Occupational Therapist (OT)
Biomechanical Approaches
Top-Down vs Bottom-Up Approach

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Top-Down vs Bottom-Up Approach

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Top-Down vs Bottom-Up Approach

Top-Down Convertible vs Bottoms-Up
There are two approaches occupational therapists use to guide their thinking when working with a client, top-down or bottom-up. The bottom-up approach is commonly seen in the medical profession and focuses on the client’s losses or deficits that have occurred. Client factors and functional skills are considered last with the bottom-up approach focusing instead on remediation, restoring or acquiring new skills to address the dysfunction. On the other hand, a top-down approach assesses a client’s functional engagement, their skills and contexts in relation to their activities of daily living, or occupations, and then develop a treatment plan based on their ability to participate in those occupations instead of looking at their deficits.
Whole-istic Human

This top-down approach is holistic, meaning that it views the client as a whole instead of as several different parts. It conceptualizes that each part is interdependent upon one another, and all are important in their own way. As the occupational therapist gains an understanding of these intersecting parts, they are able to create a client-centered intervention that not only targets remediation or restoration of what was lost but also helps them understand their strengths and empowers the client to develop skills that help with occupational engagement.

Often Compared to Biopsychosocial Models

This top-down approach is often contradictory to most medical-based models, such as the Biomechanical FOR, and instead aligns with Biopsychosocial Models, such as Cognitive Behavioral Therapy. This approach views the client’s roles and their desired goals first instead of focusing on their deficits or diagnoses.

Client-Centered Occupation-Based Approach
Client in the Center

A client-centered approach has the client involved in their own recovery. The occupational therapist guides the client to seek and rely upon their own strengths to change.

Client Sets Goals
Client Setting Goals

This approach believes that all patients have self-actualizing tendencies or desires to fulfill their potential to become the best they can be. They are tasked with identifying roles, tasks, and occupations that are meaningful. Then they work with the occupational therapist to write goals that target these meaningful occupations.

Compensatory Strategies
Compensation for Strategic-game of Chess

Compensatory strategies are either techniques or modifications of task demands that are used to avoid or in place of dysfunction.

Remediate Deficits
Fixing Deficit

The bottom-up approach focuses on acquiring new skills, remediation of lost skills, and restoring deficits. Client contexts, roles, and existing performance skills are considered secondary to these restorative techniques.

Based on Traditional Medical Models
Old Traditional Medical Model

This bottom-down approach is in alignment with most medical-based models, such as the Biomechanical FOR, and contradictory to Biopsychosocial models, such as Cognitive Behavioral Therapy(CBT). This approach views the client’s roles and their desired goals last and, instead, focuses on their deficits or diagnoses.

Therapist Sets Goals
Therapist Setting Goals

When using the bottom-up approach, the occupational therapist sets the goal. These goals target the deficits that have been identified.

Restorative Strategies
Restoring Strategic-game of Chess

Restorative strategies are used to restore previous function through participation in activity. The occupational therapist uses these restorative strategies and grades the activities up or down, gradually increasing task demands in order to return the client to optimal performance.


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