, and robot therapy. Excluding the client-centered approach from the interventions above, the RCTs intervention methods were all associated with the frame of biomechanical theory and were targeted at physical recovery. Many studies can be executed for a lot of participants, and it is thought that performing RCT studies through randomization is appropriate, because the intervention method is easy to use in therapy settings and to apply for a lot of participants in actual clinic.

The therapeutic intervention most commonly investigated in single-subject studies and case studies was the CO-OP approach. The CO-OP approach must be applied in the client’s actual environment and according to the goals decided by the client, so the client selects his/her. For this, the client selects their own desired activity goals6). For these reasons, the CO-OP approach is not suitable for RCTs. The CO-OP approach requires that therapist spend a lot of time and effort working with subjects, and this likely explains why the numbers of subjects in the studies using this approach were small. Most studies related to occupational performance provided information according to the biomechanical approach. Intervention based on the cognitive perception approach and motor control approach were used the next most often. The intervention method most commonly used was CIT, which corresponds to the motor control approach. In CIT, the strategy of constraining the non-affected upper extremity during actively engaging the upper extremity affected by hemiplegia in intensive task-orientated practice was an integral treatment component6).

Nevertheless, these approaches had the tendency to separate actions from their relationship with the background or daily life of the clients, whereas the top-down approach and relative background should be provided for occupational performance. The top-down approach applies a client-centered and occupation-based method with the purpose of improving participation6, 7). Furthermore, because each person has a different background, tailoring the strategy training according to the client can be more effective than functional training. Therapies for occupational performance should be applied with evaluations and interventions according to the goals of the client. This study did not include all studies that included the concept of occupation because it used only two main search terms for the search process. Thus, future studies should use additional search terms for a wider search to enable assessment of more research papers. In summary, this study provided information about research trends related to occupational performance and detailed intervention methods based on occupational performance. There is a need to perform interventions that focus on occupational performance by considering the context of the client.


1. Kramer SF, Churilov L, Kroeders R, et al. : Changes in activity levels in the first month after stroke. J Phys Ther Sci, 2013, 25: 599–604. [PMC free article][PubMed]

2. Silva SM, Corrêa FI, Faria CD, et al. : Psychometric properties of the stroke specific quality of life scale for the assessment of participation in stroke survivors using the rasch model: a preliminary study. J Phys Ther Sci, 2015, 27: 389–392. [PMC free article][PubMed]

3. Kielhofner G: Conceptual foundations of occupational therapy practice. Philadelphia: F. A. Davis, 2009.

4. Portney LG, Watkins MP: Foundations of clinical research: applications to practice. New York: Pearson Education, 2008.

5. Toglia J, Goverover Y, Johnston MV, et al. : Application of the multicontextual approach in promoting learning and transfer of strategy use in an individual with TBI and executive dysfunction. OTJR: Occupation, Participation and Health. Win, 2011, 31: S53–S60. [PubMed]

6. Doucet BM, Woodson A, Watford M: Moving toward 2017: progress in rehabilitation intervention effectiveness research. Am J Occup Ther, 2014, 68: e124–e148. [PubMed]

7. Sansonetti D, Hoffmann T: Cognitive assessment across the continuum of care: the importance of occupational performance-based assessment for individuals post-stroke and traumatic brain injury. Aust Occup Ther J, 2013, 60: 334–342. [PubMed]

Articles from Journal of Physical Therapy Science are provided here courtesy of Society of Physical Therapy Science

Occupational therapist uses the biomechanical frame of reference in orthopedic cases, burn cases and patients with limited range of motion and strength. The Biomechanical frame of reference is based on Joint range of motion, Muscle strength, and Endurance with the intact central nervous system.

In the last article, we have explained you about Frame of reference, it’s better to understand the basic terminology before reading the specific type of Frame of reference. If you are not familiar with the term, we suggest to read it first.
Occupational therapy frame of reference

Occupational therapist uses frames of references for guiding their practice. Occupational therapist (OT) uses purposeful activities to treat their clients, purposeful activities have some purpose and meaning to the life. OT develops the method to integrate purposeful activities and their treatment goals.

Analysis of joints and muscles during an activity is the base of the Biomechanical frame of reference. This analysis helps OT to plan and check the progress, whether goals are achieved or not.

Theoretical base-

The biomechanical frame of reference has four assumptions (by Dutton)
The first assumption is the belief that the purposeful activities can be used to treat loss of range of motion (ROM), strength, and endurance.

The second assumption is the belief that after ROM, strength, and endurance regained, the patient automatically regains function.

The third assumption is the principle of Rest and stress. First, the body must rest to heal itself. Then, the peripheral structure must be stressed to regain range, strength, and endurance.

The fourth assumption is the belief that the biomechanical frame of reference is best suited for patients with an intact central nervous system. Patients may have limited range, strength, and endurance, but have the ability to perform smooth, isolated movements.

Function – Dysfunction continua

This part of biomechanical frame of reference focuses on concern areas or problem areas. Concern areas of this frame of reference are –
1. Structural stability, 2. Passive Range of motion, 3. Low level endurance
4. Edema control, 5. Strength, and 6. High level endurance.

These areas should be focused by an occupational therapist while assuming biomechanical frames of reference in the treatment plan.

Structural stability assumed as a primary concerned area after that only, therapist can stress peripheral structures (muscle stretching). In a fracture case, bone and soft tissue healing, consider as structural stability.

And, high level Endurance should take care of at the end of treatment planning. Low level endurance training can be initiated along with low resistance activities to boost repetition.

Behaviors Indicative of Function –Dysfunction (Guide for Evaluation)

Above mentioned “concerned areas” can be assessed by the occupational therapist. In Biomechanical evaluation OT uses different tools for assessment like Goniometer for Joint range of motion, Volumetry for edema, and manual muscle testing for strength. Along with these formal tests, OT also does clinical observation, including Skin’s appearance, End feel during range of motion and grip strength.

Low level and high level endurance can be assessed by using cardiac step chart and metabolic equivalents chart (MET). After the formal and informal assessment, OT set the objectives and goals for the patient.

Postulates regarding change–

Postulates regarding change identify links among the presenting problems, biomechanical goals, and functional outcomes.

For Example, a patient who is a writer fell down on his hand and the radius bone got fractured (right side).

General Deficit / Present problemLoss of joint range of motion
Biomechanical GoalsSupination of forearm 70 degrees
Pronation of forearm 70 degrees
Wrist extension 70 degrees
Functional OutcomeAbility to hold a pen and write with wrist extended and forearm pronated.

In the above example, the patient doesn’t care about 10-15 degree improvement in wrist extension; he must be more concerned about his writing abilities for the long duration.

Postulates Regarding Intervention-

Postulates regarding intervention create links between biomechanical goals and therapeutic activities.

For example,

Measurable Biomechanical GoalsSupination of forearm 70 degrees
Pronation of forearm 70 degrees
Wrist extension 70 degrees
General Treatment MethodIt consists of heat, manual stretch and splinting. Which increases elasticity of the skin, elongates collagen fibers and position of the joints in functional position
Functional ActivitiesInvolve him/her in writing task.

In the above example, both of these, general & functional activities, helps OT to achieve better client oriented result.
In the biomechanical frames of reference, it’s easy to develop measurable biomechanical goals because this frame of reference uses quantitative evaluation data such as degree of range of motion.

Other frames of reference may be used along with the biomechanical frame of reference for the better result, it depends upon the condition and need of a client.

Read More…

Developmental Frame of Reference

Model of Human Occupation (MOHO)

Rehabilitative Frame of Reference

Psychodynamic Frame of Reference

1. Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction
2. Willard and Spackman’s Occupational Therapy
3. Frames of Reference for Pediatric Occupational Therapy by Paula Kramer

Theory and PracticeFOR, intervention, occupational therapy, Theories

0 Replies to “Biomechanical Frame Of Reference Case Study”

Lascia un Commento

L'indirizzo email non verrà pubblicato. I campi obbligatori sono contrassegnati *