At the heart of occupational therapy (OT) is the belief that health is not merely the absence of disease, but the ability to engage fully in the activities that give life meaning. And yet, the very tool most capable of restoring and enhancing participation, exercise, remains largely overlooked in occupational therapy.
Despite decades of research confirming its profound impact on nearly every domain of human function, exercise prescription is barely touched in most OT curriculums. It’s often dismissed as the realm of physical therapists, exercise physiologists, or personal trainers. That gap isn’t just academic; it’s costing us our seat at the table in both rehabilitation and preventative medicine.
The Evidence: Exercise as Medicine
Few interventions in modern medicine have been studied as extensively, or proven as powerful, as exercise.
Mental health: Regular physical activity reduces symptoms of depression and anxiety by up to 30–50%, often rivaling medication and psychotherapy in mild-to-moderate cases (Schuch et al., Br J Sports Med, 2016).
Cognition: Aerobic exercise has been shown to improve executive function, working memory, and processing speed across the lifespan (Erickson et al., PNAS, 2011).
Pain: Exercise reduces chronic musculoskeletal pain, improves pain tolerance, and promotes endogenous pain inhibition, which is essential for conditions like low back pain or fibromyalgia (Geneen et al., Cochrane Review, 2017).
Longevity: Adults who meet physical activity guidelines live 3–7 years longer, with markedly lower risk of cardiovascular disease, diabetes, osteoporosis, and certain cancers (CDC, 2023).
Bone and muscle health: Resistance training improves bone mineral density, muscle mass, and functional independence. These are all key outcomes for aging adults and individuals with disability (Howe et al., Cochrane Review, 2011).
Few interventions in health care, pharmacological or otherwise, can claim this breadth and consistency of benefit.
The Foundation of Occupation
At its core, occupational therapy is about enabling participation. Essentially, helping people do the things they need and want to do. What better way to facilitate participation than to enhance the physical capacities that make it possible?
As Occupational Therapy for Physical Dysfunction reminds us:
“The biomechanical and physiological principles that pertain to ROM, strength, and endurance are the building blocks upon which treatment for physical dysfunction is built. Remediation or prevention of limitations in these three capacities prepares an individual to fully engage in purposeful and occupation-based activities that support health and participation in life.” — Fabrizio & Rafols, 2014
When clients gain capacity, their world expands. They can lift groceries, garden, return to tennis, or simply get through the day with less fatigue and pain. Exercise isn’t separate from occupation. It enables it.
Nowhere is the gap between evidence and practice more striking than in populations with spinal cord injury (SCI).
People with SCI are among the least physically active populations worldwide, not because of motivation, but because of accessibility, uncertainty, and fear. Pain, fatigue, and fear of injury often stop clients before they start. Many don’t know what’s safe or effective. And, frankly, most OTs don’t either.
When movement feels risky, clients avoid it. But as occupational therapists, we are uniquely equipped to change that narrative through graded exposure, task adaptation, and confidence-building in movement.
The current Exercise Guidelines for Adults with Spinal Cord Injury (Martin Ginis et al., Spinal Cord, 2018) are clear:
- Aerobic activity: At least 20 minutes, twice per week, at moderate to vigorous intensity
- Strength training: At least two sessions per week, targeting all major muscle groups
These evidence-based targets improve cardiometabolic health, bone density, strength, and ultimately, independence, as these factors are often the difference between dependence and autonomy.
But how many occupational therapists can confidently: 1) determine what constitutes moderate intensity for someone with altered autonomic regulation, 2) design a safe, progressive 2x/week resistance training program tailored to functional goals, and 3) Coach movement mechanics with the same skill they use to coach ADL retraining?
Very few. Yet we should be among the professionals leading this charge.
OTs are experts in activity analysis, we understand neurological classification, and behavioral change. All of these things make us ideally positioned to help individuals with SCI integrate movement safely into their lives. The missing piece isn’t intent; it’s education.
Preventative Medicine in Action
So much of what I do as both an occupational therapist and a personal trainer revolves around a single principle: empowering people to maintain health through movement.
Exercise prevents the very conditions that send people to therapy in the first place: stroke, heart disease, osteoporosis, frailty, and falls. It improves postural control, executive function, and emotional regulation. All of which are central to occupational participation.
If occupational therapy truly aims to promote health, well-being, and participation, then exercise must become central to our practice.
Reclaiming Exercise as an OT Tool
Ask a group of occupational therapists about sensory modulation or assistive technology, and you’ll hear confident, detailed responses. Ask that same group how to safely load the human body, how to program strength and power development, or how to monitor aerobic intensity and the room will often fall silent.
That’s not a reflection of disinterest; it’s a gap in our professional education. But it’s one we can close.
Because for many people, exercise itself is a meaningful occupation. It’s a source of identity, mastery, and social connection. Running, lifting, dancing, hiking are more than workouts. They’re expressions of capability and self-efficacy. To ignore exercise is to ignore one of the most powerful vehicles for participation we have.
If occupational therapy wants to lead the next wave of preventative, holistic, and evidence-based care, we must reclaim exercise prescription as a core competency.
Understanding how to progressively load the body, dose exercise safely, and coach effectively coach movement isn’t just the realm of strength and conditioning. It’s the very essence of enabling participation in life.