OT / Blueprint — NBCOT Exam Preparation

Exam Blueprint

All four NBCOT domains, simplified

Each domain aligned to the current exam blueprint with key concepts, cheat sheets, and exam strategies.

Evaluation & Occupational Profile

~24% of exam

Gathering and interpreting information to establish the client's occupational profile and select appropriate assessments.

Occupational ProfileStandardized AssessmentsObservationInterview TechniquesClient-Centered Practice

Always prioritize client's occupational roles and goals first
Top-down approach: start with occupation, then performance skills
Know the difference: screening vs. evaluation vs. re-evaluation
Select assessments based on psychometric properties (validity, reliability)
OTPF-4: occupation, performance, context, patterns, client factors

Exam StrategyWhen a question asks "what should the OT do first?" — the answer is almost always gather information / evaluate before treating.

Intervention Planning & Implementation

~31% of exam

Developing and carrying out evidence-based intervention plans that address occupational performance goals.

Therapeutic Use of OccupationFrames of ReferenceCompensatory StrategiesGrading & AdaptingGroup Dynamics

Grade up/down: change task complexity to challenge or simplify
Key FORs: Biomechanical, MOHO, NDT, Cognitive, SI, Psychodynamic
Progression: Preparatory → Purposeful → Occupation-based
Compensatory: modify the task/environment, not the person
Always tie intervention back to meaningful occupation

Exam StrategyQuestions on intervention — look for the most occupation-focused answer. Passive modalities alone are rarely the best OT answer.

Outcome Monitoring & Program Evaluation

~21% of exam

Measuring effectiveness of services, documenting outcomes, and ensuring quality across OT programs.

SMART GoalsDischarge PlanningOutcome MeasuresDocumentationProgram Evaluation

SMART: Specific, Measurable, Achievable, Relevant, Time-bound
FIM: 7=Independent, 6=Modified Indep, 5=Supervision, 4=Min Assist, 3=Mod Assist, 2=Max Assist, 1=Total Assist
Discontinue when goals are met OR no further progress expected
Transition: ensure continuity with proper referrals and HEP
Program evaluation uses data to support evidence-based practice

Exam StrategyOutcome questions often test discharge decisions. Ask: has the client met their goals? Is skilled OT still needed?

Management, Education & Research

~24% of exam

Supervising personnel, educating clients and caregivers, advocating for the profession, and applying research.

OTA SupervisionAOTA EthicsAdvocacyEvidence-Based PracticeProfessional Development

OTR supervises OTA — OTA cannot evaluate independently
AOTA Ethics: Beneficence, Nonmaleficence, Autonomy, Justice, Veracity, Fidelity
Levels of evidence: RCT > Cohort > Case Study > Expert Opinion
Scope of practice violations = must address immediately
Supervision levels: general, routine, close, continuous

Exam StrategyEthics questions: protect client safety AND professional integrity. Never delegate evaluation tasks to an OTA.

Condition-Specific Content

Neurological Conditions

High-yield OT considerations for the most commonly tested neurological diagnoses on the NBCOT exam.

Key Facts

Stroke / CVA

Cerebrovascular accident causes contralateral deficits. Right CVA = left-sided deficits + impulsivity. Left CVA = right-sided deficits + aphasia.

Right CVA: left neglect, impulsivity, poor safety awareness, spatial deficits
Left CVA: aphasia (Broca=expressive, Wernicke=receptive), depression, cautious behavior
Spasticity: flexor pattern UE, extensor pattern LE
Subluxation: common in flaccid shoulder post-stroke

OT Assessments

Key Evaluations

FIM — functional independence measure
MMSE or MoCA — cognitive screening
Line Bisection Test / Star Cancellation — neglect
Wolf Motor Function Test — UE function
Fugl-Meyer — motor recovery post-stroke
A-ONE — ADL performance + neurological impairment

Interventions

OT Approaches

NDT/Bobath: normalize tone, facilitate movement quality
CIMT: restraint of unaffected UE, forces use of affected arm
Electrical stimulation (NMES): for flaccid UE, facilitates muscle activation
Visual scanning training: for left neglect
Environmental modifications: safe setup for hemi
Compensatory: one-handed techniques, adaptive equipment

Exam TipCIMT is evidence-based for chronic stroke with some active wrist extension. It cannot be used without any active movement in the affected hand.

Precautions

Safety Considerations

Dysphagia: assess swallowing before oral intake; refer to SLP
Aspiration risk: position upright 90° during meals, chin tuck
Shoulder pain: avoid overhead pulleys with flaccid shoulder
Falls: high risk — always address transfers and mobility safety
DVT risk: early mobility and positioning critical

⚠ Red FlagNever use overhead shoulder pulleys with a subluxed or flaccid shoulder — can cause traction injury.

Key Facts

Traumatic Brain Injury

TBI affects cognition, behavior, motor function, and ADL performance. Severity classified by GCS, LOC, and PTA duration.

Mild TBI: GCS 13–15, LOC <30 min
Moderate: GCS 9–12
Severe: GCS 3–8, LOC >24 hours
Rancho Los Amigos Scale: 8 levels of cognitive recovery (I=No Response → VIII=Purposeful/Appropriate)
Common deficits: memory, attention, executive function, impulse control

Rancho Scale

Cognitive Levels & OT

Level	Behavior	OT Approach
I–II	No/Generalized response	Sensory stimulation, positioning
III	Localized response	Simple commands, familiar items
IV–V	Confused/agitated	Low-stimulation environment, routine
VI	Confused/appropriate	Simple ADLs, errorless learning
VII–VIII	Automatic/Purposeful	Complex IADLs, community re-entry

Interventions

OT Strategies

Cognitive rehabilitation: attention training, memory compensatory strategies
External memory aids: calendars, apps, whiteboards, alarms
Errorless learning: prevents frustration, builds procedural memory
Behavior management: structured routine, calm environment at Rancho IV-V
IADL retraining: driving eval, meal prep, medication management
Community re-entry: vocational rehab, social participation

Assessments

TBI-Specific Tools

Ranchos Los Amigos Scale — cognitive level
COGNISTAT — cognitive screening
EFPT — executive function in IADLs
Neurobehavioral Functioning Inventory (NFI)
Trail Making Test — processing speed, attention
Brief-A — executive function behavior rating

Key Facts

Spinal Cord Injury

Functional independence depends on injury level. Complete injuries (ASIA A) = no sensory/motor below level. Incomplete = some preservation.

Level	Key Function	Expected Independence
C1–C3	Neck only	Ventilator dependent; power wheelchair
C4	Diaphragm, scapular elevation	Power WC; needs full assistance ADLs
C5	Shoulder flex, elbow flex (biceps)	Feeds with adaptive equipment
C6	Wrist extension (tenodesis)	Independent feeding, grooming, driving
C7	Elbow extension (triceps)	Transfers, manual WC on level surfaces
T1–T9	Hand intrinsics, trunk	Full UE independence; manual WC
T10–L1	Trunk stability	Ambulation with KAFO possible

Tenodesis

C6 Function — Critical for Exam

Tenodesis grasp: wrist extension = passive finger flexion → functional grip. Wrist flexion = passive finger extension → release.

Key at C6 level — preserve finger flexor tightness (do NOT fully stretch)
Tenodesis splint supports this pattern
Train all ADLs using tenodesis pattern
Never perform full passive ROM of finger flexors at C6 — weakens tenodesis

⚠ CriticalDo NOT fully stretch finger flexors at C6 level. Tenodesis depends on passive tightness.

Complications

Medical Precautions

Autonomic dysreflexia (T6 and above): life-threatening BP spike. Sit client upright, find and remove noxious stimulus (full bladder most common)
Pressure injuries: reposition every 2 hours; teach weight shifts
Orthostatic hypotension: raise HOB slowly; use abdominal binders/compression stockings
Spasticity: can be functional (e.g., for transfers) or limiting
Neurogenic bladder/bowel: affects scheduling of therapy sessions

Interventions

SCI OT Focus Areas

Adaptive equipment: universal cuff, built-up handles, plate guards, button hooks
Wheelchair prescription and training: power vs manual, cushion selection
Home modifications: ramps, grab bars, roll-in shower, widened doorways
Upper extremity strengthening: functional gains with available muscle groups
Skin inspection: teach mirror use for pressure area monitoring
Driving evaluation: hand controls, adapted vehicles

Key Facts

Parkinson's Disease

Progressive neurodegenerative disorder. Cardinal signs: TRAP — Tremor (resting), Rigidity, Akinesia/Bradykinesia, Postural instability.

Tremor: pill-rolling, at rest, diminishes with movement
Cogwheel rigidity: jerky resistance to passive ROM
Bradykinesia: slow movements, affects all ADLs
Festinating gait: shuffling, accelerating steps, freezing of gait
Hypophonia: soft voice; micrographia: small handwriting
Mask-like face (hypomimia), drooling, dysphagia

OT Interventions

Evidence-Based Approaches

LSVT BIG: high-amplitude movement training — shown to improve ADL function
Cueing strategies: rhythmic auditory cueing (metronome) for freezing
Energy conservation: fatigue is significant; schedule therapy during "on" medication periods
Visual cues on floor to initiate movement (colored tape)
Adaptive equipment: weighted utensils, electric toothbrush, button hooks
Falls prevention: address freezing, postural instability

Exam TipLSVT BIG is a high-yield, evidence-based OT intervention for PD. Know that "on" medication periods are best for complex task training.

Key Facts

Multiple Sclerosis

Autoimmune demyelinating disease with unpredictable course. Relapses and remissions. Fatigue is the most common and disabling symptom.

Most common in women 20–40 years old
Symptoms: fatigue, spasticity, visual disturbances, cognitive changes, tremor, pain, bowel/bladder dysfunction
Heat sensitivity (Uhthoff's phenomenon): heat worsens symptoms
Types: RRMS (most common), PPMS, SPMS

OT Interventions

Priority Areas

Energy conservation: pacing, rest breaks, task modification — #1 OT priority in MS
Heat management: cooling vests, cool environments, morning scheduling
Fatigue management education: activity logs, priority setting
Adaptive equipment: for tremor, weakness, coordination deficits
Cognitive strategies: memory aids, structure, routine
Home modifications as disease progresses

Exam TipIf a question asks about MS and function, energy conservation and fatigue management are almost always a correct answer component.

Key Facts

Dementia / Alzheimer's

Progressive cognitive decline affecting memory, reasoning, and ADL performance. OT focuses on maintaining function and quality of life.

Allen Cognitive Levels: 1 (profound) to 6 (normal) — guide activity complexity
Early stage: IADLs decline first (finances, driving, medications)
Middle stage: basic ADLs require cueing/assistance
Late stage: full care, communication limited
Wandering, sundowning, agitation are behavioral symptoms

OT Interventions

Dementia-Specific Strategies

Allen Cognitive Disability Model: match task complexity to cognitive level
Spaced retrieval: repeat target information at increasing intervals
Errorless learning: structure tasks to prevent errors and frustration
Environmental modifications: remove clutter, improve lighting, label drawers
Routine and predictability: reduce anxiety and behavioral disturbances
Caregiver training: essential component of OT in dementia care

Exam TipAllen Level 4 = clients can handle simple, repetitive, concrete tasks. Level 3 = manual actions only. Use these levels to select appropriate activities.

Mental Health OT

Psychosocial & Mental Health Practice

OT in mental health addresses occupational participation, coping, and meaningful engagement across psychiatric diagnoses.

Schizophrenia ›

Chronic psychotic disorder affecting thought, perception, and behavior. OT focuses on daily functioning and community integration.

Positive symptoms: hallucinations, delusions, disorganized thinking
Negative symptoms: flat affect, avolition, alogia, anhedonia — most affect ADL performance
OT focus: daily routine, work/vocational rehab, social skills, medication management
Cognitive deficits are significant and impact IADL performance
Evidence-based: Cognitive Remediation Therapy, social skills training, supported employment (IPS)

Exam TipNegative symptoms (avolition, flat affect) are the most functionally limiting and most relevant to OT intervention — more so than positive symptoms in chronic stages.

Depression (MDD) ›

Major depressive disorder significantly impacts occupational engagement, self-care motivation, and social participation.

Symptoms affecting function: fatigue, anhedonia, poor concentration, sleep disturbance, psychomotor retardation
OT focus: activity engagement, daily routine, meaningful occupation, sleep hygiene
Behavioral activation: graded engagement in pleasurable activities is key OT strategy
Avoid over-challenging tasks — success experiences build self-efficacy
Screen for suicide risk — refer to mental health team as appropriate

Bipolar Disorder ›

Manic phase: poor safety awareness, impulsivity, grandiosity — reduce stimulation, provide structure
Depressive phase: same as MDD — activity grading, routine
OT goal: stable routine and sleep schedule to prevent relapse
Medication adherence is critical — OT role in supporting habits/routines
During mania: do NOT engage in complex planning or high-stimulation activities

Exam TipDuring acute mania, OT intervention focuses on reducing stimulation, maintaining safety, and establishing calming routines — not introducing new complex tasks.

Anxiety Disorders & PTSD ›

OT addresses occupational avoidance, social withdrawal, and performance anxiety
Graded exposure: gradual, supported return to avoided activities/environments
Sensory-based interventions: calming sensory strategies for anxiety regulation
PTSD: trauma-informed care — never force clients; prioritize safety and control
Mindfulness, stress management, sleep hygiene are OT intervention areas

Substance Use Disorders ›

OT addresses occupational role loss, routine disruption, and co-occurring mental health conditions
Focus: meaningful occupation as an alternative to substance use
Vocational rehabilitation and social skills training
12-step program support and community integration
Motivational interviewing techniques to build readiness for change

Frame of Reference	Core Idea	OT Application
Psychodynamic	Unconscious drives; activity as symbolic expression	Projective activities (art, crafts) to explore emotions; insight-oriented groups
Cognitive-Behavioral (CBT)	Thoughts drive behavior and emotions	Thought records, behavioral activation, graded task assignment
Sensory Integration (Ayres)	Sensory processing underlies behavior	Sensory diets, calming/alerting strategies, sensory-based coping
MOHO	Volition, habituation, performance, environment	Occupational role assessment; building habits and routines
Recovery Model	Hope, self-determination, community integration	Peer support, vocational rehab, supported housing, IPS employment
Dialectical Behavior Therapy (DBT)	Distress tolerance, mindfulness, emotional regulation	OT supports DBT skills in daily occupations; particularly for BPD

Cole's 7-Step Group Format

OT Group Structure

1. Introduction — welcome, warm-up, purpose
2. Activity — therapeutic, graded, purposeful
3. Sharing — members share their work/experience
4. Processing — express feelings about the experience
5. Generalizing — identify common themes
6. Application — how to apply to daily life
7. Summary — review, close, affirm participation

Exam TipCole's group format is heavily tested. Know all 7 steps and their purpose. The OT facilitates — not dominates — the group.

Group Types

Mosey's Group Levels

Level	Group Type	Client Level
1	Parallel	Works alongside but not with others
2	Project	Short-term sharing of tasks
3	Egocentric-Cooperative	Group activity, self-focused goals
4	Cooperative	Mutual goal satisfaction
5	Mature	Flexible roles; meets all members' needs

Core Concept

Therapeutic Use of Self

The intentional, planned use of one's personality, insights, and relationship to benefit the client. One of OT's most unique tools.

Empathy: understanding client's experience without judgment
Genuineness: authentic, congruent communication
Unconditional positive regard: accept client regardless of behavior
Deliberate use: therapist is mindful of how their responses affect the client
Therapeutic relationship is the vehicle for change in mental health OT

Communication Styles

Taylor's Therapeutic Modes

Advocating: speaking on client's behalf
Collaborating: shared decision-making with client
Empathizing: emotional attunement and validation
Encouraging: instill hope and confidence
Instructing: teach skills, provide direction
Problem-solving: logical analysis with client

Exam TipKnow that the OT flexibly shifts between modes based on the client's needs in the moment. No single mode is correct for all situations.

Pediatric OT

Pediatrics — Development, Assessment & Intervention

Developmental milestones, pediatric conditions, school-based OT, and sensory processing — all high-yield for the NBCOT exam.

Age	Gross Motor	Fine Motor	Cognitive/ADL
2 months	Lifts head in prone	Hands fisted; grasp reflex	Smiles socially
4 months	Rolls prone to supine; holds head steady	Reaches, brings hands to midline	Recognizes faces
6 months	Sits with support; rolls both ways	Transfers objects hand-to-hand; raking grasp	Begins finger foods
9 months	Pulls to stand; cruises	Radial-digital grasp; pincer emerging	Object permanence
12 months	Stands alone; begins walking	Fine pincer grasp (tip-to-tip)	Drinks from cup; finger feeds
18 months	Walks well; runs stiffly	Stacks 3–4 blocks; scribbles	Uses spoon; removes shoes/socks
2 years	Runs, kicks ball, jumps in place	Stacks 6 blocks; turns pages	Puts on shoes; uses fork
3 years	Rides tricycle; alternates feet on stairs	Copies circle; uses scissors (snips)	Dresses with minimal help; toileting
4 years	Hops on one foot; skips	Copies cross/square; draws person (4 parts)	Dresses independently; buttons
5 years	Skips; catches ball; balances on one foot 10s	Copies triangle; ties shoes beginning	Full ADL independence; handwriting
6 years	Rides bike; mature gait pattern	Mature pencil grasp; ties shoes independently	School-level independence

Reflex	Stimulus	Response	Integrates By	OT Significance
ATNR (tonic neck)	Head rotation to side	Arm/leg extend on face side; flex on skull side ("fencing")	4–6 months	Persistence interferes with midline reaching, handwriting
STNR	Neck flexion/extension	Flex=UE flex/LE extend; Extend=UE extend/LE flex	8–12 months	Persistence interferes with quadruped and self-care
Moro	Sudden drop/loud sound	Arms abduct/extend then flex inward	4–6 months	Persistence = startle response affecting ADLs
Palmar Grasp	Pressure on palm	Finger flexion around object	4–6 months	Persistence prevents voluntary release; affects handwriting
Plantar Grasp	Pressure on ball of foot	Toe curling	9–12 months	Persistence delays standing/walking
Rooting	Touch to cheek	Head turns toward stimulus	3–4 months	Persistence interferes with oral motor/feeding
Landau	Suspend prone	Head/trunk/legs extend	24 months	Supports trunk extension development
Parachute	Tip forward suddenly	Arms extend to protect	Emerges 6–9 months	Must be present for safe ambulation; never fully disappears

Exam TipPersistent primitive reflexes are a major red flag for neurological dysfunction. ATNR persistence is the most commonly tested — it directly interferes with functional tasks like handwriting, self-feeding, and bilateral coordination.

Sensory Systems

Sensory Processing Overview

Ayres Sensory Integration (ASI) theory: the brain organizes sensory input to produce adaptive responses. 8 sensory systems relevant to OT:

Tactile: touch, pain, temperature — affects grooming, clothing tolerance
Proprioception: body position — affects motor planning, handwriting
Vestibular: movement, balance — affects posture, attention, gravitational insecurity
Visual, Auditory, Gustatory, Olfactory, Interoception

Sensory Patterns

Dunn's Model

Threshold	Strategy	Pattern	Behaviors
High (low registration)	Passive	Low Registration	Misses cues, appears unaware, slow to respond
High	Active	Sensation Seeking	Seeks intense input; crashes, touches everything
Low (high sensitivity)	Passive	Sensory Sensitivity	Distracted by sounds/lights; notices everything
Low	Active	Sensation Avoiding	Avoids touch, crowds, movement; rigid routines

Sensory Diet

Intervention Strategies

Sensory diet: individualized plan of sensory activities throughout the day
Heavy work (proprioception): calms and organizes the nervous system
Alerting input: fast movement, light touch, bright colors
Calming input: slow rocking, deep pressure, dim lighting
Wilbarger Protocol: deep pressure and proprioception for tactile defensiveness
Therapeutic listening: modulated music to improve auditory processing

Cerebral Palsy (CP) ›

Non-progressive motor disorder from brain damage before/during/after birth
Types: Spastic (most common — UMN), Dyskinetic/Athetoid (involuntary movement), Ataxic (coordination)
Topography: Hemiplegia, Diplegia (LE mostly), Quadriplegia
OT focus: ADL training, positioning, splinting, AAC, adaptive equipment, feeding
NDT/Bobath approach used; also motor learning and task-specific training
Handling and positioning critical to prevent contractures and deformity

Autism Spectrum Disorder (ASD) ›

Deficits in social communication AND restricted/repetitive behaviors (DSM-5)
Sensory processing differences are core feature
OT focus: sensory regulation, social participation, ADL, play skills, school performance
Evidence-based approaches: ASI, ESDM (Early Start Denver Model), DIR/Floortime, ABA (behavioral)
AAC for nonverbal clients: PECS, SGDs
Visual schedules and structured environments reduce behavioral challenges

Exam TipASI (Ayres Sensory Integration) has the strongest evidence base for OT intervention in ASD for sensory-related goals. Know this for exam questions.

Down Syndrome (Trisomy 21) ›

Low muscle tone (hypotonia) — affects posture, fine motor, feeding, speech
Developmental delays across all domains
Atlantoaxial instability: no contact sports or tumbling — check before positioning
OT focus: fine motor, ADL skill development, sensory processing, social participation
Cardiac defects common — monitor endurance during therapy

ADHD ›

Types: Inattentive, Hyperactive-Impulsive, Combined (most common)
OT focus: executive function, handwriting, self-regulation, school performance, ADL routines
Sensory strategies: movement breaks, fidgets, weighted vests (with evidence consideration)
Visual schedules, checklists, and routines build executive function skills
Homework/organization: OT teaches strategies and environmental modifications

Legal Framework

IDEA & School-Based OT

IDEA (Individuals with Disabilities Education Act): guarantees free appropriate public education (FAPE)
Least Restrictive Environment (LRE): educate alongside non-disabled peers to maximum extent possible
IEP (Individualized Education Plan): OT services documented here; requires team collaboration
504 Plan: accommodations only (not special education); for students who don't qualify for IEP
OT services must relate to educational performance — not medical/therapeutic goals

Exam TipSchool-based OT goal must link to educational participation. "Child will button shirt to get dressed for school" qualifies. "Child will improve pincer grasp strength" alone does not.

Service Delivery

School OT Models

Pull-out: student seen individually outside classroom
Push-in/Inclusion: OT works with student in classroom context (preferred under LRE)
Consultation: OT advises teacher/staff; no direct student contact
Monitoring: periodic check-in for students maintaining skills
Handwriting: OT's primary role — Handwriting Without Tears (HWT), Size Matters Handwriting Program
Universal Design for Learning (UDL): OT contributes to classroom-wide supports

Assessment	Ages	What It Measures
Peabody Developmental Motor Scales-2 (PDMS-2)	Birth–5 years	Gross and fine motor development
Bruininks-Oseretsky Test (BOT-2)	4–21 years	Fine and gross motor proficiency
Sensory Profile-2 (SP-2)	Birth–14 years	Sensory processing patterns (caregiver report)
Sensory Processing Measure (SPM)	5–12 years	Sensory processing in home/school
SIPT (Sensory Integration and Praxis Tests)	4–8 years	Sensory integration; requires certification
WeeFIM	6 months–7 years	Functional independence (pediatric FIM)
Pediatric Evaluation of Disability Inventory (PEDI)	6 months–7.5 years	Functional skills and caregiver assistance
School AMPS	School-age	Motor/process skills during school tasks
Test of Visual Perceptual Skills (TVPS)	4–18 years	Visual perceptual skills (non-motor)
Beery VMI	2–100 years	Visual-motor integration (copying designs)

Hand & Upper Extremity

Hand Therapy & Upper Extremity Rehab

Consistently high-yield on the NBCOT. Know your nerve distributions, wound healing, tendon injuries, and common hand conditions cold.

Nerve	Motor Function	Sensory	Injury Deformity	OT Focus
Median (C6–T1)	Thenar muscles (thumb opposition, abduction); wrist flexion, finger flexion (FDP index/middle)	Palmar thumb, index, middle, radial ring	Ape hand (thenar wasting); thumb adducted	Thumb opposition splint; compensatory pinch
Ulnar (C8–T1)	Hypothenar, interossei, ring/small lumbricales; 4th/5th FDP	Ulnar 1.5 fingers (ring, small) palmar + dorsal	Claw hand (ring/small); Wartenberg's sign	Anti-claw splint; prevent contracture
Radial (C5–C8)	Wrist extensors, finger extensors, thumb extensors/abductors	Dorsal thumb and web space	Wrist drop (finger/wrist extension lost)	Wrist cock-up splint; tenodesis for function
Anterior Interosseous (median branch)	FPL, FDP (index/middle), pronator quadratus	None (motor only)	Unable to make "OK" sign	Tendon transfer planning; compensatory pinch

Exam Tip — Memory AidMedian = LOAF (Lumbricals 1&2, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis). Ulnar = all other hand intrinsics. Radial = all extensors.

Flexor Tendons

Flexor Tendon Zones & Protocols

Zone II ("No Man's Land") = between A1 pulley and FDS insertion — most challenging to treat due to both FDS and FDP tendons in tight sheath.

Duran: passive ROM protocol — early passive mobilization
Kleinert: dynamic flexion splint with active extension, passive flexion
Place & Hold: semi-active approach — place fingers in flexion, hold briefly
Early Active Motion (EAM): active protected motion — for strong repairs
Immobilization: for partial tears or children; splint in safe position

⚠ CriticalFollow the surgeon's protocol exactly. Premature active motion can rupture the repair; too much immobilization causes adhesions.

Extensor Tendons

Extensor Tendon Zones & Injuries

Mallet finger (Zone I): DIP droops due to extensor tendon disruption at distal phalanx; treat with DIP extension splint 6–8 weeks continuous
Boutonnière (Zone III): PIP flexion + DIP hyperextension; treat with PIP extension splint
Sagittal band rupture (Zone V): tendon subluxes; ring or buddy strap
Never allow DIP to flex during mallet splinting — even briefly resets healing

Exam TipMallet finger = DIP extension splint continuously for 6–8 weeks. Even ONE incident of DIP flexion restarts the healing clock.

Carpal Tunnel Syndrome (CTS) ›

Median nerve compression at wrist; most common peripheral nerve compression
Symptoms: numbness/tingling in thumb, index, middle fingers; nocturnal symptoms; thenar weakness late
Provocative tests: Phalen's (wrist flexion 60s), Tinel's (tap over carpal tunnel)
OT: neutral wrist splint (especially at night); activity modification; ergonomic education
Avoid prolonged wrist flexion/extension; reduce repetitive grip/pinch

De Quervain's Tenosynovitis ›

Inflammation of APL and EPB tendons at radial styloid
Pain with thumb use; positive Finkelstein's test (thumb into palm, ulnar deviate = sharp pain)
OT: thumb spica splint (immobilizes thumb CMC and MCP); activity modification; ice
Common in new parents, gamers, repetitive thumb use occupations

Rheumatoid Arthritis (RA) — Hand ›

Autoimmune; affects synovial joints; bilateral and symmetrical; morning stiffness >1 hour
Deformities: ulnar drift, boutonnière, swan neck, Z-thumb, wrist volar subluxation
Joint protection principles: use largest joint, avoid tight grasp, maintain ROM
OT: resting hand splints at night; functional splints during day; energy conservation; adaptive equipment
During flares: gentle AROM only; heat to increase extensibility; avoid resistance

Exam TipJoint protection education is a cornerstone of OT in RA. Principles: respect pain, avoid positions of deformity, use largest joint available, distribute load.

Dupuytren's Contracture ›

Palmar fascia thickening causing progressive finger flexion contracture (ring > small finger most common)
Post-surgical OT: wound care, edema management, extension splinting, ROM
Splinting: night extension splint to maintain gains; serial static or dynamic splinting

Burns — Hand & UE ›

Antideformity position: wrist extended, MCPs flexed 70–90°, IPs extended, thumb abducted ("intrinsic plus" position)
Burn scar management: compression garments, silicone, massage, stretching
Scar maturation: 12–24 months; active management throughout
Contracture prevention: splinting, stretching, compression = primary OT role
Donor site care: keep moist, protect from trauma

⚠ Antideformity PositionWrist extension, MCP flexion 70–90°, IP extension, thumb abduction. Failure to maintain leads to devastating contractures.

Phase	Timeline	Key Events	OT Considerations
Inflammatory	0–4 days	Redness, swelling, heat, pain; macrophages clean debris	Edema management, PRICE, positioning, gentle PROM only if cleared
Proliferative/Fibroplasia	4–21 days	Collagen deposition, fibroblasts, granulation tissue, new blood vessels	Begin gentle mobilization per protocol; wound care; scar management starts
Remodeling/Maturation	21 days–2 years	Collagen reorganization; scar strengthens and softens over time	Progressive strengthening, scar massage, compression, full ADL training

Edema Management HierarchyElevation → Active ROM/retrograde massage → Compression (Coban, glove) → Intermittent pneumatic compression → Manual edema mobilization (MEM)

Joint	Motion	Normal ROM
Shoulder	Flexion / Extension	0–180° / 0–60°
Shoulder	Abduction / Internal Rotation / External Rotation	0–180° / 0–70° / 0–90°
Elbow	Flexion / Extension	0–150° / 0°
Forearm	Supination / Pronation	0–80° / 0–80°
Wrist	Flexion / Extension	0–80° / 0–70°
Wrist	Radial Deviation / Ulnar Deviation	0–20° / 0–30°
MCP (fingers)	Flexion / Extension	0–90° / 0–45°
PIP (fingers)	Flexion / Extension	0–100° / 0°
DIP (fingers)	Flexion / Extension	0–70° / 0°
Thumb CMC	Abduction	0–70°
Thumb MCP	Flexion	0–60°
Thumb IP	Flexion	0–80°

Functional ROMFor most ADLs, functional wrist ROM = 10° flexion to 35° extension, 10° RD to 15° UD. Elbow functional = 30–130° flexion. Forearm functional = 50° each supination/pronation.

Anatomy & Kinesiology

Anatomy, MMT & Muscle Function

Key muscle origins, insertions, and MMT grading. Know your functional anatomy for both evaluation and intervention questions.

Grade	Label	Description
5	Normal	Full ROM against gravity; holds against maximum resistance
4	Good	Full ROM against gravity; holds against moderate resistance
3+	Fair+	Full ROM against gravity; holds against minimal resistance
3	Fair	Full ROM against gravity only; no added resistance
3−	Fair−	Partial ROM against gravity
2	Poor	Full ROM with gravity eliminated (horizontal plane)
1	Trace	Palpable muscle contraction; no visible movement
0	Zero	No palpable contraction

Key RuleGrade 3 = the critical threshold. A muscle graded 3 or higher can work against gravity. Below grade 3, gravity must be eliminated by positioning the limb in a horizontal plane during testing.

Muscle	Origin	Insertion	Action	Nerve
Biceps brachii	Supraglenoid tubercle; coracoid process	Radial tuberosity	Elbow flexion, supination	Musculocutaneous (C5–C6)
Triceps	Infraglenoid tubercle; posterior humerus	Olecranon	Elbow extension	Radial (C7–C8)
Deltoid	Clavicle, acromion, spine of scapula	Deltoid tuberosity	Shoulder abduction (middle); flex (ant); extend (post)	Axillary (C5–C6)
Rotator cuff (SITS)	Scapula	Greater/lesser tuberosity	Stabilize GH joint; IR/ER; abduction (supra)	Various (C5–C6)
Flexor Digitorum Profundus	Ulna	Distal phalanges 2–5	DIP flexion	Median (index/middle); Ulnar (ring/small)
Flexor Digitorum Superficialis	Medial epicondyle, radius	Middle phalanges 2–5	PIP flexion	Median
Extensor Digitorum Communis	Lateral epicondyle	Extensor hood, distal phalanges	MCP, PIP, DIP extension	Radial (posterior interosseous)
Lumbricals (1&2)	FDP tendons index/middle	Extensor hood	MCP flexion + IP extension	Median
Lumbricals (3&4)	FDP tendons ring/small	Extensor hood	MCP flexion + IP extension	Ulnar
Interossei (dorsal)	Adjacent metacarpals	Proximal phalanges, extensor hood	Finger abduction (DAB)	Ulnar
Interossei (palmar)	Metacarpal shafts	Proximal phalanges, extensor hood	Finger adduction (PAD)	Ulnar

Level	Dermatome Area	Key Myotome (muscle action)	Clinical Note
C4	Cape of shoulder	Shoulder shrug (trapezius)	Diaphragm (phrenic nerve) — breathing
C5	Lateral arm — deltoid patch	Shoulder abduction (deltoid); Elbow flexion (biceps)	C5 SCI: can flex elbow; feeds self with adaptive equipment
C6	Lateral forearm, thumb, index finger	Wrist extension (ECRL/ECRB); elbow flexion (biceps)	Tenodesis grasp; independent feeding, grooming, driving
C7	Middle finger	Elbow extension (triceps); wrist flexion; finger extension	Key for transfers and WC propulsion
C8	Ring and small fingers, medial forearm	Finger flexion (FDP); thumb extension	Fine finger control; hand function improving
T1	Medial arm/elbow	Finger abduction/adduction (interossei)	Full hand intrinsic function
L2–L3	Anterior thigh	Hip flexion (iliopsoas); hip adduction	Ambulation potential improves below L2
L3–L4	Anterior knee, medial leg	Knee extension (quadriceps)	Knee control for standing/ambulation
L4	Medial foot, great toe (medial)	Ankle dorsiflexion (tibialis anterior)	Foot drop if absent; AFO may be needed
L5	Dorsal foot, great toe (dorsal)	Great toe extension (EHL); hip abduction	Controls toe clearance during gait
S1	Lateral foot, sole, lateral heel	Ankle plantarflexion (gastroc/soleus)	Push-off during gait; bladder/bowel function

Splinting & Orthotics

Splint Design, Types & Indications

One of OT's most unique clinical skills. Know splint types, positions, purposes, and common diagnoses for each.

Splint Name	Type	Position	Purpose / Indication
Wrist Cock-Up (Wrist Extension)	Static	Wrist 20–30° extension	CTS, wrist pain, radial nerve palsy, RA rest
Resting Hand Splint	Static	Wrist 20–30° ext, MCP 45–70° flex, IPs neutral	RA night splint, spasticity positioning, post-burn
Thumb Spica	Static	Thumb CMC abduction + MCP neutral	De Quervain's, thumb CMC arthritis, UCL injury
Anti-Spasticity Ball Splint	Static	Fingers extended and abducted	CVA/TBI spasticity; prevents hand contracture
Anti-Claw Splint (Ulnar Gutter)	Static	MCP flexion 70° (ring/small); IPs free	Ulnar nerve palsy; prevents claw deformity
DIP Extension Splint	Static	DIP full extension	Mallet finger; DIP extensor tendon repair
Relative Motion Splint	Static	Injured digit MCP in relative extension/flexion	Extensor tendon injuries Zones 5–7
Dynamic Flexion Splint (Kleinert)	Dynamic	Rubber band traction into flexion; active extension	Flexor tendon repair (post-op)
Dynamic Extension Splint	Dynamic	Spring-assist or elastic into extension	Flexion contractures; radial nerve palsy
Tenodesis Splint	Dynamic	Wrist extends → fingers flex (passive)	C6 SCI; enhances functional grasp
Serial Static Splint	Serial Static	End-range stretch; remolded as ROM improves	Flexion contractures; burn contractures

Diagnosis	Splint(s)	Wear Schedule
Carpal Tunnel Syndrome	Wrist cock-up (neutral position)	Night wear; during provoking activities
Mallet Finger	DIP extension splint	Continuous 6–8 weeks; do NOT allow DIP to flex
Boutonnière Deformity	PIP extension splint	Continuous initially; DIP free to flex
Radial Nerve Palsy	Wrist cock-up or dynamic extension	During function to improve ADL performance
Ulnar Nerve Palsy	Anti-claw (MCP flexion block)	Functional use; prevents claw progression
CVA / Spasticity	Resting hand or anti-spasticity	Night resting; not during active therapy
RA (acute flare)	Resting hand splint	Night; rest during flares
Burns (acute)	Antideformity splint	Between exercise sessions; during sleep
C6 SCI	Tenodesis splint	During ADLs requiring grasp
De Quervain's	Thumb spica	Continuous initially; wean as symptoms resolve

Design Principles

Splint Fabrication Rules

Two-thirds rule: splint should cover 2/3 of the length and circumference of the limb segment
Bony prominences: pad over all prominences to prevent pressure sores
Outrigger angle: 90° pull angle maximizes mechanical advantage for dynamic splints
Straps: three-point pressure for correction; broad straps distribute pressure
Thermoplastic selection: match material to purpose — rigid (control), conforming (comfort)
Skin inspection: educate client to check every 20–30 min initially

Safe Position

Position of Safe Immobilization

Used when etiology is unknown or during acute edema to prevent ligament contracture:

Wrist: 20–30° extension
MCPs: 70–90° flexion (preserves collateral ligaments)
IPs: full extension (prevents flexion contracture)
Thumb: abduction and opposition (prevents adduction contracture)

vs. Anti-Deformity (Burns)Both are similar! Burns = "intrinsic plus" = same position. The key difference is that burn splints must be worn very consistently due to aggressive scar contracture.

Adaptive Equipment & Assistive Technology

Adaptive Equipment by Task & Diagnosis

Know what to recommend, when, and why. The NBCOT tests your ability to match the right equipment to the right client situation.

Equipment	Purpose	Diagnoses / Indications
Built-up handles	Reduce grip force; easier grasp	RA, weak grip, SCI C5–C6, arthritis
Universal cuff	Holds utensil without grip	SCI C5, quadriplegia, weak hand intrinsics
Rocker knife	One-handed cutting	Hemiplegia, single UE amputation
Dycem / non-slip mat	Stabilizes objects without holding	Hemiplegia, incoordination, one-handed
Long-handled sponge/reacher	Reach without bending	Hip precautions post-THA, LE weakness, obesity
Dressing stick	Push/pull clothing without bending	Hip precautions, decreased ROM, LE weakness
Sock aid	Don socks without bending	Hip precautions, LE coordination deficits
Button hook	Threading buttons one-handed	Hemiplegia, SCI, fine motor deficits
Elastic shoelaces	No tying needed	Fine motor deficits, one-handed, cognitive
Plate guard / scoop dish	Push food onto utensil one-handed	Hemiplegia, incoordination
Weighted utensils	Reduce intention tremor	MS, Parkinson's, TBI with tremor
Shower chair / tub bench	Seated bathing; reduces fall risk	Balance deficits, LE weakness, post-surgical
Grab bars	Safety and support in bathroom	All clients with fall risk, balance deficits
Long-handled bath brush	Bathe LE without trunk flexion	Hip precautions, obesity, trunk ROM limits

Equipment	Indication	OT Role
Standard walker	Bilateral stability needed; low endurance; cognitively impaired	Train use, ensure proper height (elbow 15–20° flex)
Wheeled walker (2-wheel)	Needs forward push; Parkinson's freezing	Cue initiation strategies
4-wheel rollator	Better endurance; community mobility	Requires more coordination; assess safety
Quad cane	Unilateral weakness; more stable than straight cane	Use on unaffected side; advance with affected leg
Manual wheelchair	LE non-weight bearing; paraplegia; SCI T1+	Propulsion training, pressure relief, cushion selection
Power wheelchair	C4 and above, MS, ALS, severe weakness	Joystick or alternative control training; safety
Transfer board (sliding board)	Cannot stand for transfers; SCI, lower extremity amputee	Teach technique; ensure surface height equality
Hoyer lift / mechanical lift	Full assist transfers; total dependence	Caregiver training; proper sling fitting

Hip Precautions (Post-THA — Posterior Approach)No flexion past 90°, no adduction past midline, no internal rotation. OT provides: raised toilet seat, long-handled equipment, dressing techniques, and patient education.

AAC Systems

Augmentative & Alternative Communication

Unaided AAC: gestures, sign language, facial expression
Low-tech aided: picture boards, PECS (Picture Exchange Communication System), letter boards
High-tech aided: Speech Generating Devices (SGDs), apps (Proloquo2Go), eye-gaze systems
Access methods: direct selection, scanning, switch access, eye gaze
OT role: position device, assess access method, integrate into daily activities
Populations: ALS, ASD, CP, Locked-in Syndrome, global aphasia

Environmental Control

Smart Home & ECUs

Environmental Control Units (ECUs): control lights, TV, phone, doors via switch or voice
Voice activation: Amazon Echo, Google Home — integrate for high-level SCI, ALS
Smart home technology: high ROI for independence in severe disability
Computer access: alternative keyboards, mouse alternatives, voice recognition (Dragon)
Vision impairment AT: screen readers, magnification software, high-contrast displays

Home Assessment

Home Modification Priorities

Entrance: ramp (1:12 slope ratio), threshold removal, lever door handles
Bathroom: grab bars (toilet, tub, shower), roll-in shower, fold-down shower bench, handheld showerhead
Kitchen: pullout shelves, lever faucets, lowered countertops for WC users
Bedroom: bed height adjustment (WC transfers), path clearance (36" min for WC)
Lighting: adequate lighting throughout, nightlights for fall prevention
Flooring: remove throw rugs, smooth transitions between surfaces

Exam TipHome modifications must be client-centered — consider the client's goals, lifestyle, and financial situation. The OT recommends; the client and family decide.

Universal Design

Design for All Principles

Equitable use: design useful to all people
Flexibility: accommodates wide range of preferences/abilities
Simple and intuitive: easy to understand regardless of experience
Perceptible information: communicates effectively to all users
Tolerance for error: minimizes hazards of unintended actions
Low physical effort: efficient and comfortable
Size and space for approach: appropriate for all users

Pharmacology for OT

Medications That Affect OT Practice

OTs don't prescribe medications, but you must understand how common drugs affect client function, behavior, and therapy participation.

Drug Class	Common Examples	OT-Relevant Side Effects	Clinical Implications
Antipsychotics (typical)	Haloperidol (Haldol), Chlorpromazine	Tardive dyskinesia, EPS (rigidity, tremor), sedation, orthostatic hypotension	Watch for movement disorders affecting ADLs; fall risk; assess for EPS before therapy
Antipsychotics (atypical)	Risperidone, Clozapine, Quetiapine	Weight gain, sedation, metabolic effects, less EPS	Monitor energy/endurance; support metabolic health habits
Antidepressants (SSRIs)	Fluoxetine (Prozac), Sertraline (Zoloft)	Nausea initially, sexual dysfunction, insomnia or sedation	Allow time for medication to reach efficacy (2–6 weeks); adjust timing of therapy
Benzodiazepines	Lorazepam (Ativan), Diazepam (Valium)	Sedation, cognitive impairment, fall risk, paradoxical agitation in elderly	High fall risk; do NOT assume cognition is baseline; avoid complex tasks when sedated
Antispasmodics	Baclofen, Tizanidine, Dantrolene	Sedation, weakness, hypotonia (overmedication)	Tone reduction may improve function but excess can reduce functional spasticity used for transfers
Anticonvulsants	Phenytoin, Valproate, Gabapentin	Sedation, ataxia, cognitive dulling, coordination deficits	Address balance and coordination; cognitive strategies; schedule therapy at optimal medication timing
Corticosteroids	Prednisone, Methylprednisolone	Proximal muscle weakness, osteoporosis risk, skin fragility, mood changes	Modify resistance exercises; fall prevention; skin protection in splinting/orthotics
Anticholinergics	Benztropine, Oxybutynin	Confusion (especially elderly), dry mouth, blurred vision, urinary retention	Assess cognition before assuming baseline; vision precautions in ADLs
Beta-Blockers	Metoprolol, Atenolol	Fatigue, reduced heart rate response to exercise	Cannot use HR as sole exercise intensity indicator; use RPE (Borg Scale) instead
Anticoagulants	Warfarin (Coumadin), Heparin, Apixaban	Increased bleeding risk; bruising	Avoid deep tissue massage, invasive procedures; fall prevention is critical
Antiparkinsonian	Levodopa/Carbidopa (Sinemet)	"On/Off" fluctuations, dyskinesias when "on," freezing when "off"	Schedule complex therapy during "on" periods; simple/routine tasks during "off"
Opioids	Oxycodone, Morphine, Tramadol	Sedation, cognitive impairment, constipation, fall risk	Pain management supports therapy participation; monitor sedation; alternative pain strategies

NBCOT Exam TipKnow that OTs address the functional impact of medications — not the medications themselves. Key exam scenarios: (1) elderly client on benzodiazepines = fall risk, (2) SCI client on baclofen = monitor for functional tone loss, (3) PD client on Sinemet = schedule therapy during "on" time.

Billing & Documentation

Medicare, Medicaid & OT Documentation

Understanding reimbursement, skilled service criteria, and documentation standards is tested on the NBCOT — and essential for professional practice.

Medicare Parts

Medicare Coverage

Part	Covers	OT Relevance
Part A	Inpatient hospital, SNF, hospice, some home health	OT in acute care, SNF (must have qualifying 3-day hospital stay)
Part B	Outpatient, physician services, home health, DME	OT outpatient, home health (when homebound), DME (wheelchairs, splints)
Part C	Medicare Advantage (private plans)	Varies by plan; may have additional OT benefits
Part D	Prescription drugs	Not directly OT, but affects medication management IADL

Homebound Status

Home Health Criteria

Client must be "homebound" to receive Medicare home health OT (Part A or B):

Leaving home requires considerable and taxing effort
Medical condition restricts ability to leave home
Or leaving home is medically contraindicated
Occasional brief absences permitted (medical appointments, adult day care, religious services)
OT in home health: must be skilled and reasonable/necessary

Exam TipOT cannot initiate home health services alone under Medicare — a skilled nursing or PT need must be established first. OT can continue services after other disciplines discharge.

Skilled Service

What Makes OT "Skilled"

Services require the judgment and skill of a licensed OT (or supervised OTA)
Cannot be safely and effectively performed by the patient, family, or unskilled caregiver
Clinical judgment required: evaluation, interpretation, complex intervention
Teaching and training: skilled when requires OT expertise to instruct
Maintenance programs: CAN be skilled if OT skill needed to design and periodically reassess

Exam TipDocumenting WHY OT skill is required is essential. "Client performed exercises" is not skilled. "OT graded exercise intensity, monitored for compensatory patterns, and cued for joint protection" IS skilled.

Reasonable & Necessary

Coverage Criteria

Reasonable: consistent with client's diagnosis, condition, and goals
Necessary: required for the condition; not for general wellness
Expectation of improvement: OR maintenance of function/prevent decline (Jimmo settlement)
Frequency and duration: must be consistent with expected recovery
Documentation must support medical necessity at every visit

Setting	OT Role	Payer	Key Documentation
Acute Care Hospital	ADL eval, safety, discharge planning, equipment	Medicare Part A, private insurance	Daily notes; discharge summary
Inpatient Rehab (IRF)	Intensive ADL, cognition, UE; 3 hours therapy/day	Medicare Part A; requires 60% rule diagnosis	Admission eval; weekly updates; FIM scores
Skilled Nursing Facility (SNF)	ADL retraining, maintenance programs, dementia care	Medicare Part A (100 days); Medicaid LTC	MDS (Minimum Data Set); daily skilled notes
Home Health	Home safety, ADLs, IADL, caregiver training, home mods	Medicare Part A/B; must be homebound	OASIS assessment; visit notes; POC
Outpatient	Hand therapy, work rehab, neuro OT, community re-entry	Medicare Part B; private insurance; workers' comp	Initial eval; POC; progress notes; discharge
School (IDEA)	Educational participation, handwriting, sensory, ADLs	IDEA federal funding; school budget	IEP goals; progress reports
Mental Health	ADL, IADL, social participation, psychosocial groups	Medicaid; private insurance; community mental health	Treatment plan; group notes; discharge

SOAP Notes

Documentation Format

S — Subjective: what the client says ("I want to be able to dress myself")
O — Objective: measurable, observable data (ROM, FIM scores, performance observations)
A — Assessment: OT's clinical interpretation; progress toward goals; barriers; skill required
P — Plan: next steps, frequency, upcoming interventions, referrals

NBCOT Documentation RuleIf it's not documented, it didn't happen. Documentation must reflect SKILLED services, progress/regression, and clinical reasoning — not just a list of activities.

Plan of Care

POC Requirements

Must include: diagnosis, goals (SMART), frequency/duration, interventions planned
Physician signature required for Medicare billing
Re-certification: required every 60 days (home health) or at certification period end
Progress notes: must document toward/away from goals
Functional reporting: G-codes (though updated — know concept of functional status reporting)

Cultural Competency & Health Equity

Cultural Competency in OT Practice

Providing culturally responsive, equitable care is an AOTA core value and a tested concept on the NBCOT exam.

Core Concepts

Cultural Humility & Competency

Cultural competence: ongoing process of developing awareness, knowledge, skills to work across cultures
Cultural humility: lifelong learning approach; acknowledging one's own biases and limitations
Implicit bias: unconscious attitudes that affect clinical decisions — OT must actively reflect on these
Occupational justice: everyone deserves access to meaningful occupation regardless of culture, identity, or status
Occupational deprivation, marginalization, apartheid: systems that restrict participation

Clinical Application

Culturally Responsive OT Practice

Always ask about cultural practices affecting daily routines, diet, hygiene, religious observance
Family involvement: some cultures prefer collective decision-making — include family with client's consent
Language access: use certified medical interpreters (not family members) for clinical decisions
Modesty: ask about preferences for gender of therapist; adjust examination accordingly
Goal setting: align occupation-based goals with the client's cultural values, not the OT's assumptions

Exam TipWhen a question involves a client from a different cultural background, the BEST answer always involves asking the client about their preferences and values — never assuming based on ethnicity or identity.

Health Literacy

Communication Across Health Literacy Levels

Nearly 90 million Americans have limited health literacy
Teach-back method: ask client to explain instructions back in their own words — gold standard
Plain language: 6th grade reading level; avoid medical jargon
Visual supports: pictures, diagrams, video demonstrations enhance understanding
Written HEPs: must be readable and culturally appropriate
Never shame clients for not understanding — it's the clinician's responsibility to communicate effectively

AOTA & Social Justice

Occupational Justice Framework

Occupational injustice types: deprivation (no access), alienation (forced participation), marginalization (excluded), imbalance (too much/little)
AOTA's Centennial Vision: OT as science-driven, evidence-based, globally connected
OT's role in addressing SDOH (Social Determinants of Health): housing, food security, transportation, education
Community-based OT: extends practice beyond clinic to address occupational justice at population level

High-Yield Review

Quick Sheets — High-yield review, fast

Condensed, exam-focused one-pagers for last-minute review. No fluff. Only what matters on exam day.

🧪

Assessment A–Z

All key standardized assessments, populations, and what they measure

Domain 1

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Frames of Reference

Quick-reference FOR comparison: theory, population, and application

Domain 2

💊

Conditions Cheat Sheet

Top diagnoses, precautions, and OT considerations

Domains 1–2

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AOTA Ethics Codes

All 6 ethical principles with clinical scenario examples

Domain 4

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Goal Writing Guide

SMART goal formula with examples across all practice settings

Domain 3

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Practice Settings

OT roles, documentation, and supervision across all settings

All Domains

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Hand & UE Anatomy

Nerve distribution, splint types, ROM norms, tendon injury protocols

Domain 2

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Pediatric Milestones

Developmental milestones, reflexes, red flags, and peds assessments

Domain 2

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Pharmacology Guide

Drug classes, side effects, and OT clinical implications

Domain 4

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Mental Health OT

Diagnoses, psychosocial FORs, groups, and therapeutic use of self

Domain 2

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Billing & Documentation

Medicare parts, skilled criteria, SOAP notes, practice settings

Domain 3–4

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Cultural Competency

Cultural humility, health literacy, occupational justice principles

Domain 4

Questions Answered

Frequently asked questions

About the NBCOT exam and OT / Blueprint platform.

How many questions are on the NBCOT exam? ›

The NBCOT OTR exam consists of 170 scored questions (plus 10 pilot/unscored questions) and must be completed in 4 hours. Questions are scenario-based and test clinical reasoning across all four domains.

How long do I have access after purchasing? ›

Lifetime. This is a one-time payment with no expiration. If you need to retake the exam, you can return to all materials at no additional cost. All future content updates are included.

Is this enough to pass without any other materials? ›

OT / Blueprint covers key topics and clinical notes across all 4 NBCOT domains and is designed to support your exam review. It works best as part of a broader study plan — most students find it helpful alongside other resources such as a question bank or their program notes.

I've failed the NBCOT before. Is this still for me? ›

Absolutely — this platform was built with repeat test takers in mind. The domain-by-domain structure, condition-specific content, and targeted question generator help you pinpoint exactly where your knowledge gaps are.

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The current content is designed for OTR (occupational therapist registered) candidates. A COTA-specific version is in development. Join the waitlist via the contact form below.

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OT Blueprint

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All four NBCOT domains, simplified

Neurological Conditions

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C6 Function — Critical for Exam

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Sensory Processing Overview

Dunn's Model

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IDEA & School-Based OT

School OT Models

Hand Therapy & Upper Extremity Rehab

Flexor Tendon Zones & Protocols

Extensor Tendon Zones & Injuries

Anatomy, MMT & Muscle Function

Splint Design, Types & Indications

Splint Fabrication Rules

Position of Safe Immobilization

Adaptive Equipment by Task & Diagnosis

Augmentative & Alternative Communication

Smart Home & ECUs

Home Modification Priorities

Design for All Principles

Medications That Affect OT Practice

Medicare, Medicaid & OT Documentation

Medicare Coverage

Home Health Criteria

What Makes OT "Skilled"

Coverage Criteria

Documentation Format

POC Requirements

Cultural Competency in OT Practice

Cultural Humility & Competency

Culturally Responsive OT Practice

Communication Across Health Literacy Levels

Occupational Justice Framework

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