Tuesday, September 25, 2012

On piano tops and proprioception

OK so I haven't let my inner R. Buckminster Fuller out for a walk lately so I think it is time to address a problem that I perceive with some aspects of clinical problem solving in occupational therapy.

Here is some background first:

In this month's AJOT there is an article on Proprioceptive processing difficulties among children with autism spectrum disorders and developmental disabilities (Blanche, Reinoso, Chang, & Bodison, 2012).  It is an interesting article that demonstrates differences in test performance on an observational measure of proprioception between children who have disabilities and their typically developing peers.

The authors correctly point out that we only have limited means to actually measure proprioception.  The Standing and Walking Balance subtest of the SIPT is a good measure, but like other measures of balance it is confounded by proprioceptive processing, labyrinthine righting, and optical righting.  It is difficult to really know how much proprioception actually contributes to balance because we are measuring other functions at the same time.  Measurement with eyes closed removes an optical righting component but still does not bring us to a particularly 'clean' measure of proprioception.  So, this subtest is limited as a measure of proprioception.  The Kinesthesia subtest has known test-retest reliability problems (Ayres, 1989) and itself is not a good measure of proprioception.  These difficulties with measuring proprioception are well-established and probably not really disputed in the field.

The idea of a functional observational measure of proprioception is interesting.  However, it is really confusing as to why the AJOT editors would choose to publish this article demonstrating differences between groups on an observational measure BEFORE they publish the observational measure itself!! (Blanche, Bodison, Chang, Reinoso, in press).  It makes it a little difficult to interpret a research study on a test that has never before been published.  I don't understand this editorial choice.

The assessment tool includes observation of categories like 'Decreased muscle tone' and 'Joint Hypermobility.'  Of course we don't have the actual assessment for detailed analysis of these categories but a question in my mind relates to the fact that children may have low tone and joint laxity for many reasons that are not related at all to altered proprioceptive processing. For example, low muscle tone may be theoretically caused by poor registration of proprioceptive inputs at the local level, dysfunctional cerebellar processing at the central level, or even something entirely different like a collagen or fascial or connective tissue defect - or even a muscular dystrophy or other condition for that matter.  The point is that we don't know from observation that low tone and hypermobility are necessarily proprioceptive problems.

Additionally, there are behavioral measures on this assessment like 'Enjoyment when being pulled' and 'Tendency to lean on others.'  There are literally thousands of possible reasons why children may engage in these behaviors and they most certainly are not all related to proprioceptive processing.

These are just big questions I have about this assessment and I hope AJOT publishes it soon so that I can make better sense out of these categories.  I am hopeful that we don't have another 'Sensory Profile' type of report or assessment that includes a multitude of observed and recorded behaviors that could possibly be attributed to many different problems. 

This is R. Buckminster Fuller talking now - because in occupational therapy we have this tendency to want to solve the problem by constricting our interpretation of observed behavior so that it fits neatly in with our preconceived notions and existing models.  We may have an idea in our minds about proprioceptive processing because it is part and parcel of our theory base related to sensory processing disorders. 

Fuller stated,

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. 

Even though we have ideas, we have to be careful not to fall into the trap of attribution or correspondence bias when we make observations.  It is possible that disordered or disorganized behavior like 'Tendency to lean on others' may be somehow related to a sensory seeking strategy associated with inefficient processing of proprioceptive afferents - but it might also be something else entirely.  We have to stop making automatic assumptions about these behaviors just because that is how we make sense out of the information when we constrict our thinking to a specific model.

Anyway, publishing the darn assessment FIRST might have prevented some of this gear spinning!

There are other issues to look at in the article though - one that caught my attention specifically is that the group of 32 children included in the study who were diagnosed with ASD reportedly did NOT have any additional motor difficulties.  That does not make any sense to me.  I understand that motor delays are not part of the diagnostic criteria for ASD but in my clinical practice I don't know that I have ever seen a child who has ASD that HAS NOT had an accompanying developmental motor delay.  Research indicates that these motor delays are quite common in this population (Provost, Lopez, Heimerl, 2007).  I am kind of wondering if the article meant to convey that they don't have an organic motor disorder?  That is really a little unclear because the study says "without any additional motor difficulties."  Very confusing.

I am hopeful that I can update some of these observations when the assessment itself is published.   Stay tuned.


Ayres, A. J. (1989). Sensory Integration and Praxis Tests. Los Angeles: Western Psychological Services.

Blanche, E.I., Reinoso, G., Chang, M. & Bodison, S. (2012).  Proprioceptive processing difficulties among children with autism spectrum disorders and developmental disabilities, American Journal of Occupational Therapy, 66, 621-624.

Blanche, E.I., Bodison, S., Chang, M. & Reinoso, G. (in press).  Development of the Comprehensive Observations of Proprioception: Validity, reliability and factor analysis, American Journal of Occupational Therapy. 

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

Provost, B., Lopez, B.R., Heimerl, S. (2007).  A comparison of motor delays in young children: autism spectrum disorder, developmental delay, and developmental concerns. Journal of Autism and Developmental Disorders,  37(2), 321-328.

Wednesday, September 19, 2012

When it is not in your job description...

Well I am sleeping better tonight knowing that the Chicago teacher strike is over!!!  All of the really important things like making sure raises stayed in place and health care contributions stayed low got the immediate attention they required.  Muscling out charter schools got a lot of good attention also and of course that is good because we don't want to have competition against a failed school system.  The less important issues like teacher evaluation systems got pushed off into the future.

I don't even live near Chicago and I have no skin in that game directly but I just wanted to express how happy I was that those Union efforts will continue to work in favor of students - just like I saw them working in my own community recently.

You see there was a four year old child who has a physical disability - doesn't even matter what the disability is exactly so I will leave that detail out - and he was happy and excited to start his school year.  All summer long his COTA worked with him and the family to teach him how to use the toilet.  He made great progress and by the end of the summer he was able to access the toilet in his home independently.  He was READY for school!!

The COTA contacted the district and let them know what they would need to do so that their facilities would be accessible for the child.  Sadly, on the first day of school those accommodations were not in place.  The little four year old child who has a physical disability was not able to use the toilet in school.  The facilities are different, he was not confident with his new skills, just going to school for the first time is a big challenge itself, and so he was not able to use the bathroom.  So he had an 'accident' and had to go to the nurse so she could help him with clean up.

Well the COTA quickly addressed the situation and was meeting with the classroom teacher, the classroom aides, the nurse, and even the school principal to solve the problem immediately.  There was a lot of lip service about 'doing whatever was necessary to make the environment accessible' and 'doing whatever was necessary to make accommodations'  but there was a little bit of a disconnect between the words and the actions.

I jumped into the situation to see if I could help out the COTA.  The classroom staff stated that they would not be able to help a four year old who has a physical disability in the bathroom.  It wasn't in their job descriptions, they told us.  In fact, it was in the job descriptions of a personal care aide, and not a teacher or a teacher aide.  Therefore, Union rules prohibited them from performing the essential job functions of the personal care aide position.

"Even if that means that a four year old child urinates in his clothing - just because you don't want to provide a supporting hand as he practices getting onto and off of an unfamiliar toilet?  Even if he will only need that help for a little while until he gets his confidence up in this new setting??" I asked.

The deadpan response was, "Our Union Steward told us not to do it, so we won't.  It is not our job.  We can help adjust his pants if they are askew when he comes out of the bathroom but that is all."

 I will stipulate that job descriptions are specific for a purpose and I appreciate the sentiment of following rules because generically that is a good thing to do.  However, this child only has a very minor need for temporary support to make sure he is safe getting on and off the toilet until he translates his skill into the new context.  Besides, he is just four years old and all he needs is a supporting hand.

Sometimes when you encounter really nonsensical systemic barriers you might think that you have finally reached the pinnacle of human stupidity and there is just no more to be seen - but I am always disappointed that there seems to be another mountain of stupidity on the horizon.

So I fired off a letter to the CSE advising them that the child was at increased risk of injury if no one was willing to help him with toileting.  I also suggested that there was a need for more OT consultation to make sure that the environment would be safe and accessible.  That got their attention apparently, because in lightning quick fashion a meeting was scheduled.  In advance of the meeting, I have been informed that the system will now provide a personal care aide because that personal care aide is somehow uniquely qualified to hold the hand of a four year old child who needs a little assistance to get onto the toilet.

I will make the assumption that the personal care aide position pays Union dues.  I don't know that factually, but it seems like a fair assumption.

Anyway, this all makes me really happy that the Chicago teacher strike is over, because goodness knows we need these teachers and their Union back in the classroom as soon as possible.

I anticipate that this kind of blog post can generate some hate mail, so I will state in advance that if someone wants me to be sensitive to Union concerns ever again, they will first need to explain to me why it is OK to let a four year old child urinate in his clothing because helping is not in your job description.