Thursday, November 30, 2006

physical agent modalities and competency in occupational therapy

It will be interesting to see how far and wide this issue travels - I expect that my answer will make some people angry and other people very happy - but either way I view this as a question that comes along that is just too good for me to ignore -

Today I was asked for my opinion on the following question:

"I am a COTA and I have attended a couple of workshops on Anadyne Therapy. It is an infrared treatment modality used to treat patients with peripheral neuropathy. Treatment will initially consist of a pre-sensory test (Semmes-Weinstein monofilaments), treatment with the Anadyne and fine motor exercises. The question is: Does an OTR have to do the initial evaluation which would be the pre-sensory test prior to the treament? I am able to conduct the test and the treatment but I don't know if legally I can."

Here is my response:

According to the NY State Board of Regents, occupational therapy assistants as a rule have not demonstrated competence to perform evaluations, so they generally do not perform them. All licensed individuals must practice within their personal scope of competence. However, the occupational therapy supervisor may delegate performing an evaluation to the occupational therapy assistant if the occupational therapy assistant has demonstrated competence to perform evaluations. That leaves professional responsibility for errors of commission or omission between the OTR and COTA who decide to have the COTA complete an evaluation. So whether or not you are capable of completing evaluations is entirely between you and your supervising OTR.

In any event, the individual practitioner is subject to Part 29 Rules of the Board of Regents which requires that licensees practice within their personal scope of competence. If you are not competent to provide a service that you are legally allowed to provide, then you may not provide that service. As a licensed professional, it is your responsibility to practice within the scope of your abilities and expertise. If you practice outside your personal scope of competence, you can be charged with professional misconduct.

Under the Regulations of the Commissioner, Part 76, it states that OT interventions include, where appropriate for such purposes, and under appropriate conditions, modalities and techniques based on approaches taught in an occupational therapy curriculum and included in a program of professional education in occupational therapy registered by the department, and consistent with areas of individual competence. These approaches are based on:

The neurological and physiological sciences as taught in a registered occupational therapy professional education program. Modalities and techniques may be based on, but not limited to, any one or more of the following:

sensory integrative approaches;
developmental approaches;
sensorimotor approaches;
neurophysiological treatment approaches;
muscle reeducation;
superficial heat and cold; or
cognitive and perceptual remediation.

Infrared or phototherapy is not mentioned at all in the regulations. I am not aware that this is a standard part of any occupational therapy curriculum and I do not know that it really falls within the occupational therapy scope of practice. I would highly doubt that infrared biophysiology is taught in the typical OTA curriculum, as it involves high level educational background in both chemistry and physics.

As the use of infrared can cause severe harm if inadvertently applied over a malignancy or a pregnancy, and as there is reason to debate if it is even an appropriate OT modality, and particularly given the fact that attending a couple inservices certainly doesn't qualify someone to use a potentially dangerous modality - I would strongly suggest that a COTAs use of this modality in these circumstances could potentially constitute professional misconduct.

Unless you have background in chemistry and physics, and unless you can understand and articulate and explain the biophysical changes that are occurring at the tissue level as a result of the IR (e.g. nitric oxide microcirculation effects), and unless you have had formal training that involves evaluation and competency assessment - I would recommend that you steer clear of this intervention modality.

As an OTR with a clinical doctorate and 20 years of experience and who has taken chemistry and physics courses and who has a basic understanding of how IR works - I still don't believe it is an appropriate OT modality and I would never use it. That is my professional opinion.

This has nothing to do with the potential efficacy of IR interventions - this is just a statement on competency and appropriateness of this modality for OT in general and by COTAs in particular.

As an aside, I am continually shocked and amazed at what some OTs think they are qualified to do. I hope that PTs far and wide smack down any OTs who use modalities that they are not appropriately educated and trained to use. Training also has to include competency assessment.

A final thought for OTs: if you look at a problem and all you can see is a peripheral neuropathy and that perhaps the best intervention is to mediate the problem with a physical agent modality and exercise - are you really still an occupational therapist?


References:

Check your state's licensure laws - here is the link to the NY info:
http://www.op.nysed.gov/article156.htm

Tuesday, November 28, 2006

The Day I Saved Andy’s Life

I am not in a life-saving profession - at least not in the traditional medical interpretation of life-saving. I was never really interested in wielding that kind of power, although in many ways I think that I have learned that traditional life-saving power is easily reducible to a little chemistry, a little anatomy, a little slight of hand and technical know-how. Little else.

This is not meant to downplay that technical expertise though. Actually I am humbled by those who perform such acts on a daily basis.

I saved someone's life once. That is what I have been told anyway. I like to tell this story because the moral is that sometimes you might be in a position to make a difference, even if you did not put yourself in that position, and even if you had no intention of making a difference. I think that is important information to have tucked away for reference purposes.

One day my phone rang and it was my buddy John. John was an itinerant therapist in the truest sense of the word - meaning that he participated in his health care career episodically. Last I knew he was an FBI agent. Anyway, he told me "I told my sister-in-law to call you because they are worried about their son Andy's development - he is around 16 months old and he isn't walking yet. They are pretty worried, and I think they are going to call you this afternoon."

"No problem, John," I replied. "I'll see them right away." As I hung up the phone I remembered what a good friend John was, and that I was glad to do this for him. For his family, really. Immediately, the phone rang. It was John's in-laws, and we made an appointment for that afternoon. It was a late appointment, after hours, but I wanted to accommodate them. Least I could do.

Because of seeing him so quickly, the parents were not able to get a referral - this meant that their insurance might not cover the evaluation. As they went through the intake process and I listened to them debate the potential cost I grabbed the paperwork from them and told the receptionist we would worry about the insurance later.

"Andy's not been feeling well lately," his parents stated as I took a history. He had achieved all of his developmental milestones in a typical fashion but at 12 months everything seemed to stall. He stopped pulling himself up to furniture. He never took an independent step. And he was chronically ill: low grade fevers, sleeping more often, vomiting. His pediatrician was stumped, and kept recommending symptomatic treatment. Because Andy was not walking, the pediatrician agreed to refer him to a neurologist, but the waiting list was long and the appointment was not for another month. The parents couldn't wait that long, happened to mention it to John, and that is why they came to see me. I am not a neurologist, nor a diagnostician, but I am trained to complete developmental evaluations - and that would at least be a start.

Andy was cachectic. Pale. Clinging to his mother. He was clearly ill. I listened to the parents concerns as they explained the change in his behavior over the last couple months. They also expressed their concern that they couldn't see the neurologist as soon as they wanted to. Andy demonstrated typical development for fine motor skills, but when he reached for toys I noticed a subtle unsteadiness in his movements. The subtlety is difficult to describe... my initial impressions were that my eyes were de-focusing. As I concentrated strongly I could see that his entire body had a very slight shakiness to it. It was not just his hand or arm; the shaking was central to his trunk as well. It did not measurably impact on his performance, and he was able to crawl for mobility. When he was placed in a standing position he would become very upset and cry uncontrollably. "He does that every time we try to make him stand," the father stated. "It's as if he doesn't like the way it feels when he stands."

"Always listen to parents," I repeated in my mind as I tucked the information away. Although parents generally don't know the medical terminology or reasons, they are usually best at describing and identifying symptoms.

As I completed my observations, I was moving Andy's legs and arms to measure his range of motion and muscle tone. His ankles felt a little tight to me, but that is not always uncommon in children that are growing quickly. I quickly stretched the muscles to elicit any abnormalities in muscle tone, but there were none. Whimsically, I tapped on the patellar tendon to check deep tendon reflexes. His leg shot out *briskly* - moreso than it should have. As I tested these reflexes in other areas I noticed that they were all quite brisk. "Wow," I thought to myself. "I generally don't bother checking these reflexes, particularly in a child with no known problems, and I was glad that I took the time to check." I talk to myself all the time while completing evaluations.

I sat back to consider my observations, and started reaching for words that I could say to the parents. They wanted an opinion. They wanted to DO something to help their child. This is the moment when the therapist is on the hot seat.

As we began to chat, Andy burped, and then vomited. This was not your typical regurgitation of recently consumed liquid that can accompany a baby's hearty belch: this vomit came from someplace deeper, and it shot out of his mouth exorcist-style all over my cabinets. This is where having children can help a therapist keep their cool. I could handle vomit. I went into cleanup mode, shutting down my sensory awareness of smell and touch as I cleaned up. "I can do this," I thought to myself - just as I had done many times with my own children. "Dear God," I prayed quietly, "please help me do this."

As the parents bustled alongside me, cleaning up Andy, cleaning up everything, they worried together about his being sick, about how they had just been to the pediatrician yesterday and he said to just let 'the virus' run its course. "Just keep hydrating him," the doctor told them... I don't know if it was the vomit, or my own mind spinning, but their voices fell into the background as other pieces of information came swirling together into a logical and deadly serious pattern.

Andy had a history of unexplained low-grade fevers. He lacked energy. He *looked* sick. His motor development stopped, and he had no tolerance for being in positions where his balance was challenged. He had that very slight... ataxia? "Ataxia," I said to myself. "That is what I am seeing. And brisk deep tendon reflexes. But I paused myself, knowing that I don't always even bother to check them. "Maybe they weren't that brisk," I said to myself as I tried to talk myself out of my observations. Then I continued to think... "Projectile vomiting???" Excusing myself, I ran to the phone.

In my office, I attempted to call the pediatrician, but could not reach him. I had him paged, but he did not return the call. My mind spinning, I phoned the medical director of our division. "Dr. Johnson, I have a kid here with..." as I described all of the symptoms. "I think I should send him to the emergency room, but I can't reach the pediatrician." Dr. Johnson, ever politically correct, told me - "You're on your own then. The pediatrician should be the one to make that call though, and as I am not there I don't know what to tell you. I suggest that you keep trying to reach the pediatrician." No help there.

As I walked back to the therapy room, I knew the parents would want an explanation. I considered the fact that they were worried about insurance coverage, and I knew that having no referral to the emergency room would really cost them some money. But as I walked I considered my experience. I read these symptoms before in my textbooks. I read them in charts of patients. I knew that I needed to trust myself. Without giving a single explanation or point of justification I told the parents with conviction, "I suggest that you try to see a neurologist sooner than your scheduled appointment. If you go to the emergency department you can insist that they call the attending neurologist." I swallowed the lump in my throat as I considered the charges they were about to incur because we had no referral to the emergency department. "If it were my child, I would go now."

Andy's parents looked at each other, looked at me, and without a word between them both responded, "Let's go."

I escorted the family downstairs to the emergency department, wondering if I would incur the wrath of the pediatrician, of the parents, and the ridicule of the emergency department staff. But I saw what I saw what I saw what I saw. There was no refuting what I saw. I provided a copy of my observations to the Emergency Department resident who read my notes with a cocked eyebrow. "This is a gutsy report," he told me. "I better call the attending."

I said goodbye to the family, trying to put the whole sequence of events out of my mind as I drove home to my own children. All night long my observations replayed in my head. Did I really see what I thought I saw? I am not prone to questioning myself. But I questioned myself all night.

The next day was a Saturday, and I was scheduled to work. I checked the computer system to see if Andy was discharged but it said that he wasn't. I decided that this didn't mean anything because billing entries are often a little delayed on the weekend. He may have gone home and it just wasn't recorded yet.

As I made my rounds in the pediatric ICU I looked up at the board to see where my patients were. I saw Andy's last name on the board, and I immediately ran to his bedside and grabbed the chart.

As I scanned the notes I read the diagnosis over and over again. Posterior fossa medullablastoma. As the tumor was so advanced they chose to operate immediately - that very night. I looked up to see Andy resting quietly in bed, the gentle whir of the ventilator pushing air into his lungs. The back of his head was shaved, and he had an externalized shunt to drain excess fluid off of his brain.

One of the medical fellows in the ICU walked up beside me, saying, "I hear that someone in your department made a good catch on this case. Neurosurgical service said his tumor was so big that it was a wonder he was not in a coma. He is lucky to be alive."

"Oh. Wow." I sputtered out, not knowing what else to say.

Andy had to have a second operation because they could not remove the tumor entirely the first time. He also underwent radiation treatments and chemotherapy. He survived, although he had some significant brain damage as a result of the tumor and the effects of all the treatments.

Andy became a regular at the hospital for the next few years as he went through all of this treatment. Each time I would see the family they would turn to any person that was walking by, grab them, and say, "This is the man who saved our son's life." I always thought to myself that it was really the neurosurgeon and the ICU staff who technically saved his life. I never got used to them saying this, but I always graciously accepted their thanks.

Last that I knew, Andy was attending school and living at home. He is blind, and severely mentally retarded. But he is a member of his family, and he is loved. And he is alive.

When I doubt myself, or when I think I should go home early, or if I accidentally let insurance issues get in the way - I think of Andy. And I think that sometimes you can make a difference even when it is not your immediate intention.

Monday, November 20, 2006

Monday, November 13, 2006

child passenger safety

I don't typically pass around web sites that I think people should go visit although I have done so lately. I hope that when people see that I am referring a web site that it is not the equivalence of junk mail or spam. I would only send you somewhere that I really think you need to visit.

I got involved in child passenger safety sometime in the late 90s. I was forced there out of necessity and parent demand - a parent whose child had a spica cast chastised the hospital I was working in because there was no appropriate restraint to send her child home in. I am thankful to that parent to this day; I am not sure if she is aware of the changes that were made because of her concerns.

I educated myself on the issue and learned that a nationwide education campaign resulted in increased use of child restraint devices in automobiles but many children are still restrained improperly (Glassbrenner, 2003). National studies demonstrate that the misuse rate of child restraint devices in automobiles is as high as 80% (NHTSA, 1996). Proper installation and use of car seats is extremely effective in saving children's lives and reducing the risk of injury. Specifically, child safety seats reduce the risk of death in passenger cars by about 70% for infants and 55% for toddlers ages one to four (NHTSA, 2001).

Even with education and even with good intents and even when procedures are followed there is still no such thing as a guarantee. Click here to watch the a video tribute to Kyle David Miller; his parents uploaded this video to YouTube and you all really need to see it.


References:

Glassbrenner, D. (2003, February). The use of child restraints in 2002. Retrieved September 3, 2003, from http://www.nhtsa.dot.gov/CPS/ChildRestraints
/ChildRestraints.html

National Highway Traffic Safety Administration, U.S. Department of Transportation. Observed patterns of misuse of child safety seats. Traffic Tech, Sept. 1996. Washington (DC): NHTSA; 1996.

National Highway Traffic Safety Administration, U.S. Department of Transportation. Traffic Safety Facts 2000: Occupant protection. Washington: NHTSA; 2001. Available from: URL: www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2000/2000occfacts.pdf.

http://www.youtube.com/watch?v=azgBhZfcqaQ&NR

Tuesday, November 07, 2006

Clinical problem solving in occupational therapy and the need to eliminate special case thinking

Lots and lots of questions these days and I am doing my best to answer them...

What I would like to try here is to throw my problem solving methodology to the winds and perhaps if someone finds this useful there will be fewer questions in the world. Is that likely?

There is a difference between a primary problem and a secondary behavioral attribute but people constantly confuse the two. So when someone says, "My child won't pay attention," or "One kid on my caseload won't eat any solid foods" they will often look for a direct and concrete answer to their 'problem' and completely misunderstand what the 'problem' really is. Let's take one example and walk through it.

First of all, if you have a clinical/presenting problem, place it in a circle at the top of the page and then make 5 circles underneath it. Five is a random number, but these circles will represent the POSSIBLE causes of the problem in the circle above:

PROBLEM


REASON 1____REASON 2____REASON 3____REASON 4___REASON 5

Then start filling in the details. This is your opportunity to be creative. Let your mind fly over all the potential reasons.

Let's talk about why a child won't sit during circle time. Here are 5 possible reasons off the top of my head:

1. He is only three years old and has no experience with this context and the behavioral expectations.
2. He has an organic neurological problem like a TBI, MR, lead poisoning, etc.
3. He has to go to bathroom, or any number of common sense possibilities.
4. He has no concept of behavioral boundaries; his parents let him run roughshod all over the house with no consequences.
5. The lesson plan is not adequately engaging or developmentally appropriate.

I am absolutely certain that there are many other possible reasons here but this will do for now. The trap that clinicians (and those that rely on them) fall into is to start swinging at the behaviors but not really knowing what the problem is. Everyone wants a simple answer, and here are some examples of simple answers:

1. Implement a brushing program - the child obviously has some regulatory problems. Use lots of deep pressure, heavy work prior to sitting, and a weighted blanket or 'lap buddy' or weighted vest while sitting at circle time. Incorporate movement into circle time to accomodate for the child's obvious sensory seeking behaviors.

2. Implement a behavioral program. Use a token system that reinforces desired behavior and chart progress accordingly.

3. Refer to the physician, asking to evaluate for ADHD. This child clearly needs medication.

4. Enroll the parents in a parenting program. They need to learn how to set limits because this child is simply out of control.

Any of these answers may be inherently inappropriate for the given situation. What happens is that clinicians and intervention teams get into ruts and start swinging their sensory bats at this pitch, or their behavioral bats at this pitch - excuse the baseball analogy. Sometimes they will hit a home run, but sometimes they will strike out. You can't automatically use the same 'bat' to try to hit a pitch - you need to choose your intervention to meet the actual need.

A dose of R. Buckminster Fuller fits here:

"I am enthusiastic over humanity’s extraordinary and sometimes very timely ingenuities. If you are in a shipwreck and all the boats are gone, a piano top buoyant enough to keep you afloat that comes along makes a fortuitous life preserver. But this is not to say that the best way to design a life preserver is in the form of a piano top. I think that we are clinging to a great many piano tops in accepting yesterday’s fortuitous contrivings as constituting the only means for solving a given problem. Our brains deal exclusively with special-case experiences. Only our minds are able to discover the generalized principles operating without exception in each and every special-experience case which if detected and mastered will give knowledgeable advantage in all instances."

So my strong recommendation is that next time you believe that you are presented with a problem, make sure that you really have a problem and not a secondary behavioral attribute that is associated with the problem. Root out the cause of the behavior and your treatment plan will be so much more likely to be effective.

Finally, if you find yourself stuck in a rut and swinging the same kind of bat at every problem you perceive - please spend a couple hours with Bucky Fuller. I promise that you will be cured of special case thinking.

References:

Fuller, R.B. (1968). Operating Manual for Spaceship Earth, Carbondale: Southern Illinois University Press.

Friday, November 03, 2006

Pediatric encopresis and occupational therapy

Today I had contact with three families who were all dealing with problems relating to encopresis. Encopresis can be essentially defined as a lack of fecal continence and it is a huge problem for families. I have to admit that there was no training in my occupational therapy curriculum relating to encopresis, although occupational therapists spend a lot of time talking about helping people with self care activities of daily living. I suppose that my educational programs assumed that intervention ends when a child can let their pants down and sit on the potty?

The lack of any mention of pediatric encopresis in the occupational therapy literature certainly doesn't stop occupational therapists from weighing in on this subject when it comes to giving parents advice. I read an evaluation once where a therapist talked about a child's constipation and encopresis being related to a craving for deep pressure stimulation, and it was a reflection of poor sensory processing. The recommended treatment was to provide the Wilbarger protocol every two hours until bowel habits became more regular. Recently I had another parent ask me if there were sensory contributions to encopresis and I had to admit that there is no evidence in the literature to suggest that.

So what is the evidence about encopresis? A Cochrane Revew review (2006) identified that behavioral interventions when used together with laxative therapy may improve continence in children with non-organic fecal incontinence and constipation. Biofeedback interventions did not seem to have any positive effects. So in trying to help one family with this problem we tried writing a social story as a cognitive-behavioral strategy to improving continence. The parents are still ruling out medical issues - so I am not sure what the answer will be.

The literature points to several difference issues relating to encopresis that OTs need to be aware of. There are significant psychological differences between children who have encopresis and peers who do not (Cox, Morris, Borowitz, & Sutphen, 2002). However, not all of those differences fall within the range of 'clinical significance' on behavioral measures.

In another study, Klages, et.al. (2005) found that children who had early onset Bipolar I disorder were more likely to have encopresis and atypical/hostile mother-child interaction. When writing that it is reminiscent of autism and refrigerator-mom research, but I think their point was that children who have encopresis also had disturbed parental relationships as part of an overall 'phenotype' to Bipolar I disorder.

In another study Johnston and Wright (1993) identified a co-morbidity between encopresis and attention problems. In sum, kids who had encopresis had much higher (clinically significant) scores on the Hyperactive subscale of the CBCL.

These different studies all point out interesting facts about encopresis. Some children who have encopresis have measured differences on their CBCL scores, but not all of those differences are in the range of clinical significance. Some kids have elevated hyperactivity CBCL scores that are clinically significant. Another group of kids have encopresis associated with more severe mental illness, specifically Bipolar I disorder. For intervention, laxatives probably help and cognitive-behavioral approaches probably help.

So are there sensory factors? I suppose one could argue about the nature of the term 'sensory.' It seems that children who have encopresis may have some difficulties with attention and therefore 'regulatory' function. Perhaps there is a subset of children who have encopresis related to decreased ability to attend to internal messages that they need to go to the bathroom. We still need to gather more information before we recommend brushing programs for children like this though.



References:

Brazzelli M, Griffiths P. (2006) Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children (Cochrane Review). The Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD002240.

Cox, D.J., Morris, J., Borowitz, S.M., & Sutphen, J.L. (2002). Psychological differences of children with and without chronic encopresis. Journal of Pediatric Psychology, 27, 585-591.

Johnston, B.D., Wright, J.A. (1993). Attentional dysfunction in children with encopresis. Journal of Developmental and Behavioral Pediatrics, 14, 381-385.

Klages, T., Geller, B. Tillman, R., Bolhofner, K., & Zimerman, B. (2005). Controlled study of encopresis and enuresis in children with a prepubertal and early adolescent bipolar-I disorder phenotype. Journal of the American Academy of Child Adolescent Psychiatry, 44(10), 1050-7.

Thursday, November 02, 2006

Smiles from Nicholas

I knew a boy named Nicholas, and I don't think that it needs to be confidential any longer. Nicholas had cerebral palsy and I was randomly chosen to be his occupational therapist. That's the way referral patterns go sometimes - and it just amazes me - because on any given day as an occupational therapist you just don't know what your life might be thrown toward.

I am not going to attempt to re-tell Nicholas' story because his parents have already documented it far better than I ever could.

I would like to ask everyone to go visit their web site and Foundation Smiles from Nicholas.

I learned a lot from Nicholas and his family So although there were tears, there was laughter more. And although there was pain, there was joy more. And when things seemed bleakest, they lived.

I have been thinking about them a lot and I don't know how a world can right itself after the death of a child, but I trust that it will in one way or another (with a a little help from above of course).

Nicholas and his family inspire me, and I know you will feel the same. Please go visit, and enjoy some Smiles from Nicholas.