Are Pegs Really Occupational Therapy?

What I did not realize was that the field was changing. In my geographical area, all but one of our state residential mental health facilities were in the process of closing the year that I graduated. Only one of our local hospitals used full-time occupational therapy services in their behavioral units. No job opportunities existed in mental health for occupational therapy practitioners. Most of the jobs available were in-patient rehabilitation, skilled nursing, home health and outpatient. This was also exciting to me because I would have the opportunity to help individuals through their recovery and rehabilitation, so I took a job in in-patient rehabilitation. 

I remember that the OT department was stocked full of puzzles, games, pegs, electric razors, adaptive equipment for ADLs, as well as hot packs, paraffin bath and a fully working kitchen. This was what I expected, but I was a little surprised at how much everyone used the wrist weights, therabands, theraputty, and pulleys. On the job, I was taught to carry out upper body rote exercises, lots of pegs, arm bikes, arm pulleys and cones. I quickly forgot my training in stacking cans in cabinets, folding laundry, and washing mirrors and cabinets in order to facilitate upper extremity strengthening. It just became a habit to explain to my clients why we were doing the shoulder arc and pegs with weights on their wrists. It became a habit to convince my clients why they needed these interventions. It became a habit to explain to families why these interventions would be helpful. I did not question why I was not using my previous training, I did not question the “rules” for medical necessity. I did not question anything because people were recovering and returning to their prior levels of function. There seemed no need to question it. Before you know it, it was just my habit to utilize these interventions over and over again.

Fast forward to 2012, my first weekend of the OT bridge program. One of the professors stated that “working with pegs was not occupational therapy”. It seemed like the entire room fell silent instantly, then came the disagreements from the class, to be honest I disagreed as well. How could this be? Pegs are a therapeutic activity to increase fine motor coordination; we can modify them to increase upper extremity range of motion and strength and even use them for visual-perceptual and cognitive activities. Right? It took me half of a semester to begin reconsidering my position on pegs. As we delved into the occupational therapy models and frameworks now supported with an abundance of research, I began to feel flickers of past excitement for my profession and realized the hard reality that I should have questioned those interventions I had previously been using. I realized that I had not even tried to use occupation-based interventions in quite a long time. It is as if I had just somehow accepted that OT as I learned it in occupational therapy assistant school didn’t really exist. I realized that I had not been looking at the current research, I was not using evidence-based practice. As I progressed through the bridge program, I was exposed to more and more research that supported all that I had previously learned regarding the use of occupations therapeutically and the benefits of focusing on engagement in meaningful occupations. It took me almost the entire program to change my opinion, all the while that flicker was being fueled and became a fiery passion for my profession.  

I am changed, hopefully for good. I now see that self care activities can be both the goal but also the modality. I understand that health management is an important occupation to be addressed. It became clear to me that if I had to convince someone why they are doing something, it was not meaningful to them. I now avoid burdening my clients to learn a new exercise or peg activity and then expect them to translate that skill into a functional activity like opening a water bottle or tying a shoe. Now I just work on grading the activity of tying a shoe as well as opening water bottles. I feel comfortable giving my clients the choice of how to address upper body strength, coordination, and balance. For some clients rote exercise is a meaningful occupation, but most of my clients choose activities such as folding laundry, putting dishes into cabinets and simply washing themselves or combing their own hair to improve factors such as coordination, strength, or balance. The client chooses to work on the areas that they are most concerned about. I now feel comfortable explaining to my clients how research supports the strategies I recommend. I now have very few clients decline occupational therapy services, I no longer find myself convincing my clients or their loved ones to participate in occupational therapy. I see significantly improved client engagement because they are directing their own care. I see improved outcomes including improved self-management of their chronic conditions. I now realize that psychosocial interventions are medically necessary when mental health impacts self-care and health management and I see the benefits of addressing it. Most of all, I feel more fulfilled in my clinical practice than I ever have.  I have not utilized pegs, a shoulder arc or arm bike in my treatment in over 7 years and I can’t imagine using them again.

AOTA’s first of Five Things that Patients and Providers Should Question is “Don’t provide intervention activities that are non-purposeful (e.g., cones, pegs, shoulder arc, arm bike)”.

I am grateful to have AOTA make this public statement to provide me as an occupational therapy practitioner a rationale for providing occupation-based treatment. But it also causes me to regret the years that I provided these very interventions. I often wonder how many of my past clients could have been better served had I not utilized these interventions. What if I had been more evidence informed? But I can’t change the past, you can’t change the past. But we can each change the present and future for our clients. Niccole and I created Aspire OT to empower other occupational therapy practitioners to not only better serve their clients, but to help them fuel their OT fires.  Together we can change the future for ourselves and our profession. 

For more information:  AOTA’s Choosing Wisely recommendations.

Gillen, G., Hunter, E. G., Lieberman, D., & Stutzbach, M. (2019). AOTA’s top 5 Choosing Wisely® recommendations. American Journal of Occupational Therapy, 73, 7302420010. https:// doi.org/10.5014/ajot.2019.732001