Wednesday, October 26, 2011

The end product associated with a decided lack of true productivity

We have a lion in my office that was left by a child several years ago. Here is his picture:

I placed him on my cable modem in plain view of everyone who came into the office hoping that someone would claim him. No one ever did, and I felt sad about it because he is a Webkinz and they were rather popular for a while and I am sure that some child was very happy at one time to have this toy. Anyway, I leave him on top of my cable modem just in case his owner ever makes a claim. He is our office mascot, and I have come to enjoy his company every day.

Today I was cleaning and organizing because I couldn't settle myself into documentation. I found a bunch of stray toys. I found the following:

1. a yellow clothespin that goes to a full set
2. an orange sheep that is matched to a full set of parent/baby animals
3. a green peg that goes to a pegboard activity
4. blue and yellow blocks that are part of a construction set
5. a peg from the BOT-2 (a motor test)
6. scissors
7. an ant from Ants in the Pants
8. the letter A from a wooden puzzle
9. a lion that goes with a set of jungle animals
10. an orange pencil gripper
11. the letter P that goes to a bead stringing set
12. a small red lion that goes to Mastermind Jr.
13. a yellow triangle that goes to a parquetry set

Here is the collection:

Undoubtedly, parents are familiar with the phenomenon of stray pieces of toys and games being lost or misplaced. It happens here too and periodically I round everything up and try to return toys to their proper home.

I decided to take a more proactive approach and create a temporary 'home' for all stray pieces and parts. Here is the picture:

I think I want to keep it in a central location, maybe near the lion. It makes sense to me.

Wednesday, October 19, 2011

Product Review: The PenAgain

I was recently contacted by Baumgartens who sent several PenAgain products to my office and asked if I would write a review on my blog. I told the company that I only provide unvarnished reviews and I don't accept any compensation for my reviews - and since they agreed to those terms I was willing to take a look at their products.

My first impression when I saw these pens and pencils was "So, how exactly are you supposed to hold the PenAgain?"

The product doesn't come with any specific instructions so I looked at the packaging to see if that offered any hints. The picture on the package seems to show a person holding the pen in full pronation of the forearm so that there is very little to no ulnar contact with the writing surface. Use of the PenAgain in this position is supported by a few YouTube videos as well - although I don't know if the person who made these how-to videos has any relationship to the manufacturer. The idea of full pronation and the weight of the hand as the source of pressure for writing is not necessarily new. OTs might be familiar with the 'writing bird' product that accomplishes this type of function.

The problem with full pronation and hand weighting is that it does not allow a clear visual of what is actually being written - and often contributes to spacing and accuracy problems. I tried using the PenAgain in this fully pronated position with decreased ulnar contact and I thought it was rather awkward. I don't recommend using the product in this position for people who have the skill to use a more typical forearm position. I suppose that it is equivalently helpful as the 'writing bird' though for people who lack precision grasp or supination.

Then I switched to a more traditional supinated position of my forearm and relatively full ulnar contact with the writing surface, which is generally the way the forearm and wrist would be positioned during a writing task. When in this position I found that the lines and forms of the PenAgain were ergonomically comfortable but the tactile stimulation against the volar surface of the MP joint was very unfamiliar. Personally, my writing was less legible with the PenAgain - probably due to the fact that I have firmly established tactile-sensory expectations of what it is supposed to feel like to write. Altered sensory input has an obvious impact on associated motor accuracy - so there would likely be a learning curve while a person acclimated to the different sensory input of the PenAgain. Most of the kids that I tried the products with said the exact same things: first was "Wow, that's cool!" and then "Wow, that feels weird!"

This all leads to the larger question of whether or not the PenAgain is advantageous from an ergonomic perspective. There have been a few studies done that looked at pencil grasp and writing efficiency/legibility and they have not shown a significant impact of grip on efficiency. I am aware of studies that measured pen force on a writing surface and that a lot of this early work was probably fed into development of pressure sensitivity for tablet PCs and SmartPhones, but I don't know that any of it led to any grand conclusions for learning how to write. I think that the best we can say about this right now is that the jury is still out on whether or not these kinds of writing tools improve performance or skill in writing.

The PenAgain certainly promotes what most people consider to be a more 'mature' dynamic grasp pattern. The question is "Does it matter?"

I don't know.

These products are more expensive than standard pens and pencils but the costs are not prohibitive. Some kids might think they are cool so they will be more engaged in writing. That may have some value.

Should occupational therapists use the PenAgain? I think it could be most useful in special case circumstances where someone has a specific positioning need and this particular product could address that need. It is always nice to have product options because most OTs have run across situations that are unique where you say, "Hey, Product X might be worth giving a shot in this circumstance!" The PenAgain might be good for such situations.

I wouldn't toss out all my pens and pencils though or start suggesting that all children should learn with these products. There just isn't any evidence that different grips and grip patterns have a significant enough impact on function anyway. They might for someone. Or they might not. That means that therapists should continue to evaluate people individually and make determinations about whether or not such a product would be helpful.

My unsolicited advice to the PenAgain folks is to develop a product insert that reviews standard and adapted uses of the product, including some information on forearm rotation and wrist positioning. That would make it a little more friendly to consumers so they would know what to do when they pick up the product and try to write!!!

Background reading:

Benbow, M. (1995). Principles and practices of teaching handwriting. In Henderson, A. & Pehoski, C. (Eds.) Hand function in the child: Foundations for remediation (255-281), St. Louis: Mosby.

Dennis, J. L., & Swinth, Y. (2001). Pencil grasp and children’s handwriting legibility during different length writing tasks. American Journal of Occupational Therapy, 55, 175–183.

Ferriel, B.R., Fogo, J.L., (1999) Determining the effectiveness of pencil grips: An electromyographical analysis, Occupational Therapy in Health Care, 12(1), 47-62.

Wednesday, October 12, 2011

Annual obligatory rant about health insurance premiums

Background reading:



Well this year the annual increase to our health insurance costs are only 19% but the plan has a higher out of pocket maximum and slightly fewer covered benefits so it isn't exactly the same plan. I thought I would be clever and call my Provider reps for the different plans and tell them that I would be shopping and purchasing based on information they could give me regarding 2012 fee schedules. Historically, even though the cost for these plans goes up exponentially the amount of increase that any provider might see is just a tiny fraction (and often even ZERO PERCENT) of that increase. Also, what happens each year is that the co-pays are increased so even though allowable fees might go up the costs are passed entirely to the consumer with higher deductibles and higher co-pays. In other words, the insurance company's objective is to put all of YOUR skin in the game and as little of their own as possible.

The mechanisms that allow this to happen are primarily attributed to a farce of a regulatory environment, absolute lack of serious competition in the marketplace, increasing federal and state mandates, and gross profiteering.

For the record, corrections and controls for these mechanisms were exactly what was LEFT OUT of the hilariously entitled Patient Protection and Affordable Care Act.

Anyway, I thought I would purchase a plan that at least dropped a few crumbs from the trough where the insurance company pigs feed. No such luck, because even though we are in the fourth quarter and they obviously have the actuarial data to set rates for insurance plans next year they all report that they don't have the data on what the fee schedules will be for providers. I individually asked the local insurance companies why they think I am stupid and why they are trying to make me believe that they set plan costs without already knowing reimbursements and cost outlays to providers. They were all really good at towing the company lines though - I have to give them credit for that. I am not sure if they really think they are fooling anyone and I also don't know if they sleep with a clear conscience at night but oh well.

I will continue to post these things here because I think it is important for people to know that when the insurance company sets a co-pay amount that is IN EXCESS of the allowed reimbursement to a provider - that means you are having your premium money STOLEN from you. Yes, this year we have plans that actually have $50 co-pays for specialist visits (which is what therapy is identified as) and the amount that they allow for reimbursement is just $42.50.

That means that you pay it all - and it also effectively means that your therapy is no longer a covered benefit - except that they are artificially price controlling your medical care to make sure that they will continue to make as much profit as possible.

The net result is that receiving many services like therapies will be restricted to larger hospitals and institutions that cover the cost by other revenue-enhanced activities like $1000 toothbrushes.

More next year... stay tuned...

Saturday, October 08, 2011

When writing gives you the willies: Reconsidering 'tactile defensiveness'

For as long as I can recall most therapists talk about tactile defensiveness as being an oversensitivity to touch - and that it includes a sympathetic nervous system response that is allegedly 'out of proportion' to the incoming stimulus. The result of this characterization is that most people start looking AT the sense of touch as the primary culprit of the problem. This is why you then see therapists struggling to describe what textures a child tolerates and does not tolerate. This structural understanding of the problem is reinforced by sensory integration theory which posits that children are not able to process incoming sensory information accurately.

In the real world this model is poorly described and subsequently notoriously unreliable - and again you will hear therapists explain the inconsistency in sensitivity as a "sensory modulation" problem because sometimes certain kinds of touch will be tolerated and other times it will not be tolerated. Still, the focus often remains on describing the problem in terms of the sensory channel and not as much on the central nervous system mechanism that governs the response.

I would like to see all this evolve to a point where people understand that there is not a problem WITH the sense of touch. The problem can be observed THROUGH the sense of touch.

This is a pretty important distinction because when we continually describe something as 'tactile defensiveness' it leads people down a natural thinking path that the tactile input is the critical issue that requires study or intervention. That causes us to wring our hands over trying to find a way to accurately and reliably measure tactile localization or how we can provide an alternate form of tactile stimulation that will help to 'modulate' the system. We would probably be better served by also looking at central control mechanisms as opposed to only considering these peripheral tactile-based mechanisms.

This reminds me of some rather large fights I had with a neurologist who HATED splinting when I told him we were trying to see if we could achieve an inhibitory effect on spasticity by effectively lengthening the muscle and 're-biasing' the muscle spindle. He understood spasticity as something that was centrally driven by a lesion and not a function of a whole system - so he used to take my splints and toss them in the trash can. Anyway, not to get off topic, but I am saying that I am aware that we might have some impact on a central problem by intervening at the periphery but that doesn't mean we ignore the central problem either. So I am hat tipping to that crotchety old neurologist.

Still, therapists bristle at any threat to their longstanding description and understanding of the 'tactile' problem. Several notable studies have been completed that talk about 'anxiety' constructs but as close as these studies come to hitting what I think will eventually be considered as the pay-dirt of this problem, they tend to veer off and talk about how this 'anxiety' is co-morbid to the sensory processing problem. This is a classic example of several people feeling different parts of the elephant and describing the elephant in absolutely disparate terms.

I've been thinking about all this again lately because I had a young fellow come into my office recently who stated, "I can't write because I can't touch paper. The only way I can write is when I put my papers into these plastic protectors and I use a marker to write on the plastic."

"What do you mean - you can't touch paper?" I said. This was new for me to have a child be THAT aversive to paper - and then I was doubly surprised to see another clinician describe the same level of sensitivity on an online forum - and TRIPLY surprised to see that for the child discussed on the online forum the school came up with the same solution of writing on plastic overlays. So either we are all talking about the same child or people around the country come up with the same 'solutions' to this 'problem.'

"Touching paper gives me goosebumps. See!!!" Then he dragged his index finger across the VMI test booklet and pointed to the piloerection on his forearms. Indeed, he had goosebumps. "Its not just goosebumps. Touching paper also makes my teeth hurt."

The problem with my young friend's story is that as far as I know there are no tactile receptors for paper. Over the course of the evaluation I observed him touching other objects of equivalent texture quality and with equivalent amplitude or force. I also brushed papers against him when he wasn't paying attention and couldn't elicit the same physiological response. I also focused his attention on his hands while I was checking range of motion, and while doing so brushed and rubbed his forearms against the VMI test booklet that was resting on the table. No aversive response. Still, the piloerection that he could automatically elicit by dragging his fingers across paper was very real.

I qualitatively checked his stereognosis using the SIPT Manual Forms Perception subtest and he was functionally unable to discriminate the forms, but he did not have any defensiveness to the plastic pieces of the test. I also checked for defensive responses by trying the Localization of Tactile Stimulation Test and the Graphesthesia test and he was not defensive to that stimulation either. He had no other apparent or reported defensiveness to sound or movement or visual stimulation. He was a very picky eater. Still, none of this helps to explain his defensiveness to paper.

I get a lot of referrals like this, actually. Kids are 'defensive' to their clothing, or they are 'defensive' to their shoes/socks, or they are 'defensive' to having their hair washed. These all tend to be very focal kinds of defensiveness and in fact they cause severe functional difficulties with ADL completion or school. But how can we understand this in 'sensory' terms when there is no physiological explanation or consistency based on what we KNOW to be true about tactile perception?

The answer to this is that we need to understand that sometimes the explanation is best found in behavioral terms and conditioned responses. Although there may have initially been some developmental sensitivity or even a negative sensory experience, the operant cause of the piloerection and tooth pain can sometimes be conditioned fear.

If we consider this as a possibility, our interventions change dramatically. You still might try some 'brushing' technique IN CASE there is some local physiological dampening effect on the overall amplitude of incoming sensory messages to the CNS. You might get equal impact off of the placebo effect of giving the child attention and suggesting that the intervention actually works. You might also try progressive desensitization and relaxation training.

The particular child I saw had many other problems in addition to his 'paper sensitivity.' There were perceptual deficits, hyperkinesis, mood instability, and many other problems that all can cycle around a chicken or egg argument of what was causing what. I can state rather emphatically that he does not have tactile defensiveness (if that even exists). However, we can understand his central emotional regulation problem that is triggered by a conditioned fear to very specific forms of tactile input.

This distinction matters because accuracy in understanding the problem can lead us to correct interventions that respect the scientific evidence and our understanding of how sensory processing actually works.

Quick thoughts for background reading:

Masuda, Y., Suzuki, M., (1999) Developmental and pharmacological features of mouse emotional piloerection. Experimental Animals, 48(3), 209-211.

Reynolds, S., & Lane, S. J. (2009). Sensory overresponsivity and anxiety in children with ADHD. American Journal of Occupational Therapy, 63, 433–440.

Wednesday, October 05, 2011

An open letter to an occupational therapy evaluator

Dear Evaluating Occupational Therapist,

You evaluated a preschool child who has been receiving private occupational therapy for a year. I referred the family to their local school district because I thought it would be a better option for the family to receive services this way. Your evaluation was thorough and a fair representation of how that child functions - which is always good to see because sometimes evaluating preschoolers is tough and their performance can be variable. I was a little disappointed that you didn't make any attempt to contact me and get any input on the case. I think it is important for evaluating therapists to talk to previous therapists especially when high stakes decisions are being made, like eligibility for services through a system.

The agency that you work for sent a very nice person to the CPSE meeting to represent all of the evaluations that were completed. I asked the representative person what their position and role was at your agency and I learned that this person was a representative. I asked a second time and was told that the person was a representative for CPSE and CSE meetings. I didn't want to ask a third time because it might have been embarrassing - so I am not sure if it was a janitor or the executive director from the agency. They were very nice though.

The Representative read selected portions of all the evaluations at what I would call breakneck speed and it was very difficult to process the information that was provided so rapidly. I read over all of the evaluations prior to the meeting so I would be fully prepared to discuss them and am very familiar with all of the contents. What came across in the rapid review was not fully representative of what you and some of your colleagues documented in the evaluations. It was close, but it was not really accurate. At this point in the meeting I started to worry a little.

The CPSE chairperson was also very kind and friendly. I was happy that they asked me for my input. I explained that I worked with the family for a while and encouraged them to pursue services through the CPSE. I told them my own evaluation findings which were pretty close to yours. I spent some time going over the ways that this child would have difficulty in a pre-academic context, because it really wasn't explained all that well by the Representative.

I think that the CPSE chairperson was pre-disposed to finding the child eligible because no questions were really asked - which was good, because the evaluations that were completed really did support the child's classification. You didn't put any recommendations for services in your evaluation - I know that a lot of therapists don't because they are told not to put recommendations into their assessments. I understand that the idea is that final determination of eligibility and services provided rests with the CPSE - which is fine - but I still stand quite firm in the belief that the recommendations should be made and then the committee should be responsible for accepting, rejecting, or modifying those recommendations as the full committee sees fit.

I find that committees don't like to have dissenting opinions in the room, and I think that is unfortunate because when everyone is agreeing it really undermines the collaborative planning process that is actually supposed to be occurring. It really would have been OK for you to make some recommendation - and then the whole group can decide what the best solution is in context of all the other information on the table. Something bad happens when you don't make any recommendations at all - and I think you really need to know about it.

So the good evaluation that you completed was reported a little inaccurately because you weren't at the meeting. The janitor or executive director representative really didn't understand the full nature of this child's difficulties, but it was mostly ok because I tried to fill in the gaps and thankfully the CPSE chairperson was in essential agreement anyway. Something odd happened though because there were no recommendations about frequency or duration of service from you - so the CPSE chairperson turned to the district speech pathologist who has never before met the child and said

What do you think?? Once a week or maybe twice a week??

Well you can thank this very nice speech pathologist who never met the child before because they thought the child should get OT services at least twice a week. I have absolutely no idea why the CPSE chairperson would ask the district speech pathologist this question but in this situation it worked out ok.

So I know this is a long letter, Evaluating Occupational Therapist, and you are probably really busy and perhaps being so busy made it impossible for you to represent your evaluation at a child's meeting. I just thought you might want to know that THIS TIME all the stars aligned:

  1. even though you didn't contact me about the child's therapy history and performance
  2. even though the agency representative didn't represent your evaluation very clearly
  3. even though you didn't make any recommendations in your report
  4. even though some random speech pathologist made the determinative statement on how much OT the child should receive
So EVEN THOUGH all these factors were working against this child today I certainly know better than to open my mouth and stop something that just happens to be working in a child's interest. Call it good fortune. I prefer calling it divine intervention. Either way, it worked for a child today.

It might not work out so well next time - so I thought you might just want to be aware of this story.