Wednesday, April 30, 2008

Myofascial release and evidence-based practice

File this under 'required reading.'

Please head over to myphysicaltherapyspace.com, specifically to the entry on evidence-based practice and myofascial release interventions. This is an excellent discussion and I hope you all have the chance to take a look at it.

Myofascial release is a modality that is much more widely used in physical therapy than occupational therapy, but it still crops up in OT interventions from time to time. I am especially concerned about so-called craniosacral therapies and the ways that some therapists combine these dubious interventions with other OT quackery.

I really don't have more to add than what was posted by Jason Silvernail, DPT - so please go read his excellent entries!

Monday, April 28, 2008

ADHD - stock question and answer

I recently got this email question, again. It is a relatively common email that I receive so I thought I would post the question and my stock answer here...


The Question:

My school district/teacher keeps telling me that my child has ADHD and needs to be medicated. They have been harassing me at every IEP meeting and want me to medicate my child. I have absolutely refused because I never believed that medication would fix the problems my child has.

How do I know if my child even has ADHD, and what should I do about it? How do I get the school to stop harrassing me? Any advice would be greatly appreciated.


The Answer:

The school district is not qualified or licensed to make medication recommendations for your child. Medication suggestions should come from your pediatrician/other physician, or psychologist who is working in concert with the physician. The point here is that medication is a medical recommendation and not an educational recommendation. Only people who are medically qualified should be making medication suggestions.

Frankly, I am always a little shocked when I hear that a school district or district personnel (teachers, etc.) are making medication recommendations - but it happens frequently. Some municipalities have even written laws to stop school districts from making these recommendations, or to stop districts from funneling students to doctors who will provide the diagnosis and medication.

Try to work cooperatively with your child’s educational team to coordinate an appropriate educational plan. That plan may include behavioral, educational, and therapy interventions. Use this plan to inform your physician of how things are going in school. Choices to medicate a child should be made only when the physician has all of the appropriate information from the educational team and parent so that an informed and correct decision can be made.

If you are dissatisfied with one recommendation, seek out additional opinions.

If there is any way we can help you at ABC Therapeutics with occupational or physical therapy evaluations, second opinion reports, or ancillary therapy please give us a call at (716) 580-3040

Regards,

Christopher J. Alterio, Dr.OT, OTR
ABC Therapeutics


Background reading:

Sax L. & Kautz, K.J. (2003). Who first suggests the diagnosis of attention deficit/ hyperactivity disorder? Annals of Family Medicine, 1, 171 –174.

Schneider, H. & Eisenberg, D. (2006). Who receives a diagnosis of attention-deficit/hyperactivity disorder in the United States elementary school population? Pediatrics, 117, 601-609.

Saturday, April 26, 2008

Dangerous things happen when flights are delayed

I am currently stuck in Chicago, and have been for the last several hours. To an action-oriented person like myself free hours feel like they are taffy-time - stretched beyond any point of recognition of what they originally were.

This means that I have uninterrupted opportunity to mentally operationalise some plans. Mental operationalisation is somewhat oxymoronic, and I will need to explain that at another time. Also, I don't mean to use spelling that would more likely be found in other countries but a certain letter on this laptop is not working (the letter after 'y') and so I can't spell things in the way I normally would.

Anyway, I spent some time thinking about occupational therapy 2.0, which of course is stolen from the web 2.0 lingo which I actually kind of think is funny. Again, a story for another time. Anyway, it is time for occupational therapy 2.0. The blog was the first foray for me into the 2.0 world, and I have talked about the power of social networking on the blog in the past. Now it is time to take a larger step into the open source world, or at least invite the open source OT world to start behaving in a more 'open source' mode. I wonder if it will work.

I had an idea a couple years ago for an open database project (secured, of course - and participation after approved application, of course) for a certain assessment instrument. The open source format would have allowed us to collect a tremendous amount of raw data that could be used for research purposes. At the time, I couldn't get the authors interested, or the publisher interested. There were too many proprietary interests in the way, and that is kind of unfortunate - because it would be a good format for knowledge generation.

I need to dust off this concept again, and begin to apply it to open source data collection in the OT world. There is a wealth of information that exists in unpublished manuscripts, half-baked ideas, and even full baked ideas that have not been put to the rigors of traditional peer review. Knowledge collection facilitates knowledge creation. That will be the working policy.

I'll post more of the details soon. It is an opportunity and a fun idea. Will you join me??

Tuesday, April 22, 2008

Occupational Therapy Street Reality: Early Intervention

Here is a quick clinical scenario, in case anyone is out there glamorizing pediatric occupational therapy practice.

This one is more "dirt road" reality as opposed to "street" reality.

I have been in squatter's homes before that have amounted to little more than foundation-less sheds and shacks tucked away on corners of land that other people have abandoned or forgotten. These are sad stories, but they are realities nonetheless, and these people make up a certain underclass of society that require a lot of support. As I drove up a country road toward my destination I saw rows of dilapidated trailer homes with lots of bare plywood, litter-strewn 'yards', and many roaming cats. There must be good hunting for the kitties around here.

The saddest part, I considered, is that this is an organized trailer park. Someone is actually charging these people for the electric and water hookups. I wondered what kind of person would want to make a business of supplying water and electric to such run-down buildings, or how in good conscience they can charge for the 'trailer space' where people construct or park their home-shacks.

There wasn't much sound made when I rapped my knuckles on the water-rotted hollow-core front door. "Come on in," I heard through the door, and as I opened it up I was overwhelmed with a strong odor of kerosene gas.

I was there to see Amanda, a two year old with very chubby cheeks and a pointy elven chin. Grown-up perspective exaggerates her facial features, but as she stared straight up at me all I saw were uneven bangs partially covering very large eyes and even larger cheeks. She was cute.

Amanda stumbled around the floor and I wondered if she was stumbling on the debris or if she was stumbling because of some partially diagnosed neurological problem. The mom knew that Amanda had some kind of seizure disorder but they haven't followed up because pragmatically she heard the doctor say that 'they weren't going to do nothing for it anyway.' I am not certain that this is the message the doctor meant to convey.

Anyway, all this was kind of lost because I couldn't get over the very strong smell of kerosene. Turns out that they don't have kerosene space heaters, but that they were burning kerosene in their furnace that had a leak in it. I asked the mom if we could open windows for ventilation and she said, "I don't have no screens - Amanda might be falling out the windows if I did." It was a concern: with all the rusted and twisted metal, and all the rotting boards with exposed nails there was real possibility of injury if she tumbled eighteen inches out of the window into the yard.

In true deus ex machina form, at that moment a car pulled up to the shack which prompted the mother to yell, "Fxxx! It's CPS again!" Amanda just smiled and tripped around the room, unfazed by the mother's outburst.

The CPS (Child Protective Services) worker thought the odor was cat urine, but I educated her on the source of the kerosene gas smell. She called in the kerosene provider and the toothless owner of the trailer park and they all began debating about the faulty vent on the furnace and how no one wanted to crawl up onto the roof because it would collapse. I left, praying for St. Nicholas to watch over the children if the CPS worker didn't. I didn't know what else to do, and I figured that is what my grandmother would have done.

Fast forward one week and CPS is satisfied that as long as the family doesn't turn on the furnace again there is no risk of the shack blowing into orbit. That is comforting. From the CPS worker's perspective, opening the door to dissipate the fumes is adequate, and after all, 'the carbon monoxide detector hasn't gone off.' I am still scratching my head and trying to figure out why they didn't understand when I said that the carbon monoxide detector is not designed to measure combustible kerosene vapor. The kerosene company states that the shack is "unhealthy, but not dangerous." Can anyone help me decipher that?

The early intervention program accepts the determination of CPS. That means that I can either resume the case or they will assign another provider. Ethics dictates that I will remain on this case until they remove me. In the meantime, I intend to make a few waves with CPS, and maybe a county legislator or two.

Our systems are very broken. I can not fix these problems, but I can point them out.

Friday, April 18, 2008

Personal examples of 'being in place' and how it relates to parenting

OK that last entry was too philosophical so I needed to find something to counterbalance the point I was trying to make. I wrote this seven years ago and it will serve the purpose of illustration.

Again, the concept here is that there needs to be some way to approach the meanings and intentions behind parenting decisions, and to find ways to harness phenomenological analysis as a tool to help parents move from point A to point B.

Anyway, this is a personal example of how it applies - and I hope this will demonstrate the depth of meaning behind a parenting moment. Knowing this depth from a personal perspective actually intimidates me - how can we achieve this knowledge of parents whose children we evaluate?

_____________________________

"The sun dipped slowly behind the last dying hill as I travelled westerly toward home. I used to look at the landscape when I first arrived here and bemoaned the lack of geographic relief - I was so accustomed to the lazy rolling of worn-down Adirondack and Appalachian mountains blanketed by acres of primarily deciduous forestation. That is what I grew up with, and what I felt most comfortable living around.

I felt naked when I first moved here. There was nowhere to hide. Arriving here was like stepping out of those forests, stepping out onto the beginning expanse of the Great Plains. It made me feel small. And exposed.

But as I drove into the sinking sunset I felt that if I stayed on the road long enough the sun just might swallow me whole and take me with it - to wherever it goes after the day is completed. All that existed was the road. And me in the car. And the sun looming larger with each passing moment, threatening to swallow me whole.

At this time I saw where the earth and the sky met, with no geographic barriers that would limit my perception. The Earth curved outwardly in all directions, and the sky was equally large but in a conversive orientation. As I drove I thought how beautiful it was, how large the sky was, how the earth and sky moved in and out in congruence with my breath.

I was foreign here once, but over time I have learned to be a part of this environment. I don't need to hide here, or look for the shelter of the hills where I was able to be small and where I could hide when I was a child. Now I can't help melting into the larger expanse of earth and sky, and I can't help seeing myself reflected in the environment. I am larger than myself in this way and I am as much a part of my environment as it is a part of me.

This happens gradually as you age. And I still have a long way to go. But I can feel it happening all around me.

It was getting late, and I spent my last minutes in the car thinking that I was glad to be home. I was initially planning on being away tonight but something made me want to come home, to bathe the kids, to tuck them into bed. It was late, but I could make it home in time to do this.

Bath time was relaxing and the children were resting comfortably in their beds when I sat alone in the dark downstairs thinking about my day. After several minutes I heard a muffled whimpering from Casey's room - so I gently peeked in to see her sitting in the middle of her bed crying.

"Oh Casey, what's the matter?" I asked as I slipped into her bed, putting my arms around her. She just kept crying, and after a few moments she said to me: "Daddy, I just want to be back like a baby again. I liked being a baby, and I don't want to grow up yet."

"But why?" I asked. "Don't you like going to school and don't you like learning new things and don't you always want to be like the older kids?"

"Daddy I do but it is just hard getting older" she continued between sobs. "I am the smallest one in my family and I have to grow up more than anyone else does. It's just hard Daddy, and I just want to be a baby again." She was holding her favorite picture of the two of us where I was cradling her close to me.

I started reeling, groping for what to say to her. But then I realized why I came home tonight. Why I thought the things I did while driving. So I whispered to her as I held her:

"Casey, when I was a little boy and when I felt all alone I would always look at the hills around me. You know those hills that we drive in when we go to your grandparent's house. They made me feel comfortable, and safe, and warm. Sometimes when I feel sad I just think about those hills and that makes me feel better."

I didn't tell her how I really didn't need those hills in my physical reality any longer, or how I learned to find a larger harmony with my new environment. That lesson is for another day.

"But Casey, whenever you feel alone, or scared, or when you don't want to grow up... I will be your hills for you. I promise."

As she laid quietly in my arms our breathing synchronized, and slowed, and she fell asleep.

And I knew why I came home tonight.

_____________________________

coming next: how does this all apply to the parent who wants their child to eat something besides yellow american cheese, raspberry poptarts, and buttered bread.

On phenomenology and the challenge of helping parents

I know that I am a pediatric occupational therapist, but I am also an adult occupational therapist because all the kids come attached with parents. Often, the primary point of intervention is with the parent and I think the roadblocks that I run into make me spend a lot of mental time considering the problems that adults have in operationalizing their occupational roles.

Now I know that I just dared to utter the term 'occupational roles' which I believe is probably not theoretically in vogue, but the concepts are still quite useful at times. That is a discussion for another time, I suppose.

Anyway, I am currently stuck on Rowles again and the concept of 'being in place' particularly as it relates to parent's abilities to find themselves and function within some constricted occupational niche of parenting.

So of course this problem in helping parents brings me to the core of meanings, values, and intentionalities that underly adaptive parenting behaviors. This of course takes me to the very basic concept that phenomenological approaches are primary in trying to understand and decipher individual occupational dysfunction.

The primary purpose of the phenomenological method is to describe the structures of experience as they present themselves to consciousness, without consideration of the theory, deduction, or assumptions from other disciplines. Edmund Husserl is the founder of this philosophical school of thought; he developed phenomenology as an a priori and eidetic methodology of scientific inquiry. Husserl believed that phenomenology would provide a basis for reform in all fields of science.

Pure phenomenological inquiry, as it applies to occupational science, answers the research question: “What is the essence of occupation?” By ‘essence’ Husserl means the absolute basis of knowledge regarding a subject. Husserl proposes that all un-provable assumptions should be discarded when describing what is given in experience and represented this opinion in his famous statement ‘zu den sachen selbst,’ or ‘to the things themselves.’

The primary procedures for conducting phenomenological inquiry (commonly referred to as phenomenological reduction) are phenomenological intuiting, phenomenological analyzing, and phenomenological describing (Gray, 1997).

Pure phenomenological reduction provides basic sense-data on the essential content of a phenomenon. The essence of occupation as described by Gray (1997) includes ‘doing’ by the patient, involves goal directed behavior, carries meaning for the individual, and is repeatable.

Husserl uses the term epoche to refer to the method of suspending judgment regarding the true nature of reality. The process of suspending judgment is also referred to as ‘bracketing’ any information about the subject being analyzed. By intuiting, analyzing, and describing within the rules of epoche, the true nature of an object could be determined.

Presumably, analysis of objects through phenomenological reduction is the only valid methodology for arriving at Truth. This was a large problem for Husserl, who attempted to explain that reduction could be done through a ‘transcendental ego,’ so as to avoid criticism that his ideas were solipsistic. Unfortunately, he died before he could complete his work in this area. Other philosophers (Heidegger, Sartre, Merleau-Ponty) disagreed with Husserl’s version of intentionality because it limited description of knowledge to a process of ‘bracketing’ where there was no influence of other factors. In brief, there was considerable debate about the nature of ‘true’ or ‘reliable’ results from Husserl’s phenomenological analysis, and this disagreement provided a basis for the creation of another philosophical movement known as existential phenomenology.

Gray’s (1997) article is based primarily on Spiegelberg’s historical recounting of phenomenology, thereby limiting the perspectives noted in the article. Gray’s descriptions of Husserl’s ideas are sometimes simplistic, but in fairness, it probably is not really possible to dilute Husserl’s phenomenology into a single journal article. A wider variety of source material would have been helpful, particularly regarding other phenomenologists’ applications of Husserl’s ideas.

Gray (1997) uses Husserl’s basic concepts appropriately, although there is a fundamental contradiction to studying something as meaning-laden as occupation within the confines of a ‘bracketed’ methodology. This was my biggest concern with Gray’s article. Husserl’s ideas are foundational to other philosophical systems that are much more applicable to occupational science, particularly Heidegger’s concepts of Dasein. This is also where I believe the Rowles article is so important.

Gray’s presentation would have been more applicable to occupational science if she were more expansive in her consideration of other phenomenologists.

Husserl’s phenomenology is itself a reductionistic form of inquiry in that it strips interpretation of reality away from the context that would make it applicable to occupational science. Occupations, by their nature, can’t be de-contextualized from the individuals who are engaging in them. However, this does not make phenomenology useless to occupational science. Hermeneutic and narrative inquiries, both of which fully embrace the interpretational perspective of the subject that is based on a larger (shared) conceptualization of reality, are based on phenomenological ideas. Phenomenology’s applicability to occupational science lies most in an embrace of subjective interpretation, not in the intentionality of disconnected sense-data interpretation.

Gray’s (1997) article is a useful starting point for occupational scientists’ study of phenomenology. However, it is important for occupational scientists to move beyond Husserl’s original ideas and to study the phenomenology of other philosophers.

I'll try to operationalize some of this later this week. Really, I do have some points to make.


References:

Gray, J.M. (1997). Application of the phenomenological method to the concept of occupation. Journal of Occupational Science, 4, 5-17.

Rowles, G.D. (1996). Beyond performance: Being in place as a component of occupational therapy. In R.P. Cottrell (Ed.), Perspectives on purposeful activity: Foundation and future of occupational therapy (pp. 201-208). Bethesda, MD: AOTA, Inc. Reprinted from American Journal of Occupational Therapy, 45 (1991), 265-271.