Department of Occupational Therapy, Bangladesh Health Professions Institute

1. TS1_Shamima_2017

2. GRADING ACTIVITY
Shamima Akter
B. Sc (Honours) in Occupational Therapy
& M. Sc in Rehabilitation Science
Assistant Professor,
Department of Occupational Therapy
Bangladesh Health Professions Institute (BHPI)
Centre for the Rehabilitation of the Paralysed (CRP)
Chapain, Savar

3. GRADING
• Grading is the way in which the physical, cognitive and
psychological characteristics of an activity can be
gradually modified or progressed to meet a
therapeutic goal.
• The therapist needs to pay careful attention to the skill
and ability level of the client. The therapist must also
know which steps might be difficult for the client in
order to anticipate these and modify the activity
accordingly.
TS1_Shamima_2017

4. TYPES OF GRADING
• Up-grade grading: A general rule is to 'up-grade’
(make the activity more difficult) an activity when
the client is able to accomplish the task and
further progress is desired.
• Down-grade grading: 'Down-grade' an activity
(make it easier) when the client is having too
much difficulty with performance.
TS1_Shamima_2017

5. PROCESS OF GRADING
• Grading of a treatment programme
This can be done by starting with easy activities
and than progressing to harder or more difficult
one.
E.g. for a tetraplegic person the activity of
drinking a glass of water with both hand could be
easily practiced initially with or without support.
But teaching the same person to perform lower
limb dressing would be very difficult.
TS1_Shamima_2017

6. Continue…
• Grading of an activity
Grading of an activity can be ensured by determining
patient’s abilities with activities and tasks the patient
needs or wants to do (occupation-as-end) and select
the most appropriate activity for remediation from
those that are available and are of interest to patient
(occupation-as-means).
TS1_Shamima_2017

7. Continue…
Therefore, the grading and selection of a therapeutic activity
can be divided in two forms:
• Occupation-as-end: Activities and tasks that constitute
the roles of a given individual. That means occupation-
as-end is activities and tasks that constitute the
patient’s life role.
For example: If a patient is experiencing
occupational dysfunction and she likes to resume
gardening. We can use the gardening activity as a
therapeutic activity.
• Occupation-as-means: Activities and tasks chosen to
remediate deficient abilities or capacities.
TS1_Shamima_2017

8. Remediation Goal Key Factors of the Activity
To retrain sensory
awareness and/or
discrimination
The activity must provide components that offer a
variety of textures, shapes, and sizes, graded from large,
distinct, common shapes to small, less common shapes
with less distinct differences between them.
To decrease
hypersensitivity
The activity should involve objects or media whose
textures can be graded from those that the patient
perceives to be least noxious to textures perceived to be
tolerably noxious. Another plan and objects from soft to
hard to rough and grades the contact with the objects
from touching them to rubbing them to tapping them.
TS1_Shamima_2017

9. TS1_Shamima_2017
Remediation
Goal
Key Factors of the Activity
To relearn skilled
voluntary
movement
Organization of voluntary movement depends both on the unique
problem or purpose to be addressed and the constraints operating at
a given time. The activity must have a clear goal or purpose,
demand the sought-after movement or movements, and offer the
opportunity to self-monitor success (feedback)
To increase
coordination and
dexterity
The activity should allow as much active range of motion or skilled
motor actions as the patient can control and allow grading from
slow, gross motions to precise, fast movements involving greater
skilled movement at more joints.

10. TS1_Shamima_2017
Remediation Goal Key Factors of the Activity
To increase active
range of motion
The activity must require the part of the body being treated
repeatedly move to its limit and it’s graded, naturally or
through adaptations, to demand greater amounts of
movement as the patient’s limit change.
To increase passive
ROM or elongate
soft tissue
contracture
The activity must provide controlled stretch or traction to
the part being treated and be held at the end of range for
several seconds.

11. TS1_Shamima_2017
Remediation Goal Key Factors of the Activity
To increase
strength
Stress to muscle tissue increases strength. Stress can be graded by
activities that increase the velocity and/or resistance needed to
complete the activity or, for very weak muscles, by increasing the
number of repetitions of an isotonic contraction or the amount of
time an isometric contraction is held while performing the activity.
To increase
cardiopulmonary
endurance
The metabolic demand of activity should match the patient’s
health status. The demand can be graded by increasing the
duration of an activity, by increasing the frequency of doing the
activity, by changing the muscles used in the activity or by
increasing the intensity.

12. Continue…
Remediation
Goal
Key Factors of the Activity
To increase
muscular
endurance
The activity must be repetitions over a controlled number
of repetitions or duration. To increase muscle endurance,
the resistance provided should be held to 50% or less of
maximal strength.
To decrease
edema
The activity should entail repetitive isotonic contractions
of the muscles in the edematous portion of the body
structure. An activity that requires repeated movement of
the extremity into an elevated position helps to drain the
fluid out of the extremity.
TS1_Shamima_2017

13. Continue…
Remediation
Goal
Key Factors of the Activity
To improve
perceptual
impairments
The activity should involve varied practice of information
processing or perceptual processing at the outside edge of the
person’s capability. For example, if the person has impaired figure
ground discrimination skill, practice may start with detecting one
object from a plain background (white socks on a black table) and
progress through finding multiple objects on a plain background
(various clothing items on a dark surface) or finding one object in
more complex backgrounds (white sock in a drawer filled with
clothes) until the person has developed the skill he or she requires.
TS1_Shamima_2017

14. Continue…
Remediation
Goal
Key Factors of the Activity
To increase
attention
Attention involves multiple capacities including noticing an
environmental cue, sustaining attention over time, attending to
relevant stimuli, alternating attention between different tasks, and
keeping track of two or more items during an ongoing activity.
To increase
memory
Memory is described as a multistep process including the encoding,
storing, and retrieving of information. There are four types of memory
that individuals use: working memory (e.g. temporary storage of
information during an event or task), declarative memory (e.g.,
conscious memory of events and facts), procedural memory (e.g.,
unconscious memory of how to perform an activity), and prospective
memory (e.g., remembering information for the future)
TS1_Shamima_2017

15. Remediation
Goal
Key Factors of the Activity
To relearn skilled
voluntary
movement
Organization of voluntary movement depends both on the unique
problem or purpose to be addressed and the constraints operating at a
given time. The activity must have a clear goal or purpose, demand the
sought-after movement or movements, and offer the opportunity to
self-monitor success (feedback)
To increase
coordination and
dexterity
The activity should allow as much active range of motion or skilled
motor actions as the patient can control and allow grading from slow,
gross motions to precise, fast movements involving greater skilled
movement at more joints.
To improve
problem solving
Practice may start with simple activities that present concrete problems
involving objects that the patient can see and touch. Gradation involves
proceeding to more complex activities that require a higher level of
abstraction. Further gradation can involve unexpected challenges for
which the patient must solve a problem.
TS1_Shamima_2017

16. TS1_Shamima_2017

17. TS1_Shamima_2017

18. TS1_Shamima_2017

19. TS1_Shamima_2017

20. TS1_Shamima_2017

21. TS1_Shamima_2017

22. TS1_Shamima_2017

23. TS1_Shamima_2017

24. TS1_Shamima_2017

25. TS1_Shamima_2017

26. REFERENCE
• Trombly CA 1996, Occupational Therapy
for Physical Dysfunction, 5th ed, Mosby
Company, Philadelphia
• Radomski and Trombly-Latham 2008,
Occupational Therapy for Physical
Dysfunction (6th Ed). Philadelphia:
Lippincott, Williams and Wilkins.
• Radomski and Trombly-Latham 2014,
Occupational Therapy for Physical
Dysfunction (7th Ed). Philadelphia:TS1_Shamima_2017