Integrating the Dynamical Systems Theory,

the Task-Oriented Approach, and the Practice

Framework for Clinical Reasoning
Kathleen E. Yancosek, PhD, OTR/L, CHT
Dana Howell, PhD, OTD, OTR/L

ABSTRACT. This paper describes the purposeful integration of dynamical systems

theory, the occupational therapy task-oriented approach, and Framework II to inform
clinical reasoning. Dynamical systems theory provides the clinician with information
about how systems interact to influence motor behavior. The task-oriented approach
helps the practitioner to clinically improve motor behavior. Framework II gives the
clinician guidance in terms of scope of practice and an overarching goal of intervention.
Ideological similarities between these three resources for clinical reasoning include
client-centeredness, an emphasis on occupation, and interaction between person, task,
and environment. The process of clinical reasoning is illustrated using an integrated
practice model applied to a clinical example of an adult with a hand injury requiring
transfer of hand dominance.
KEYWORDS. Hand dominance transfer, handwriting, model of practice

Occupational therapy practitioners may rely on several key resources to guide their
clinical reasoning. Ideally, rehabilitation intervention strategies emerge from theory,
and the professional advances through refinement and application of testable theories
that inform about clinical decisions (Bellner, 1999; Herman, 1992; McColl, 1998). In
addition, a document such as the Occupational Therapy Practice Framework: Domain
and Process (2nd edition) (Framework II) (American Occupational Therapy Association [AOTA], 2008) may influence clinical decision-making. The Framework II provides standardized language and overarching areas of concern for clinical practice, and
complements the theories and models of practice that guide clinical reasoning. While

Kathleen E. Yancosek is a Major in the United States Army, and is affiliated with the Department
of Rehabilitation Sciences, University of Kentucky, Lexington, Kentucky.
Dana Howell is Associate Professor of Occupational Therapy, Department of Occupational Therapy, Eastern Kentucky University, Richmond, Kentucky.
Address correspondence to: Kathleen E. Yancosek, 42 Kansas St., Natick, MA 01760, USA
(E-mail: Kathleen.yancosek@us.army.mil).
Occupational Therapy in Health Care, Vol. 24(3), 2010
Available online at http://informahealthcare.com/othc


C 2010 by Informa Healthcare USA, Inc. All rights reserved.
doi: 10.3109/07380577.2010.496824

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many theories and models of practice have been proposed to guide occupation-based
approaches (Barrett & Kielhofner, 2003; Bass-Haugen, Mathiowetz, & Flinn, 2007;
Kielhofner, 1995; Shapero Sabari, 2007), there are relatively few examples of how to
specifically integrate the Framework II with them to inform clinical reasoning. The
challenge in successfully combining concepts from a chosen theory, model of practice,
and the Framework II may be based on factors such as the sheer number of closely
related theories and models of practice available to choose from and potentially limited
time to devote to explore different options. Pragmatic and explicit demonstration of how
to clinically integrate theory with the Framework II may benefit occupational therapy
students as well as provide continued refinement of quality service delivery among
experienced practitioners.
This paper describes the purposeful integration of a theory, a model of practice, and
the Framework II to inform clinical reasoning, through a clinical example of an adult with
a hand injury requiring the transfer of hand dominance. Adult clients with injuries to the
dominant upper extremity may require rehabilitation intervention strategies that focus,
at least in part, on changing motor behavior related to the transfer of hand dominance
for occupational tasks, such as handwriting. Many occupations are renegotiated as part
of a hand dominance transfer process, for example, dressing, oral hygiene, driving, meal
preparation, work, education, sports, child-care, and home maintenance (Smurr, Gulick,
Yancosek, & Ganz, 2008). Handwriting skill acquisition is the chosen example for
two reasons. First, handwriting is the occupation most commonly accepted as defining
ones dominant hand (Doyen & Carlier, 2002). Second, handwriting is not a skill of autoemergence but rather needs to be trained directly through deliberate practice (Woodward
& Swinth, 2002).
Handwriting often becomes second nature unless challenged by unusual or unexpected environmental or personal factors. Imagine an adult sitting at a desk in a quiet,
well-lit office building using a black-ink pen to write on papers attached to a clipboard
to complete an application for employment. He has a normal tripod grasp on the pen,
medium pressure around the pen, a familiar writing speed, style, letter shape and slant,
and content knowledge for what he is writing. Now suppose the electricity goes out
in the office building and the backup generators turn on dimly lit safety lighting. To
finish the task and avoid making errors on the job application, he must adapt to the
environment change and renegotiate the task. He immediately slows his writing speed,
leans closer to the paper, and increases the pressure around the pen, thereby drawing
from personal attributes, which place additional constraints on his body and permits an
adaptive response to the increased task demands.
To appreciate the complexity and potential variability of the motor task of handwriting, imagine other possible variations: writing a phone number on a small scrap of paper
using ones hand to provide the stable surface upon which to write, writing an essay
on a college exam, writing in a poorly lit and loud room, writing with a large marker,
writing on a digitized computer screen with an interactive pen that is attached to the
digitizer via a short wire, writing in the sand with a stick, or writing while wearing
gloves. These variations demonstrate the dynamic nature of the familiar occupation of
handwriting. An injury to the dominant hand, requiring transfer of hand dominance, adds
even further complexity to this familiar occupation. To clinically address this situation,
practitioners may benefit from using an integrated practice model to guide their clinical
reasoning.
An integrated practice model emerges when occupational therapy practitioners give
careful consideration to the selection of a theory and model of practice that is congruent

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with the Framework II. A theory can be thought of as a set of principles used to explain
a phenomenon, whereas a model of practice outlines methods used in clinical practice
that are representative of underlying theoretical beliefs. For simplification of terms,
we propose that a theory answers a clinicians why questions; a model of practice
answers a clinicians how questions; and the Framework II answers a clinicians what
questions. For example, when working with an adult with a hand injury requiring
hand dominance transfer, the clinician may choose to integrate the dynamical systems
theory, the task-oriented approach, and the Framework II. In this proposed integrated
practice model, the dynamical systems theory provides the clinician with information
about why a dominant-hand injury changes motor behavior, the task-oriented approach
helps the clinician know how to engineer interventions to facilitate improved motor
behavior (Jongmans, Linthorst-Bakker, Westenberg, & Smits-Engelsman, 2003), and
the Framework II gives the clinician guidance in terms of what is the scope of practice
and the overarching goal of intervention. These three resources combine for improved
clinical reasoning in large part because of their ideological congruence. Each of the
three resources is described below.

DYNAMICAL SYSTEMS THEORY

The dynamical systems theory has been foundational in the development of practice
models that embrace the nonlinear (chaotic) nature of human performance, such as the
model of human occupation (Kielhofner, 1995), the personenvironmentoccupation
model (Law et al., 1996), the personenvironmentoccupationperformance model
(Baum & Christiansen, 2005), the Canadian model of occupational performance
(Canadian Association of Occupational Therapists, 1991), the Canadian model of occupational performance and engagement (Townsend & Polatajko, 2007), and the ecological
of human performance framework (Dunn, Brown, & McGuigan, 1994; Gielo-Perczak
& Karwowski, 2003). The dynamical systems theory is multi-disciplinary theory and
has been used in many basic sciences, such as nonlinear mathematics, physics, biology,
chemistry, and human movement sciences (Davids, Button, & Bennett, 2008). It has
been called chaos theory or complexity theory (Alligood, Sauer, & Yorke, 1997;
Cambel, 1993; Waldrop, 1992; Zellermayer & Margolin, 2005) by other scientists. The
five main tenets of the dynamical systems theory are described below. A system is
represented by an adult client.

Systems Are Sensitive to Initial Conditions

A systems sensitivity to initial conditions means that a subtle difference in the state
of beginning of the system can influence the systems final outcome (Hilborn, 2004).
In other words, the initial attributes and competencies of the client, and the initial task
characteristics, influence where and how far the client advances in his or her movement
or task. For example, when learning to transfer hand dominance for handwriting, the
subtle difference between writing with a fountain pen versus writing with a dull pencil
will clearly impact the final outcome of the task.

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Redundancy in the System

Systems that possess redundancy in degrees of freedom (DOF) are inherently able
to adapt under changing circumstances (Mark, Taub, & Morris, 2006). There is a high
degree of variability in sensorimotor performance, meaning that a system can accomplish
a task in a variety of ways based on the many possible approaches that multiple DOF
allow (Davids, Glazier, Araujo, & Bartlett, 2003). For example, it is possible to write
with a pen held in a hand, foot, mouth, or in a prosthetic limb. The redundancy of
the system permits adaptation, flexibility, and variability of movement that ultimately
impacts the outcome of the task. Redundancy in DOF helps explain how a client can
solve a motor or behavioral challenge in real time that is unique to a particular situation
(Rose, 1997).
Systems Emerge as Self-Organizing and Self-Similar
The emergence of self-organization and self-similarity characteristics of the system
describes the eventual equilibrium and patterning(also called fixing) that is achieved
in a dynamical system (Mason, 2008). This tenet captures the idiosyncrasy of the
individual as a self-organizing system controlled by nonlinear dynamical systems (Kelso
& Fuchs, 1995). One may think of repeatable motor behaviors that people develop,
such as signing their name. Over time, signatures become a written communication
pattern that are efficient (demands lowest energy), effective (reach performance goals),
predictable (consistent), and stable (minimal performance variability). The concept
of self-organization can also be understood in terms of maladaptive behaviors seen
by rehabilitation professionals, such as chronic pain or soft-tissue contracture. These
examples demonstrate a tendency for a system to reach a seemingly rigid state of
balance, albeit maladaptive, that may limit a clients ability to significantly change his
or her motor behavior.
Constraints from the Environment, Person, and Task Combine to Influence
Performance
The idea of constraints is based upon the earlier-mentioned construct of redundancy
of DOF. This tenet speaks of the concept of interconnectedness of many subsystems
within the larger system, each with embedded DOF. Davids, Button, Araujo, Renshaw,
and Hristovski (2006) explain that constraints shape (limit and enable) movement and
can be categorized into person, task, and environment components. Importantly, it is
the interplay between constraints that drives a systems (re)organization. This captures
the idea that behavior emerges out of the interaction between clients competencies, the
task demands, and the environmental affordances.
Effector States and Attractors Guide Action Along a Trajectory
The final tenet is the idea of effector states and attractor conditions. This is the notion
that action is directed toward a goal behavior (effector state) based on inputs (attractor
conditions) that ultimately creates a trajectory of performance (Livneh & Parker, 2005).
Ikiugu (2005) wrote about the occupational-life trajectory and purported meaningfulness

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to be the key performance attractor of human life. This tenet speaks of the notion that
behaviors are not merely neural events but are also goal-directed, purposeful, and the
manifestation of what was available to meet task demands.

THE TASK-ORIENTED APPROACH

Based in part on the dynamical systems theory, the task-oriented approach is a
model of practice that is multi-disciplinary and has influenced fields such as physical
education, athletic training, and physical therapy (Bass-Haugen et al., 2007; Dobkin,
1998). The approach has been promoted as a preferred service delivery approach for
several occupational therapy theories (Christiansen & Baum, 1997; Law et al., 1996;
Trombly, 1995a). The task-oriented approach also resonates with the philosophy of
the founders of the occupational therapy profession, who believed occupation to be a
powerful therapeutic agent of change and catalyst for improved health (Dunton, 1915),
and a bridge toward physical and mental health (Reilly, 1962; Trombly, 1995b). The
task-oriented approach is marked by four primary characteristics, which are described
below.

Client-Centered Intervention
From this perspective, the client is at the core of assessment and intervention. This
requires a clinician to work closely with the client to determine goals, interests, and
other information specific to that individual in order to customize the clinical interaction.
Clients are encouraged to be active participants through facilitated problem-solving, selfevaluation, and even task analysis (Bass-Haugen et al., 2007). The approach focuses on
the client and his or her meaningful roles and occupations to elicit changes in motor
behavior. For example, an adult client with a hand injury may be asked to select a
meaningful task, such as handwriting to perform during intervention, and also asked to
rate their anticipated performance before beginning the task.

Occupation-Based Intervention
Meaningful, purposeful, and goal-directed tasks are used as the basis for assessment
and intervention. The clinician observes the client engaging in the selected occupation and identifies what movements are necessary, optimal, or superfluous (Schmidt
& Wrisberg, 2008). Motor behaviors are also analyzed to determine if the movements
are stable or in transition (Bass-Haugen et al., 2007), a concept which is based on the
dynamical systems theory premise of effector and attractor states. A client with a recent
injury to the dominant hand is likely to have movements that are in transition; in other
words, each time the client engages in a task, the movements are unpredictable. Using
a self-selected, meaningful occupation as the task may help to stabilize the movement
due to the re-emergence of preferred movement patterns as well as the importance of
goal-directed movement.

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Interaction of Client with Environment

The task-oriented approach emphasizes that the environment should be natural (or
a realistic simulation) and the objects in the environment should be authentic in order
to encourage optimal motor behavior (Bass-Haugen et al., 2007). The clinician must
identify aspects of the environment that may assist or hinder occupational performance,
as well as understand that occupational performance varies depending on constraints or
changes in the environment. It is necessary for the clinician to be aware of environmental
aspects as well as personal factors related to the client, such as spasticity, weakness,
or limited range of motion that may influence motor behavior, and to address all of
these issues in treatment. For instance, the therapist may have to address a clients
limited active finger flexion to maximize engagement in handwriting. This might be
accomplished through stretching exercises, or environmental modification by adapting
the seating position, desk design, or writing surface (Shen, Kang, & Wu, 2003).

Practice and Feedback

Finally, the task-oriented approach capitalizes on motor-learning research that emphasizes whole versus part learning, practice schedules, and providing appropriate
feedback. Clinicians must make decisions about whether to teach a skill as a part or a
whole, and whether to teach a skill using blocked practice (practicing the same skill
repeatedly) or random practice (varying the practice) (Guadagnoli & Lee, 2004). Often
the most effective practice schedule begins with blocked practice, and moves toward random practice. In addition, the clinician should initially provide the client with extrinsic
feedback about performance, but move toward self-evaluation, independent problemsolving, and intrinsic feedback (Guadagnoli & Lee, 2004). In the case of client with a
dominant-hand injury working on transferring hand dominance for writing, the clinician
must determine if breaking writing down into its parts by copying letters, or working
on the whole by asking the client to write a letter to a friend, will be the best approach.
The clinician must also engage the client by varying the practice, and asking the client
to identify problems or successes during the intervention.
In summary, there is a dynamic interplay between person, task, and environment,
in such a way that no two clients have the same recovery experience (Pierce, 2003).
Furthermore, by working collaboratively with the client, based on an appreciation for
the uniqueness of the individual, the involvement of the environment, and the demands
of the occupational task at hand, occupational therapy services are customized and
contextualized.

OCCUPATIONAL THERAPY PRACTICE FRAMEWORK II:

DOMAIN & PROCESS
The Framework II sets professional boundaries for occupational therapy by providing a domain of practice, which is supporting health and participation in life through
engagement in occupation (American Occupational Therapy Association, 2008,
p. 627). Within the domain of practice, the following six interacting aspects are considered to affect engagement, participation, and health: (a) areas of occupation, (b) client

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factors, (c) performance skills, (d) performance patterns, (e) context and environment,
and (f) activity demands (see Table 1).
The Framework II encourages practitioners to focus on performance of occupations
that results from the dynamic intersection of the client, the context and environment,
and the clients occupations (p. 626). The Framework II also captures the process of
occupational therapy by explicitly defining clientpractitioner collaboration as a central
component of service provision. The intervention process revolves around the clients
regaining or sustaining health in order to fully participate in life occupations.
For the adult client working on transferring hand dominance, the Framework II advocates a thorough evaluation by which the practitioner works with the client to create
an occupational profile. The occupational profile could reveal an essential client goal,
such as attending college. Handwriting retraining, or the augmentation of written communication, would then be addressed as a skill necessary to fully participate in college
activities. The Framework II provides language to describe the dynamic, nonlinear occupational therapy processes of evaluation, intervention, and outcomes that will transpire
over the rehabilitation course.
IDEOLOGICAL CONGRUENCE
Dynamic systems theory, the task-oriented approach, and the Framework II, each
reflects a shared belief that behavior is shaped by the interaction between the person,
task, and environment. There is a sense of appreciation for a holistic and complex view
of a person interacting with the environment to meet task demands. Accordingly, there is
an agreement that the functional output of a person can neither be known nor predicted
based on reducing the whole into components and knowing something of those components. Rather, the human system, in its full complexity, interacts dynamically within
and upon the environment to engage (participate) in life and meet various occupational
demands (Kamm, Thelen, & Jensen, 1990).
All three resources also share an emphasis on the client. Both the Framework II
and the task-oriented approach call for client-centered goal setting, recognizing that
the client contains the all-important variable of volition or motivation that vigorously
influences much of what transpires in any practice setting. The client is therefore the key
force as a change-agent in his or her situation. Acknowledging an individuals capacity
to adapt to constraints placed upon him/her, justifies early focus on participation and
function, rather than starting with a component-based (reductionistic) service delivery
plan.
Likewise, the dynamical systems theory views an individual as a complex system
capable of adaptation based on unique attributes, coordinated by available redundancy
of DOF, ultimately drawing upon personal competencies and environmental affordances
to produce goal-directed behavior. Personal competencies are related to the idea that a
dynamical system is sensitive to initial conditions, and both ideas underscore the belief
that a persons starting point influences his or her final outcome. This may well account
for the wide variability of client outcomes despite standard, protocol-based interventions
provided by the same practitioner.
The concept that behavior emerges from the interaction between person, task, and
environment is fully developed and recognized by the dynamical systems theory, the
task-oriented approach, and the Framework II. The correlation between the construct of
emergence (the dynamical systems theory) and performance patterns (the Framework II)

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Client Factors

Routines

Motor and praxis skills

Emotional regulation skills Roles
Cognitive skills
Rituals
Communication and
social skills

Habits

Performance Patterns

Sensory perceptual skills

Performance Skills

Virtual

Physical
Social
Temporal

Personal

Cultural

Context and
Environment

Required body
functions
Required body
structures

Social demands
Sequencing and timing
Required actions

Objects used and their

properties
Space demands

Activity Demands

Note: All aspects of the domain transact to support engagement, participation, and health. This table does not imply a hierarchy. (Duplicated from the Framework II,
p. 628; reproduced with permission from AOTA.)

Leisure social
participation

Play

Values, beliefs, and

spirituality
Instrumental activities of Body functions
daily living
Rest and sleep
Body structures
Education
Work

Activities of daily living

Areas of Occupation

TABLE 1. Aspects of Occupational Therapys Domain

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is strong. In essence, performance patterns are the product of the emergence of selforganization and self-similarity by the establishment of engrained routines, habits,
and rituals that are related to a clients roles. There is also a strong conceptual link
between effector states (the dynamical systems theory) and areas of occupation (the
Framework II) because a client is drawn toward effector states of function in key
areas of work, play, education, leisure, activities of daily living (ADL), work, and
social participation. Attractors (the dynamical systems theory) can be associated with
performance skills (the Framework II) because various body structures and functions
contribute to the ultimate emergence of function.
Using the task-oriented approach, the practitioner can use therapeutic goals to create
effector states and reinforces attractors to create ideal performance trajectories. By
engaging clients in meaningful occupations, there is a modulation and regulation of
DOF that drives an adaptive (emergent) response. Ultimately, it is the engagement in
meaningful occupations that drives behavior. This gives credence to establishing relevant
interventions that are harmonious with what the client wishes to address.
INTEGRATING THEORY, MODEL OF PRACTICE, AND FRAMEWORK FOR
CLINICAL REASONING
Choosing of a theory and a model of practice that are ideologically similar and
congruent with the Framework II is an important aspect of clinical reasoning. The relationship between these three may conjure up a vision of a linear (nonchaotic) model that
shows input (theory) throughput (practice framework) and output (model of practice);
however, a three-dimensional model may be more accurate and clinically applicable.
The metaphor of a house is used to conceptualize the interdependent relationship (see
Figure 1). The foundation of the house represents a chosen theory (in this case, the
dynamical systems theory), supplying the boundaries, shape, stability, and depth of
knowledge, and answering the clinicians why questions, such as, Why is functional
change possible following a hand injury? The inside of the house represents choices
in clinical decision-making, strategizing, and customizing service delivery orientation
to meet the unique needs of a particular client using a model of practice (in this case,
the task-oriented approach). Questions of how are addressed here, such as, How will
clinicians engineer an effective hand dominance intervention program? The frame of
the house represents the Framework II, supplying the height of understanding and limits
of application, answering the what questions, such as, What is the domain of concern
for occupational therapy in relation to a given diagnosis?
This three-dimensional metaphorical construction is intended to capture the flexibility
of intervention strategies within an established professional framework, using a general
approach to service delivery, both of which are based upon a theoretical foundation of
understanding a clients capacity to change and adapt. In keeping with this metaphor,
imagine 10 of these houses in one neighborhood, all appearing similar in size and
structure from the outside, and yet a seemingly limitless variability within. The combined
effect of the idiosyncrasies and interactions of the people and the activities that occur
therein makes each house unique. In the context of clinical application, the houses
metaphorically represent 10 ways a practitioner could make clinical decisions for a
particular client based on different combinations of theory, framework, and model of
practice. Each client is undeniably unique, with variability in attributes, deficits, future
goals, and past experiences. Next add variability from the process by factoring in the

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FIGURE 1. Conceptual practice model of theory, framework, service delivery approach.

dynamic interaction each client will have with the occupational therapy practitioner.
Finally, consider the potential variability from service delivery options. In house and
human terms, no 10 will be alike.

CLINICAL APPLICATION
The hand is the most frequently injured area of the body and accounts for over 28%
of injuries to the musculoskeletal system (Trybus, Lorkowski, Leszek, & Hladki, 2006).
Hand injuries often require specialized, extensive, and costly rehabilitation of clients
to return to previous occupations (Trybus et al., 2006). And perhaps most importantly,
the hand represents the body part that interacts with the environment through various
tasks and is, therefore, a focal, junction point between person, task, and environment
(Kimmerle, Mainwaring, & Borenstein, 2003). Clinicians may benefit from using an
integrated conceptual practice model, incorporating concepts from the dynamical systems theory, the task-oriented approach, and the Framework II that serves as a guide
to effective clinical decisions about transferring hand dominance for functional tasks,
such as handwriting.

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TABLE 2. Examining Hand Dominance Transfer Through a Dynamical Systems

Theoretical Perspective
Five Main Tenets of
Dynamical Systems Theory
Sensitivity to initial
conditions
Redundancy in DOF

Emergence and patterning

Constraints

Effector states and attractor

conditions

Considerations of a Hand Dominance Transfer

Initial conditions, such as age, gender, occupation, previous experiences,
motivation, and laterality (strength of preference for the dominant hand)
affect the final outcome of hand dominance transfer.
Loss of function in the dominant hand causes a drastic reduction in DOF
within the body system.
Other injuries or limitations (such as brain or ocular injury) further reduce
DOF, and impact the clients ability to transfer hand dominance.
The client reorganizes and invents behavior strategies using the intact
hand to accomplish basic movements.
The client is capable of learning new movement strategies over time,
including maladaptive strategies, such as learned non-use (Taub et al.,
1993) of the residual or flail limb.
Each client devises unique movement strategies that vary within and
between task performances.
Over time, the clients sensorimotor performance emerges toward a state
of equilibrium and the previously nondominant hand emerges as the
new-dominant hand.
Initial movements will be unsteady, uncoordinated, and generally unstable,
but will (with time and experience) emerge as effective, efficient,
predictable, and stable.
A combination of task demands, environmental pressures, and personal
factors affects movement strategies.
Constraints can be manipulated to direct skills acquisition through
repetitious exposure to task and environmental demands.
Effector states dictate new movement strategies, such as one-handed
approaches, adaptive equipment, desire for and use of a prosthesis, the
use of the mouth, feet, and other body parts to complete tasks.
Attractor conditions influence what the client has to draw upon in order to
accomplish any given task.

Dynamic Systems Theory

Injury-induced hand dominance transfer is challenging, and the practitioner must
work closely with the client and negotiate many potential variables and timelines to
optimize health and restore participation. Table 2 provides examples of how the five
tenets of the dynamical systems theory may inform the clinicians understanding of
hand dominance transfer. Although the dynamical systems theory is helpful in providing
foundational knowledge about why change is possible (and probable) given the complex,
dynamical, and emergent nature of the client, it provides limited information about what
a practitioner should do, or even how to facilitate a hand dominance transfer. The model
of practice and practice framework are therefore necessary and valuable components to
an integrated practice model.
Task-Oriented Approach: A Model of Practice
In using the task-oriented approach, the intervention should be client-centered, meaningful, and occupation-based. The clinician addresses questions such as How should

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the therapy sessions be structured? How do activity demands drive performance?

and How should the environment be set up to facilitate optimal performance? The
clinician appreciates that competence in handwriting is linked to participation in many
tasks, such as signing ones name, paying bills, writing letters or lists, completing
paper-and-pencil-based leisure tasks, and completion of work or education demands.
In a study done with children, the task-oriented approach demonstrated effectiveness
in improving the quality, not speed, of handwriting (Jongmans et al., 2003). Rather
than approaching a hand dominance transfer-training program through repetitive hand
and digit strengthening exercises, fine-motor manipulation exercises, such as grasp,
move, and release of various small objects, and copying the same letter in repetition,
the task-oriented approach is marked by features of direct engagement in functional
tasks.
Variability is inherent in the client and the environment; therefore, the use of a
standard protocol or program to guide practice does not undermine customized therapy
services and is an acceptable and intelligent clinical strategy. The practitioner may
select from two commercially adult handwriting-training programs. The first program
is called Callirobics-for-Adults (Laufer, 1995). This program uses a workbook and an
audio compact disc that plays accompaniment music from the 1920s, 1930s, and 1940s.
The program can be self-guided but also contains a teachers guide. There are 38 practice
exercises included in the program. The workbook uses repetition of simple pen strokes
and letter formations as the general approach to training.
A second adult handwriting program, developed as part of the hand dominance
transfer program used for military service members, is a workbook called Handwriting
for Heroes (Yancosek & Gulick, 2008). This workbook utilizes both repetitive exercises
and functional tasks, such as expressive writing in response to prompts as in journaling,
writing appointments on a calendar, balancing a checkbook ledger, and filling out
simulated and standardized forms.
By selecting one of the workbooks as a strategy of service delivery, the practitioner proceeds by manipulating constraints (person, environment, and task) to exploit
attractors and drive performance toward the effector state of handwriting skill mastery. One possible attractor is memory of past because the client was most likely
highly proficient in handwriting before the loss of hand function, and would likely
remember his engrained handwriting style (highly personalized, predictable in shape,
slant, style, size, and a clear representation of a personalized motor behavior). This
example of an attractor highlights individualization of both process and outcome of
services.
Constraints further imprint a mark of idiosyncratic nature to each writer and potentially each writing experience. Some task constraints include writing with different
instruments on various papers or surfaces, and characteristic demands of the task, such
as length of writing required (signing ones name, filling out a form, or composing
a thought in a journal). Environmental constraints are less varied as handwriting is a
closed-task; however, temperature, noise, and lighting could pose considerable influence
over occupational performance. In addition, when writing for emotional expression, the
environment may facilitate or inhibit creativity. Personal constraints include age, gender, visual perceptual skills, psychological factors, such as insight into functional loss,
past occupational experiences, and future occupational goals, values and beliefs in the
need for and meaning of written expression, and motivation for change that may impact
willingness to learn to write with the other hand. See Table 3 for a complete list of
possible constraints.

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TABLE 3. Personal, Task, and Environmental Constraints on Handwriting Performance

Personal
Age, gender, handedness
Co-morbidities (examples: eye or
brain injury)
Occupational history and goals (is
writing a hobby or related to a
work/school role?)
Neuromusculoskeletal functions:
joint mobility, stability, muscle
power, tone, endurance
Mental functions: attention, memory,
perception, energy
Vision and perception
Values and beliefs (meaningfulness
of writing)

Task

Environmental

Properties of the writing instrument

Properties of object being written on
digitizer, white or chalkboard, paper,
fabrics
Time demands of writing

Lighting
Temperature

Intensity/duration of task

Angle of writing
surface

Purpose of writing

Height of writing
surface

Noise/distractions

Size of the space to write in

Expectation of font (manuscript versus
cursive)

The Framework II: Domain and Process

The domain and process set forth by the Framework II guides the clinicians efforts
to facilitate occupational engagement to support participation in life. Given a hand
dominance transfer program, service provision could take many different shapes depending on a multitude of variables based on the clients occupational profile, goals,
and interests. The clinician must make decisions about what will be evaluated? what
does the collaborative relationship between the practitioner and client look like? and
what is of concern and what is the manner of service delivery? The clinician could
design an intervention session focused on filling out college applications, an occupation
meaningful to the client and appropriate for transferring hand dominance.
CONCLUSION
Integrating theories and practice models is one way to increase the effectiveness of
rehabilitation and occupational therapy intervention strategies; such integration, along
with research studies on the techniques themselves, will provide evidence of effectiveness. For rehabilitation intervention strategies to be most effective, practitioners
can benefit from integrating theories and practice models to create a strong foundation and structure to guide their clinical decision-making. Specifically, the ideological
similarities between the dynamical systems theory, the task-oriented approach, and the
Framework II create a distinct perspective to create change in occupational performance
during rehabilitation following injury, with the explicit acknowledgment that each client
is different and therefore experiences rehabilitation differently. This examination illuminated how dominance transfer is possible for an injured adult client and explored
constraints available to elicit improvement in occupational performance. Examining the
utility of this proposed practice, model will strengthen understanding of human behavior
and thereby aid in refining service delivery approaches. As occupational therapy practitioners work to improve client performance, integrating concepts from a theory and

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model of practice that is congruent with the Framework II may ultimately strengthen
the profession.
Declaration of interest: The authors report no conflict of interest. The authors alone
are responsible for the content and writing of this paper.

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Received: 09/14/2009
Revised: 05/24/2010
Accepted: 05/25/2010

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