FROM THE DESK OF THE ASSOCIATE EDITOR

Occupational Therapy in Chronic Progressive Disorders:

Enhancing Function and Modifying Disease
MeSH TERMS
 chronic disease
 human activities
 motor activity
 occupational therapy

Ashwini K. Rao

Rao, A. K. (2014). From the Desk of the Associate EditorOccupational therapy in chronic progressive disorders:
Enhancing function and modifying disease. American Journal of Occupational Therapy, 68, 251253. http://dx.doi.
org/10.5014/ajot.2014.012120

Ashwini K. Rao, EdD, OTR, FAOTA

Ashwini K. Rao, EdD, OTR, FAOTA, is Associate

Professor of Rehabilitation and Regenerative Medicine
(in the Sergievsky Center) Columbia University Medical
Center, New York, NY; akr7@cumc.columbia.edu

major goal of occupational therapy is

to improve health and participation of
clients through engagement in occupation.
According to the American Occupational
Therapy Association (AOTA; 2007), occupation includes engaging in activities of
daily living, instrumental activities of daily
living, education, work, play, leisure, and
social participation.
AOTAs strategic planning initiative
for the Centennial Vision in 2017 resulted
in the following shared vision statement:
We envision that occupational therapy is
a powerful, widely recognized, science-driven,
and evidence-based profession with a globally
connected and diverse workforce meeting
societys occupational needs (AOTA, 2007,
p. 613). Occupational therapy researchers
have engaged with two elements of the vision statement in particular, namely, helping occupational therapy develop into (1)
a science-driven and (2) an evidence-based
profession. The efforts, partially reflected in
articles published in the American Journal
of Occupational Therapy, have begun to
clarify outcome measures that are valid,
reliable, sensitive, and easy to use in clinical
settings. The efforts are also beginning to
clarify the effectiveness of occupational
therapy in chronic disorders.
Implicit in the Centennial Vision is
that occupational therapy must evolve
with changes in medicine and health
science. In this editorial, I present some
recent advances in health science and

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neuroscience that have considerable implications for occupational therapy research

and practice.

Physical Activity and

Mortality in
Chronic Disorders
Recently the British Medical Journal published an important meta-analytic study
comparing the effectiveness of exercise and
drug interventions on mortality outcomes
in chronic disorders (Naci & Loannidis,
2013). The study examined 305 published randomized controlled trials (total
of 339,274 participants), of which 57 trials
(total of 14,716 participants) included physical activity as an intervention. No statistically significant differences in mortality
outcomes were found when comparing
physical activity and drug intervention in
prevention of coronary heart disease and
prediabetes. Note that physical activity
was more effective than drug intervention
for individuals who had a stroke.
This meta-analysis is important for
several reasons. It is the first study to examine the impact of physical activity on
mortality, which traditionally has not received the same attention as medical or
surgical interventions. Second, level of physical activity is a modifiable factor, despite
the fact that population-level physical activity is reported to be low. The American
College of Sports Medicine (ACSM) has
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recommended at least 30 min of moderateintensity activity daily (Nelson et al.,

2007). In the United States, less than
50% of adults meet the guidelines for
physical activity (National Center for
Health Statistics [NCHS], 2013).

Physical Activity as
a Disease Modifier
Over the past few years, physical activity has
been recognized for its importance as
a disease modifier for chronic diseases, such
as Alzheimers disease (AD). In AD and in
its prodrome, mild cognitive impairment,
there is evidence of loss of neuronal volume in the hippocampus (which is implicated in memory) and the prefrontal cortex
(which is important for executive function;
Erikson, Weinstein, & Lopez, 2012). Recent work has revealed a relationship between engagement in physical activity and
reduced incidence of developing dementia
(Buchman et al., 2012; Sattler, Erickson,
Toro, & Schroder, 2011). Although the
greatest reduction in dementia risk occurred in people who were physically active
as young adults, reduction of dementia risk
was also seen in older adults who became
physically active later in life (Middleton,
Barnes, Lui, & Yaffe, 2010). Physical activity was also reported to improve cognitive function and delay the onset of AD in
people with mild cognitive impairment
(Lautenschlager et al., 2008). Thus, it appears that engaging in physical activity has
benefits in reducing dementia risk irrespective of the age at which physical activity begins.
The beneficial effects of physical activity are partially mediated through
modification in the size of brain areas that
typically diminish with aging, such as the
hippocampus (Bugg & Head, 2011). Physical activity preserves the volume of the
prefrontal cortex in older adults (Weinstein
et al., 2012). Thus, it appears that physical
activity provides protective benefits by altering brain physiology.
There is also emerging evidence for the
benefits of exercise as a disease modification
agent in Parkinsons disease (PD; Petzinger
et al., 2011). PD is a chronic disorder
characterized by neuronal loss of dopami-

nergic cells in the substantia nigra (pars

compacta), a nucleus of the basal ganglia
(Kandel, Schwartz, Jessell, Seigelbaum, &
Hudspeth, 2013). Loss of dopaminergic
cells leads to symptoms of bradykinesia,
rigidity, resting tremor, and gait and balance impairments, which affect functional
independence. Using a mouse model of
PD, a recent study demonstrated that intensive treadmill exercise improved motor
performance by modifying dopamine
transmission (Petzinger et al., 2007).
Engagement in physical activity not
only preserves volume of certain brain regions
but also has the potential to modify neural
transmission. According to researchers, physical activity needs to involve skill learning,
with high level of complexity, intensity, and
repetition (Petzinger et al., 2011). All of
these factors are typically evaluated and manipulated by occupational therapists during
activity analysis.

therapy (which included environmental

enrichment in the form of engagement in
social play) and control (which included
solitary activity without enrichment). In the
enriched mice, volume of the striatum was
preserved, and onset of motor impairments
was delayed, leading van Dellen et al. to
suggest that occupational therapy based on
the principles of environmental enrichment
may have a similar effect in humans.
Studies led by occupational therapists
have shown that occupational therapy
consisting of lifestyle intervention can help
prevent the loss of function typically seen
in aging (Clark et al., 2001, 1997, 2012).
The Clark et al. studies have demonstrated that embedding occupational
therapy interventions in the daily routines
of independently living older adults has
a tremendous benefit in improving independence and delaying or preventing
loss of function.

Implications for
Occupational Therapy

Conclusion

Even with all the benefits of physical activity, it appears that changing behavior to
include higher levels of physical activity
is harder than one might expect, given
that less than 50% of adults engage in
recommended levels of activity (NCHS,
2013). According to Marteau, Hollands,
and Fletcher (2012), people typically engage
in two categories of behavior: reflective
and automatic. They proposed that longterm behavioral change is possible only if
activity becomes part of automatic routine behavior.
Evidence for this proposal can be seen
in a study that used an animal model of
Huntingtons disease (HD), a fatal, degenerative disorder that leads to a loss of
neurons in the striatum, which are part of
the basal ganglia. The disease is characterized by motor, cognitive, and behavioral
impairments that lead to functional dependence and reduction in quality of life.
As with PD, HD has no cure, and pharmacological intervention only provides
symptomatic relief. van Dellen, Blakemore,
Deacon, York, and Hannan (2000) randomized mice with the HD gene mutation
to one of two interventions: occupational

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Converging lines of evidence suggest that

engagement in functional activity as part
of our daily routine may not only improve
function but also have important diseasemodifying benefits. Given the expertise
that occupational therapists have in
using functional goal-oriented occupations, occupational therapists have an
emerging role in disease modification and
prevention. s

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