Friday, September 26, 2008

Erie County Executive Collins: Right and wrong at the same time

The issues are just too fast and furious lately - but this one had me falling out of my chair. Check out Collins comments on the burden of unfunded mandates from the State in this Buffalo News article.

Collins statement as it relates to preschool services is excruciatingly correct - although I am not sure if his solution really solves the problem. The article states:

"Besides Medicaid — the local costs for which eat up all the $200 million in revenues raised by property taxes in Erie County— Collins cited as among the unfair mandates a program that provides special services for children younger than 5 who need help to get ready for going to school.

He said the county pays the costs of the program — $23 million a year — but has no authority in running a program administered by local school districts. When children turn 5 and schools have to then pick up the costs, Collins said, pupils are “miraculously cured” and no longer offered the services."

This is oh so true, but the preschool/UPK advocates will correctly point to numerous studies that demonstrate the benefit of providing this kind of programming and how it provides long term educational benefits.

But there is something more interesting to watch - see how politicians duck their heads and hope no one sees why all the preschoolers who had problems are suddenly declassified once the responsibility for payment slides back onto local school tax rolls.

I guess it is easier to spread the pain, point fingers, and have a broadly distributed and partially state subsidized tax pay for these programs. No one wants that pain when it starts to exclusively and specifically impact the local property tax rate.

In the end it boils down to a moral issue: do we want to provide these programs for children and do we think that we get enough benefit for the money spent? If we believe in the positive outcomes then the investment is worth the cost - no matter what politician's budget it lands in.

Or do we allow the politicians to tell us that it is not worth the cost - not based on any measured outcome but rather because they are afraid that the cost of the program on their budgets will jeopardize their chances of re-election?

And to think that people have the mistaken idea that these decisions on who gets how much service has anything to do with the welfare of children or the creation of a functional educational system!

NYSOTA response re: continuing competency regulations

I received an excellent response from Jeff Tomlinson about the recent continuing competency issues. I didn't want his response to get lost in comments, so I am posting it as an entry. There is a lot of good information here. I would really like to hear more about the direct access issue and problems in securing scripts for school aged children - sounds like something that could benefit from roundtable conversation.

Anyway, here is Jeff's response:

I have also been encouraged by another occupational therapist to check out this discussion.
We were certainly surprised by the speed with which the physical therapists were able to pass their mandatory continuing education bill. It was quite an accomplishment in a legislative session that passed very few bills that regulated the professions. I will be talking to the lobbyist and the leadership at NYPTA about how they got this done.

At the same time, it should also be noted that the PTs continuing education law is not like the NYSOTA's continuing competency bill. NYSOTA's proposal is much more consistent with the NBCOT continuing competency program and all the research that has been done over the last fifteen years on promoting professional competency. So in my own view, I'm concerned that a mandatory continuing education program will not be the best thing for the profession of physical therapy.

NYSOTA considers both the practice act amendments bill and the continuing competency bill a priority. We have asked legislators to combine the bills into one, and that request has been denied. We have been told that the practice act must be amended first so that the regulatory authority over the ota is straightened out first. Then the continuing competency bill will follow. We are certainly hoping that the continuing competency bill might move as quickly as the PT bill did, once the practice act amendment bill is passed.

Regarding splitting off the OTA section of the practice act amendments bill and passing that separately. NYSOTA has certainly considered this option since we consider the regulation of OTA practice an urgent public protection issue. However, at the same time we have another issue that may be considered by many to be just as urgent. We have learned over the last year that possibly hundreds of children in lower socio-economic school districts, face lengthy delays or receive no occupational therapy because of the prescription requirements in the practice act. We believe that the amendment allowing for direct access in non-medical conditions may address this issue. The idea that children are going without necessary OT services is very disturbing to me.

The biggest issue that we have had opposition to has been our addition in the definition of our practice of the concept that we address cognition. NYSOTA has fought hard for that cognition amendment and we have negotiated in good faith with our opposition, and we have made progress on the issue.

Finally, it is unfortunate but very common practice to combine less palatable, or less mobile legislation together with legislation that is easier to move. That is a reality in the legislative world. For example, the extension of the exemption process on the Medicare Part B Therapy caps was included in a bill with the physician fee schedule, a much more public and poular issue. The recent mental health parity legislation passed by the US Senate on Tuesday was included in a Tax bill! This is how legislation gets done. Our assessment is that many of the amendments in the OT bill would potentially languish for years if not attached to more urgent issues.

As far as I can recall I never saw the letter to NYSOTA regarding this issue, but, consider the silence broken. And always feel welcome to communicate directly with me at legislation@nysota.org

Jeff Tomlinson
NYSOTA Legislative & Government Relations Coordinator

Thursday, September 18, 2008

Time for more name changing?


Juliet:

"What's in a name? That which we call a rose
By any other name would smell as sweet."



There is a history of name changes in describing sensory integration problems. People have probably heard:
  1. SI disorder
  2. SID (sensory integration dysfunction)
  3. DSI (Disorder of sensory integration)
  4. SPD (Sensory processing disorder)
You can check here for someone's blog entry on the issue. The SPD Foundation (formerly KID Foundation) has mostly scrubbed references on its website to the words that are no longer in vogue. That is helpful, particularly since they are seeking DSM-V recognition of SID/DSI/SPD.

Have I used enough initialisms and acronyms in this entry yet?

Now we have a companion problem in that there are multiple meanings for the concept of a 'sensory profile.' I was googling some information on the Sensory Profile assessment and I came across these references:

Sensory profile of mandarin chilled juices and consumers' acceptability

Mexican Mennonite-style cheese: Sensory profile of young cheeses from Chihuahua Mexico

Development of a sensory profile for the specific denomination “Galician potato”

When machine tastes coffee: Instrumental approach to predict the sensory profile of espresso coffee

The poor sensory researchers just can't catch a break. How many times will the name of the disorder and now the tests used to measure the disorder be co-opted???

I assure you all - our name will never change and we will always be ABC Therapeutics!

Wednesday, September 17, 2008

Occupational therapy and habit re-training for idiopathic toe walking

I don't know that I have ever seen any occupational therapy literature on idiopathic toe walking.
For an excellent overview and references on this condition please check this article from the Journal of Family Practice.

As the reference states, it is important to avoid 'over medicalizing' the problem especially since there are not many toe-walking adults that are presenting themselves for intervention. It is possible that toe walking is a self limiting problem in many children. However, there is a reasonable concern when toe walking begins to contribute to pes cavus deformities which of course can have longer term implications. In our clinic we see a few children each year with toe walking that is beginning to cause functional foot deformity.

Idiopathic toe walking is a relatively common condition that is often seen by occupational therapists - but not generally as a primary reason for referral. Some professionals view toe walking as a marker of other developmental immaturities. It is critical to make distinctions between true idiopathic toe walking as opposed to toe walking associated with cerebral palsy, autism, muscular dystrophy, or other conditions. Toe walking should always be evaluated by a medical diagnostician first to rule out these other more severe conditions.

Some occupational therapists attribute toe walking to sensory problems but there is no evidence that this is true. Many occupational therapists leave intervention for toe walking to physical therapy colleagues who are often more specialized in nuances of gait analysis and biomechanics of ambulation. However, I have found that traditional physical therapy interventions often fail to address some of the specific problems associated with idiopathic toe walking.

There is a lot of literature that discusses different treatment options including serial casting, range of motion, and strengthening. Medical interventions often include botox injections or muscle lengthening. There is debate over which of these are most effective, or if they are at all effective.

At our clinic we try to complement traditional biomechanical interventions with re-training for self care (dressing) habits. Many of these children do not like to wear shoes and as soon as they come home from school the shoes are off and the children are tiptoeing around the house and yard barefoot. Toe walking without shoes promotes hyperextension of the toes and exacerbates the muscle imbalances that are already occurring in the foot and lower leg. Even when parents know that allowing their children to be barefoot can exacerbate the problem - it is difficult for them to effect behavioral change.

When there is no orthopedic or neurological cause of the toe walking we add a positive reinforcement component to the intervention program. The goal of this is to promote shoe wearing throughout the day and to break the habit of being barefoot. We find that children respond well to a 'puzzle' that has bones of the foot, and they can 'earn' puzzle pieces each day for successfully keeping their shoes on for a specified duration of time. Each day that they wear their shoes they get a new piece to add to the puzzle.

After the children complete the puzzle by earning all of their foot bones they are able to win a specified reward. Children respond well to the visual cue of the puzzle, are easily able to understand their progress toward the goal of wearing shoes every day, and like to learn about the way their feet work. Parents also benefit from use of the bone puzzle because it is easy to implement and is also helpful as an educational aid for teaching them about biomechanics of the foot.

If shoes fit properly and are supportive it is difficult to toewalk. Thankfully, Converse Chuck Taylors are back in style with kids! We find that compliance with regular shoe wearing is improved with use of 'cool' sneakers and the prospect of earning a reward by completing their puzzles.

It is important to have good dialogue with the orthopedic doctor and orthotist. Depending on the degree of functional foot deformity sometimes it is necessary to have even more modification to shoes including SMOs, AFOs, or modified shoes with a high toe box to avoid pressure sores.

We don't see enough children with idiopathic toe walking in our clinic to do a well designed study but still have had good anecdotal success with our combined biomechanical intervention and behavioral program. It would be interesting to see if the behavioral component increases the length of time that children demonstrate more functional gait patterns following intervention.


Reference:

M. Patrice Eiff. "What is the appropriate evaluation and treatment of children who are "toe walkers"?". Journal of Family Practice. . FindArticles.com. 17 Sep. 2008. http://findarticles.com/p/articles/mi_m0689/is_5_55/ai_n26877929

Tuesday, September 16, 2008

Professional competence: How do you weed the weeds?

We are making strides in promoting continuing competence and ongoing professional development in the occupational therapy profession but there is still work to be done. The current theme running through my head has to do with quacksalvers and quality in continuing education offerings.

As far as I can tell, there are few if any standards for the quality in continuing education courses as it relates to the CONTENT of the offering. I read the IACET standards and was disappointed that Standard 7 didn't really delve deeply into the issue of regulation of the QUALITY and CONTENT of continuing education courses. So if the primary standard-setter of quality in continuing education does not address quality of CONTENT, what should be done?

As an aside, I don't know that I blame IACET - how could they possibly address quality across so many diverse topic areas? Does this leave the professional associations to make statements about quality of content? Or is this left to certification bodies?

Here is what the physical therapy profession did. I especially like standard 5 which states "Each CE offering must be based on referenced scientific evidence, reflect evidence in practice and clearly label personal experience or hypotheses." I am still not sure if it makes much difference though: if we look at myofascial release as a case example I am not sure if many physical therapy course offerings in this area really meet standard 5. Even more frightening, check out what happens when you start to poke the tiger.

I did some cursory searching and couldn't find a similar OT document from AOTA that directly addresses the continuing education quality of content issue. The document may exist - I just couldn't find it. If anyone knows of any such document please let me know so I can include it here.

And if it does exist - does it matter? Any given professional association doesn't really have the resources or even teeth to address the issue. Would someone actually step forward and say that over two decades of continuing education on the Wilbarger DPPT without accompanying progress in researching the technique is ENOUGH ALREADY? Or will these types of little student projects that are done every year in EBP classes remain the hushed secret that all OT students know but are never admitted to by the people who continue to promote the madness?

A good colleague today suggested to me that perhaps all this is best left to the marketplace. I don't know. Maybe I just need to rub some lavender essential oils on my temples or something. I hear it works.

Friday, September 12, 2008

Silence from NYSOTA on OT Continuing Competency

I recently posted on the status of continuing competency requirements for occupational therapists in NY State. In summary, my concern is that the bill for these requirements has been stalled in senate committees but a very similar requirement for physical therapists just passed. I wrote to NYSOTA asking about an update on this issue and have not received any response.

Of course this is an issue that I have all kinds of historical interest in - and it is no secret to anyone that I am a long-term volunteer for the National Board for Certification in Occupational Therapy. This is where my passion over the issues of competence and competency was born and bred.

Still, my feelings on this matter also have a lot to do with the perceived legitimacy of occupational therapy as a profession and broad protection of the public. Regulation is sometimes unnecessary and stifling - I am not a believer in the nanny-state. However, health professions are historically unable to police themselves appropriately - and occupational therapy is absolutely no different than any other health profession. Case in point:

In New York State the therapist treating your grandparent who fractured a hip or your child who has cerebral palsy only needs to pass a certification exam ONCE. There is no requirement that this therapist ever steps foot inside a classroom or continuing education course EVER AGAIN. There is no requirement for them to advance their knowledge and competency in any way. Even if they DO decide to pursue continuing education our current models are accepting any continuing education course from a provider that is IACET approved.

Now consumers might not realize that there are many IACET approved courses that have truly dubious content. A recent local example is a continuing education course for Western New York occupational therapists on Quantum Touch. Undoubtedly, continuing education organizers and providers reap reasonable financial dividends through their offerings; I am just so disappointed to see that occupational therapy professionals in my own community who offer continuing education would advance themselves over the larger well-being of the people we are entrusted to provide services to. Please, someone help me here: in what way is this Quantum Touch quackery consistent with the scope of practice of occupational therapy?

So watch out, Western New York consumers! Even if your therapist does attend continuing education courses - make sure that they aren't attending continuing education that is based on mysticism. The New York State Occupational Therapy Association is silent - only choosing to comment on other bills. When it comes to protection, the public has to look out for itself.

Thursday, September 04, 2008

The power of words

There is more opportunity to follow the conversation in the Advance for Occupational Therapy magazine about early intervention service delivery. I read the magazine today and still felt uncomfortable as I kept stumbling over what Dr. Jane Sorenson wrote:

“At the end of the year, all of them were performing at maximum potential… I explained, as I do with all parents whose permanently disabled child is performing at his maximum potential within the reality of the disability, that more treatment won't mean more function right now… I believe it is our responsibility to the children to discharge them from direct service when they have reached realistic goals within the reality of their diagnoses.”

I wanted to do some self-checking to be sure that I wasn’t applying any bias to reading her based on my disappointment over her previous comments. After a lot of consideration, I think I understand the nature of my concern and discomfort.

It is the words.

As an amateur anthropologist I have some passing understanding of the Sapir–Whorf hypothesis. This hypothesis states that there is a power to words and that words frame our perspectives and understandings. This is not a discussion about political correctness which has pejorative connotations because of the way that the concept has been co-opted in American political discourse. This is about the power of words and the language we use.

Language is a medium for expression of a culture – and a culture is a shared set of beliefs and practices. In the simplest form, language transmits the beliefs and practices of people. I would be remiss if I did not also reference Jerome Bruner, who described the construction of reality through narrative. In short, words are powerful. Words reflect our beliefs that frame our narratives and support our culture.

Occupational therapists have a culture. There are variations in the culture but there are some basic beliefs that most occupational therapists hold. Perhaps the most important of those beliefs has to do with human potential.

I am not talking about human potential from some wishy-washy 1960s mind-expansion perspective. I am talking about the basics of humanistic psychology, and people’s needs, and how they experience their lives and how their needs are met. Occupational therapists, perhaps more than any other professionals, understand this dynamic nature of human need, and how needs ‘imperatively demand satisfaction’ – which I believe is an Eric Fromm quote that was recycled by Mary Reilly in her Slagle lecture. People have needs and meeting those needs is often derailed and impeded by life experiences or disability.

So what are we saying when we state that someone is performing at their maximum potential? What exactly does that mean? What is potential and how does one know when it has been maximized? Is there anyone that reads this who has ever believed that their own potential has been maximized?

For your potential to be maximized your needs must be met. To state that someone has maximized their potential is to state that they Need no more.

If you Need no more, you can not have growth. And perhaps you have no meaning. If I say that you Need no more than I have placed you in a box, de-humanized you in every way possible, and stated that your human potential is complete. To take away your Need is to take away your human-ness. You are a defined object and not a self-actualizing subject.

The words are horrifying – I can only imagine the punched-in-the-stomach feeling that a parent would feel to have someone tell them that their child has no Needs and that they are at their maximum potential within the reality of the disability.

Whose reality? The reality of the all-knowing professional who after having completed some assessments in a limited contextual understanding of that child completely and abjectly disregards the parent’s larger hopes and aspirations? Is that reality?

I can’t imagine harsher words. That is where I am getting stuck.

There is no doubt that there are times to discharge a child. There are times to change from direct to indirect interventions. There are times to make all kinds of changes in the recommended intervention program of a child. These are not real issues – everyone knows these things.

But it should never be time to use words that limit the human potential of anyone.

Here is an easy fix – how about saying that “the child has derived the maximal benefit from participating in occupational therapy at this time.” I can accept that.

I can’t accept the statement that they have achieved their maximal potential given the reality of their disability. It is just too cruel and this is not the culture of occupational therapy.

There is a difference of articulation here: is the child done and do the parents need to accept some reality? Or is the therapy done for that particular time and context?

I know they are just words – but let’s hear your opinion – isn’t there a difference?