Coming home from hospital has been something of a turning point this week. With radiotherapy finished, that’s the end of all ‘treatment’ for now. We’d envisaged that as the start of ‘getting back to normal’. The reality however, with my hand and arm as they are, is that I’m entering a new phase of my life that’s all a bit unknown and scary. I’ve found myself quite tense and my emotions are a bit all over the place, but I am starting to put the pieces together that I need to move forward.

I’m not sure how clearly I’ve explained the situation with my hand because it’s crept up gradually and things are now very severe. Towards the end of chemo I had tingling in both hands and lost a bit of sensation in all of my fingers – a common side effect of the chemo I was on. However, as soon as chemo finished the sensation started to return to my right hand (which is now completely normal again) but not the left, which then got worse and worse. By the time I had my operation back in November it had become clear that the nerves were being affected by whatever was going on in my shoulder and armpit. A big nerve cluster in your shoulder controls all sensation in your arm and hand and the tumour was somehow stopping sensation. We hoped the removal of the tumour would start to see an improvement as it relieved pressure on the nerve cluster.

It got to the point where I could just wiggle my fingertips, and then about 6 weeks ago I lost all ability to move any part of my hand. I have only the tiniest sensation of touch in some parts of my hand. On top of this, my lymphodema has been very exaggerated. This basically means that the hand is about double it’s normal size as it is full of surplus fluid.

My arm is also recovering still from the operation itself – it does have movement down to the wrist but is so heavy with fluid that I find it tiring to carry it around. Luckily when I go out and about I have a velcro sling I can wear to ensure I don’t get too tired. It also creates a lot of problems dressing – both in terms of clothes that actually fit and also being able to dress myself – I have a very limited choice.

I have no way of knowing right now whether I will ever get my nerve sensation back. All of the experts believe it is very possible – the nerves can re-grow if they have been damaged, but the rate of growth is very slow. What has become clear is that we are certainly talking about several months in this condition even if it is not permanent.

What this means for me right now is that I need to focus the next ‘phase’ of my recovery on adapting to live as a one-handed person. There are several aspects to this and this last week has kicked a few things off I’m pleased to say. Helen from the hospice came out on Wednesday morning and we put together a ’shopping list’ of all the help I would need to get started. She has all the right contacts and they are now all making appointments or calling to get things started. I am about to meet with a physio to deal with the physical side of recovery, an occupational therapist who deals with adjustments that can be made in the home etc to help and a ‘family support advisor’ who can help me work out what official help I can get in terms of benefits (and more important to me with adapting cars and learning to drive again). Additionally, to get me out and about I am hoping to get lifts up to the hospice for some complementary therapies after christmas (reflexology, reiki etc).

I have also had a community nurse visiting me a few times over the last week or so to help me deal with managing the tail end of this infection at home. I still need to wear significant dressings but we have had to be creative in how we apply these as my skin is too sensitive following radiotherapy to use anything adhesive. This has actually resulted believe it or not in me wearing Kim’s boxer shorts around my neck as a sling for much of the past week. Luckily the dressings she brought today should now allow me to stop doing this!

Dealing with the one handedness gets me cross and frustrated, but I have also been encouraged by how much I CAN do. I am slow and clumsy, but decided to make breakfast in bed on Sunday. It took me 45 minutes to make a pile of toast, the tea went cold and then I had to get Kim out of bed to carry it upstairs anyway! It just goes to show really that the motivation is there, I’ll make mistakes and I’ve just got to go at a different pace from the past and take the pressure off myself.

I’ll leave it there and will update when I’ve met some of these new contacts.
Amy

Preserving memories: using photographic images, Nursing & Residential Care, 2009 Mar; 11 (3): 155-8

Julia Swann

Abstract:

Preserving images in alternative formats can offer an activity as well as providing an end product that can add familiarity to a personalized space. Julie Swann introduces some ideas for storing and presenting photographs.

Residents living in care homes may have many photographs on display, but photographic material is vulnerable to varying degrees of deterioration caused by light. Many photographs will remain in a drawer, or in an album, but other environmental factors, such as exposure to temperature and humidity, or handling can add to their deterioration. This article explains how to help to preserve these images in alternative formats, and, taking this a stage further, to transfer the images onto material to personalize a room, decorate items or to use within a gift.

Lancashire Care staff can request the full-text of this article, email: susan.jennings@lancashirecare.nhs.uk

Dear Miracle Workers,

When I was diagnosed with breast cancer I was given a CT scan (short for computerized tomography scan).  In fact I had several CT scans and MRIs too before I abandoned the system.  I remember being concerned that the CT scan was probably not good for me.  My doctors assured me the risk was minimal.  They were looking for metastasized tumors on my liver and elsewhere. They found something once but instead of a tumor it was fat and the spot on my spleen was a hematoma. Now there’s a new study out linking CT scans to cancer.  They are predicting that 29,000 future cancers could be related to CT scans received in 2007 and most of those cancers will be in the pelvic and abdominal region.  How ironic.

The study also says that the amount of radiation received was more than a mammogram but varied widely.  Some patients received only 1/10th the amount of radiation as other patients.  Did you know that CT scans were not standardized?  Apparently the more radiation the clearer the picture.  Hmmmm?

Intuitively I did not feel right about these procedures but I went ahead anyway… because I was scared.  Yes I was SCARED.  I was scared I was going to die from breast cancer and I wanted to know how far along I was. No one twisted my arm… they just encouraged me.  I was on medicaid so I didn’t have to pay anything.  During the 3 years I was in the grip of the medical system I tried to remain open to what was the best route for me, but I drew the line  when they advised me to have chemo, radiation and double mastectomies with reconstructive surgery.

A friend of mine and someone whom I had spent many hours praying with in Lakota Sioux sweat lodges happened to be a radiologist and worked in the lab at the hospital I went to.  She called me one day and pleaded with me to get the operations.  She told me my type of cancer was very aggressive and my best chances for survival were to do it.

My family encouraged me to go the allopathic route.  I come from a medical family.  My dad was a doctor, my brother-in-law is a doctor.  My sister was afraid I was choosing death.  My kids were scared. I prayed a lot about it. It took great courage for me to say no.  I prayed I wouldn’t regret it.  I had to follow my intuition even if it meant I would die trying.  I strongly believe the body can heal itself given the opportunity and the right circumstances… also the right mindset.

The right mindset is probably the most important.  It’s probably why allopathic treatment works some of the time. I say some of the time because it doesn’t always. Did you know that iatrogenic error and  illness is the third leading cause of death in the US, behind heart disease and cancer? In fact according to the Starfield Study, the total of medically-caused deaths in the US every year is 225,000...

I remember thinking that if western medicine offered me something that just targeted the cancer cells I might consider it, but I work too hard to stay healthy and I don’t want my immune system being compromised.  I remember thinking if I could either reverse my condition completely naturally or hang in there until a better alternative was discovered I would be fine.

Well guess what there is a new breakthrough I recently read about coming from Tel Aviv “A never-approved drug developed to prevent the death of nerve cells after a stroke can efficiently kill cancer cells while keeping normal cells healthy and intact, an international team led by a Tel Aviv University researcher is reporting in the journal Breast Cancer Research.”

“Prof. Malka Cohen-Armon of TAU’s Sackler School of Medicine found that the stroke drug — a member of a family of phenanthridine derivatives developed by an American drug company — worked to kill cancer in mice which had been implanted with human breast cancer cells.

“‘Not only did the drug kill the cancer, but when we investigated normal cells, we discovered that they’d reacted as though they hadn’t come in contact with the drug,” says Prof. Cohen-Armon. “This is the result we were hoping for. If human trials go well, we could have an entirely new class of drugs in our hands for the fight against cancer.’”

Is it a coincidence that this researcher’s name is Malka?  That’s my hebrew name too.  It means Queen and it sits in the center of the logo for my ministry.

So who knows what is beyond the horizon for many of us who have been hanging in there post breast cancer. BTW it’s really cruel to implant breast cancer cells on mice and this may be a thing of the past (see A Legal Challenge to Animal Research:Animal rights law courses may threaten the use of animals in medical research.)

I have not totally given up on the medical system, I just think they lag behind and do not respect enough, the body’s innate ability to heal. But the medical system is made up of people, and it is the people that need to change if the system is going to change.

Some of the healthiest people I know in the system are therapists- physical therapists, occupational therapists and speech therapists.   Many of them truly understood the value of exercise, diet, independence and quality of life.

I wish crafts were still an important part of Occupational Therapy as that was what motivated me to become an OT in the beginning.  There’s been a shift in the last 10 years. Insurance no longer pays for therapeutic activity unless it can be categorized under activities of daily living or exercise. The psychological pleasure of creating something and the increase in self-esteem is not acknowledged like it used to be.  Utilitarian activities are favored.

I remember 10 years ago making a woven basket with one of my centenarian patients.  Her eyesight was failing and her mind was a little fuzzy but I talked her through the weaving of the ribbons for the simple basket. “Put it under this one and over that one…. and under this one… now put the glue here and press it here…” You get the picture. At the end of the week she had a completed basket and she was so proud of herself, she showed everyone what she had made, the nurse, the aide, her family and friends. She couldn’t stop admiring it sitting there on her bedside table.   Then she looked up at me and she said “I want to make lots of these for everyone for Easter. “  That made me smile.

Wishing you all creativity and joy this holiday season.

Expect Miracles!

Blessings,

Melinda

The power of pilates, Nursing & Residential Care, 2009 Oct; 11(10): 520-3

Julia Swann –

Abstract:

Pilates is a beneficial physical fitness system used to develop core muscle strength and flexibility. It can be adapted for use within the care home setting. This article provides an introduction. 

Pilates is a low-impact, complete body workout that develops body awareness, strengthens core abdominal and back muscles, thereby improving stability and support in the body. As some care homes offer Pilates, it is important that staff understand its concepts. Pilates can complement other treatments within the care home, and help to improve or maintain residents’ levels of physical ability.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

We are acutely aware of how the current economic environment limits opportunities for our children with Down syndrome to access physical, occupational, and speech/language therapeutics and support. Because these skills are central to the development of thinking, reasoning, remembering, as well as social inclusion and integration, CODSS is committed to meeting this emerging need.

The CODSS Childhood Intervention Program is a pilot initiative designed to: 1) increase access to physical, occupational, and speech therapeutics and support that help bridge the gap with county-provided services; and 2) foster continual development and achievement by further educating parents on how to confidently and consistently reinforce therapies for their child while at home.

The CODSS Board of Directors is enthusiastic about this program and eager to launch it as it will provide our children with Down syndrome a solid foundation of critical skills that will allow them to live meaningful and more independent lives.

In the traveling healthcare industry, it is important to master your telephone interview skills.  Sometimes, you will only be given a brief overview of a position, and will be asked to discuss your experience, and how your background will fit into the current needs of the facility. However, there are times when the interviewee will want to delve a bit deeper. In any case, here are some helpful tips:

• Introduce yourself, and engage in a small amount of small talk. Show them your personality.
• Speak clearly! Make sure you are in a quiet spot, without background noise.
• Remember to show enthusiasm in your voice- you can hear a smile over the phone!
• Get rid of distractions. If you are in front of a computer- don’t type or check your e-mail. Stay focused on the task at hand.
• Remember, your primary goal during an interview is to prove that you are the best person for the job!

For more information on the latest Physical Therapy, Occupational Therapy, and Speech Therapy openings, please contact me today!

Melissa Gabriel 866-518-1750 Ext. 2319

Hi.

Ok, This site is a little more complicated to use than I anticipated! I intend to use this blog to document my personal progress through my Occupational Therapy degree. I will welcome all comments on my posts, especially tips on how to get the most out of this site and get this blog to the ‘right’ people! I will be sharing my developing thinking, and sharing my progress with anyone interested. I decided to do this as part of developing my ‘reflective’ self … and a way to share my thoughts on subjects that I may not wish to discuss within college.

…… but for now , I am just wanting to get settled into this way of working.

All advise gratefully received.

will post more about me tomorrow

P x

In the Fall of 2009, Sullivan Library subscribed to an OT/PT database called Rehabilitation Reference Center. This EBSCOhost database is a clinical reference tool useful for OT/PT students and faculty of Dominican College.

Let’s say you had a paper on multiple sclerosis. Under the diseases and conditions tab, you can look up causes, risk factors, useful drugs, parts of the body affected, examination tips, assessment, care plans, desired outcomes, theraputic exercises, and similar pieces of information. There is also a drugs tab, where you can input MS drug names for further information. Other useful resources include Patient Education, Exercise Images, and Practice Resources.

Interested? Connect now

I have no idea how many wrist and ankle fractures occur every year, but I can bet it’s not a small number by any imagination. For most of us, I’m guessing we’d expect to have a fracture, wield a wonderfully-autographed cast, get it removed and go on our merry way – but after reading this article, and having seen some very sad people over the years, perhaps my expectations of speedy return to normal might be over-inflated!

This paper by Linton and colleagues from Orebro, Sweden, is a novel one in that most of our knowledge about chronic pain comes from observing people recovering from low back pain. After all, low back pain is one of the most common pains, it’s the one that produces the most long-term work disability, and treatments for it eat up health budgets like little else. BUT, in a fracture, we have a nice clear-cut incident that begins the process of recovery, a well-known pathophysiology, and a well-understood recovery process from a biophysical perspective, so it provides us with a great opportunity to see what the risk factors are for longterm pain and disability.

Methodology
I’ll just briefly describe the methodology here – 79 participants were sequentially recruited to the study if they had a distal fracture, were aged between 18 – 70 years, without any other fractures and not experiencing dementia. Nine dropped out and these were older and female. Each participant completed a modified Fear Avoidance Beliefs Questionnaire, completing this in respect of their beliefs about pain before their injury; the Pain Catastrophising Scale, numeric rating scale for pain before the injury, expected recovery at six months, and actual recovery at six months. Mobility and strength were also tested a time one and six months later.

Results
Pain and worry reduced over time, as expected. Pain level started at 4 (ranging between 0 – 8), and dropped at T2 and T3. The number of people reporting no pain or no worry increased from T1 to T3 from 4% to 46% and from 30% to 57%.
69% of patients thought they should be fully recovered within six months when they were first asked. 36% thought this at T2, but the percentage who actually thought they were fully recovered at T3 were only 29%. That means that although most people thought they would be recovered within 6 months, actually less than 1/3 actually were. I certainly didn’t expect that!

Mobility and strength ratings at T3 showed 45% were not fully recovered at six months if they had a wrist fracture, while 33% of people with ankle fractures were not fully recovered. And yes, they do describe the processes used to measure mobility and strength.

Looking at fear-avoidance and catastrophising, there was a bit of work to get the groups divided into high and low levels of fear.
The proportion of patients with low fear at T1 and T2 was 54%, while for catastrophising was 56%. 29% of the participants had a high fear and pain profile at T2. What this lead to, after looking at an odds ratio analysis examining the relationship between fear and catastrophising, was that higher fear-avoidance beliefs increased the risk for pain , but high fear wasn’t significantly related to future self-rated recovery, mobility or strength. For catastrophising, there was a relationship only for strength.

What can we conclude?
OK, apart from the small sample size, and the need to use the strength of the noninjured limb as a substitute for the fractured one at T1, and the authors suggest that taking more frequent repeated measures might have helped; we can conclude a couple of interesting things:

1. People over-estimate how rapidly they will recover from distal fractures, and expect to be fully recovered within six months, when 2/3 of people won’t be
2. Higher-than-average scores, or increasing scores on pain-related fear and catastrophising are linked with future pain and recovery levels.  This is similar to the repeated findings in back pain and other types of pain, so shouldn’t be unexpected.
3. As catastrophising and pain-related fear drop over time, this could mask those who are at risk of failing to recover.

Linton and colleagues suggest that close monitoring of fear-avoidance beliefs and catastrophising over the first few weeks of recovery would help health professionals intervene with psychological input designed to reduce fear and normalise expectations.  In other words, reassure patients that it’s normal for distal fractures to take a lot longer than 6 months to fully settle down.

One problem with this for me is that I don’t know anywhere in New Zealand where fear-avoidance and catastrophising is measured in people who have distal fractures! Most orthopaedic departments are singularly lacking in psychologists, and provided the fracture is uniting, patient’s fears and worries rarely get a look-in!  I can’t speak for GP’s who might have some ongoing input with a person who has a distal fracture, but I’d expect that unless the person attends and asks for help, their worries and fears won’t be identified.  This then means the physiotherapist who might be involved to help improve function (and maybe the occupational therapist) are the ones who may be left trying to address the patient’s fears.

Do we need to introduce another layer of psychological input delivered by psychologists for this group of people?

I think not – I do think maybe occupaitonal therapists and physiotherapists could be mindful of the natural healing process, the time it takes to recover, and be aware of how fear-avoidance and catastrophising interact to produce disability – and start to structure graded activities to increase the  confidence a person can have in their own ability to move.  And perhaps encouraging gradual return to functional activities rather than ‘exercises’ per se could be a better approach.  No gadgets please OT’s!  Learning to use the limb, attending to fear and catastrophising and addressing these quickly are well within the clinical skills of occupational therapists, physiotherapists, nurses and GP’s – so watch, listen and respond, even in these acute and so-called ’simple’ injuries.

Linton, S., Buer, N., Samuelsson, L., & Harms-Ringdahl, K. (2010). Pain-related fear, catastrophizing and pain in the recovery from a fracture Scandinavian Journal of Pain, 1 (1), 38-42 DOI: 10.1016/j.sjpain.2009.09.004

Pre-emptive occupational therapy for healthy older people, College of Occupational Therapists, 27th Novemeber 2009

Click on the title above to access the full-text

Abstract:

The College of Occupational Therapists propose the implementation of a programme of preventive occupational therapy for healthy older patients to maintain health, function and quality of life. Similar work has been shown to be cost effective in the US and a pilot study has been undertaken in the UK.

Lancashire Care staff can request the full-text of this document, email: susan.jennings@lancashirecare.nhs.uk

This week, we have undergone two big changes:  a new orthodontist and a new occupational therapist.  All of us are rather attached to our regular routine so these changes feel rather jarring to our household.  One way we have been coping with these changes is by turning to a good book.   We are reading two at the moment, The Happy Hollisters and The Cricket in Times Square.  Losing ourselves in a good story really helps us to let go of our anxiety and enjoy the day.

This muse won’t be quite as lengthy as my last rant on occupational therapy and science, I promise! At the same time, it’s on a similar theme – and touches also on my post about ‘back to the basics’ where I discussed the recent review of pain contracts by ACC in New Zealand.  This review criticised the number of pain intervention services (eg injection therapies) and functional reactivation programmes that are provided without due regard to integrating the psychosocial along with the biomedical.  I suggested that perhaps providers need to be ‘risk profiled’ as well as claimants, because some of the behaviour seen in providers is likely to disregard high risk psychosocial factors and reinforce disability.

If clinicians are to be something other than ‘technicians’ applying a process to their patients, they (we) need to understand the concepts lying behind an intervention.  At the same time, we also need to be able to understand when an intervention isn’t likely to succeed, and when a variation on an intervention might suit better.  To do this requires effective clinical reasoning – aha! a theme!  I’ve hammered on a bit about clinical reasoning because it underpins the WHY we might choose to use one intervention over an other.  Clinical reasoning implies working backwards from what is evident in the patient’s presentation to hypothesise about how those features might occur.  In other words, developing a clinical theory to explain how and why the person is showing this behaviour.

Clinical reasoning can be quite straightforward in many settings.  After all, building on the knowledge of centuries, clinicians know enough about bone healing to align a broken bone, stabilise it, and wait for it to heal without doing too much thinking about it.  (Pssst! Don’t tell the orthopaedic surgeons this!)  Similarly, in an acute hospital setting, some fairly simple reasoning is needed to establish whether a person can get on and off the toilet with a raised toilet seat and then issue one if need be!  However, clinical reasoning can be (and usually is) much more complex than this.  Depending on their professional orientation, clinicians working with an acute fracture might ask why the person broke the bone, what the implications of that immobilised limb might be on occupations, might be considering the need for supports at home, might be monitoring for signs of shock – and the point is, these further interventions depend entirely on the theory-base of the clinicians working with that person.

Even in the case of someone needing a raised toilet seat in order to be discharged safely home, the clinical reasoning behind that simple intervention is not just about the biomechanics of getting on and off the toilet!  It could also be asking why the person has trouble standing up and keeping balanced, how the person might cope at night without lighting, whether the person can (or does) ask for help and so on.  Without having a good theoretical framework on which to base information collection, and a similarly effective way to organise that information, the clinician might as well simply issue a raised toilet seat and be done with it!

I’ve deliberately used simple examples to illustrate so-called simple clinical reasoning.  Now lets consider more complex examples.

Firstly, an analogy.  If I wear a set of glasses that occlude my vision on the left hand side of each visual field, I can still see. What I can see is limited, and I need to move my head around to scan the whole of my environment, but I can see.  After a while wearing these glasses, perhaps a week or so, finding my way around becomes easier, and in fact I’d have trouble after just another week of wearing the glasses, adjusting to ‘normal’ vision.  The world would look ‘normal’ to me even though part of my visual field is blocked.  New items appearing on the left side of my field of vision could suddenly ‘pop’ out of nowhere, and unless I know I’ve got those glasses on, I could be quite unaware of the amount of visual information I’m missing.

This is exactly what happens when a professional dons a single theoretical perspective.  I’m guessing we can all recall the first years of becoming a professional, and how strange adopting that new ‘persona’ felt.  After a while, though, it becomes familiar and we hardly notice it.  Then along comes new research, new theory, new models and new interventions.  The world gets a little shaken up!  We either integrate this new information, or we work hard to ignore it. ‘High risk’ clinicians are, IMHO, those who fail to recognise the contribution of information from outside their existing frame of reference. It’s my opinion that these clinicians can and should be identified, and either helped to integrate the new knowledge – or not allowed to practice in a field like pain management where the contribution of information obtained from so many fields is critical.

Bringing this back to clinical reality, if we are unaware of the theoretical models or even the professional models we use, we can be completely stumped when a new situation arises, or when a new piece of information is brought to light – a bit like that object coming into view on the left field of vision when I’m wearing those glasses!  By taking the glasses off, opening up the whole visual field, we can be much more aware of the fact that we do have constraints on what we can see, and if we look more broadly we can identify areas we want to look at in more detail.

OK, enough with the analogy.  Some clinicians scoff when I talk about my interest in science, theory, models and the process of clinical reasoning.  I think it’s vital.  Without articulating why a certain intervention is recommended, I think it’s impossible to distinguish between following a protocol as an assistant and being a versatile and adaptive clinician.  An assistant may not know how a process works, just that if (a) and (b) are following in a certain order, (c) will ensue.  If (g) or (h) are present, an assistant won’t know how to respond.  A good clinician knows that people may present with the same behaviour, but the underlying factors influencing that behaviour could be very different.  For example, someone saying that he or she can’t sleep and wakes often might be due to pain, a natural wakening during normal stages of sleep, having chronic sinus problems, low mood, anxiety – or even the effects of having a new baby in the house!  The work of clinical reasoning doesn’t start with simply ‘identifying the problem’ and then solving it: it begins with the way in which the clinician views the situation and the contributing factors.  If we’re not careful, even as experienced clinicians, we can jump to conclusions or simply ‘assume’ that the clinical problem is the one with which we’re most familiar, or the one that springs to mind the most easily.

It takes a lot of effort to avoid prematurely deciding on ‘what the problem is’ during a clinical intervention.  Being aware of our cognitive limitations, noticing our assumptions and broadening our view to include searching for as many different pieces of information as we can helps to prevent clinicians from working from a recipe – but it’s also hard work.

I’m referring back to Vertue and Haig’s paper on Abductive Theory of Method in clinical reasoning as the basis for today’s post. Read it if you’re keen on science, models, theory and clinical reasoning, and let me know what you think.

Frances M. Vertue, Brian D. Haig (2008). An abductive perspective on clinical reasoning and case formulation Journal of Clinical Psychology, 64 (9), 1046-1068 DOI: 10.1002/jclp.20504

Yesterday I went to see my OT (occupational therapist) for a regular assessment, and afterwards she said to me, “I’ve never in all my years – and there are a lot of years – seen someone recover so smoothly and quickly!”

I can’t explain how happy I was to hear that, because I’m sure you all can understand how friggin’ scared I was that I would have debilitated sensation forever. To know that I have been blessed with a speedy recovery is a testament to how faithful God is.

I know I won’t ever be back at 100% sensation, but at least I know I am getting better and that soon it’ll all be over!!

A new centralized application service for occupational therapy, OTCAS, will launch in August 2010 for use by the entering class of 2011. Read more here: http://www.aota.org/Educate/EdRes/OTCAS.aspx.

In New Zealand, the national accident insurer, Accident Compensation Corporation, has been reviewing its pain management service contracts. The latest message from both the Government and ACC is the need to reduce costs (not that I’ve ever heard anyone say ‘let’s go for broke, let’s spend all we can!’) and one way to do this is to look at how to reduce the risk of long-term disability associated with chronic pain. So, in their pursuit of ways to do this, ACC has consulted with providers and reviewed opinions about services provided to claimants under the various pain services contracts and come up with some pretty sensible options.

Some of the findings from examining current services simply do not surprise me – amongst two of the most common services, pain interventions (ie nerve blocks and infusions etc), and ‘functional reactivation’ programmes (ie let’s get fit in a gym), the providers rarely use a biopsychosocial model – apparently, these services are provided within a biomedical model, and those factors that are so well known to complicate recovery are simply not addressed. Now I’ve mentioned before in this blog that some interventional doctors actually believe that if they can abolish the pain the person’s problems will simply disappear and they’ll return to normal – and this is an opinion that now ACC is fully aware of, and hopefully will reconsider! The evidence from empirical studies just does not support the idea that pain and disability are linked in a nice tidy causal relationship. In fact, for a really lovely illustration of this in another health condition, angina, by Gill Furze, I think you’ll enjoy it.

So, from my somewhat cursory reading of the recommendations from ACC, it looks like a ’stepped care’ approach is being adopted.  In this, ‘low risk’ people are provided with fairly simply input – advice from a GP, maybe a DVD or pamphlet advising people that it’s OK to move, that returning to work is good, and to simply get on with it.  ‘Medium risk’ people are provided with ‘reactivation’ but with some attention to psychosocial factors, and a comprehensive pain assessment is less likely to be on the cards for them.  Finally, ‘high risk’ people will be able to access ‘the whole works’ including comprehensive pain assessment, multidisciplinary and interdisciplinary pain management, and with a strong emphasis on attending to the psychosocial factors that are known to influence recovery.  Good ideas. With one catch – how ‘risk’ is identified is not yet clear.

In New Zealand we’ve used the Orebro Musculoskeletal Screening Questionnaire in some form since 1997 or so.  Unfortunately, this wonderful tool is often either not interpreted, or the ‘warning signs’ are not addressed, and for some people, a high score can almost be a flag for a case manager to be especially punitive in terms of ‘lets get this person back to work any way we can’ rather than using it as an indication that this person requires more support.  If this tool is used to screen for risk, and used well – then there could be some excellent results, and hopefully ‘low risk’ people won’t be over-serviced, while ‘high risk’ people will receive that help that they need.  But it will need case managers and other service providers to really come to grips with what the biopsychosocial model actually is, and how to truly address psychosocial factors in a systematic way.

How this plays out will be interesting.  Currently a claimant could see several providers concurrently: perhaps a doctor who is completing medical certificates, the physiotherapist providing the ‘reactivation’, an occupational therapist helping with return to work, and maybe an independent psychologist providing ‘CBT’ for pain.  If each of these providers has a slightly different understanding of the risk factors influencing disability in chronic pain, the poor claimant is going to be very confused.

For example, the doctor may be aware of the person’s home situation and certify fitness for work based on his or her knowledge of the overall ’stress’ level of the person in context.  Without good understanding of how pain can influence function, the doctor could suggest ‘no heavy lifting’ – but fail to indicate how heavy ‘heavy’ is, whether this applies all day every day, whether there is a difference between lifting from the ground or above the head etc.  And the rationale for ‘no heavy lifting’ is fairly limited – what ‘damage’ will actually occur? or is the doctor responding to the person’s distress about ‘having to lift’ and experiencing pain?

The physiotherapist could be focusing on fitness generally, and asking the person to complete a full gym routine, maybe with some ‘core stability’ thrown in for good measure.  If the person is still fearful about his or her pain (because the doctor has said ‘no heavy lifting’), while completing the gym programme may actually be avoiding specific movements like bending because of this.  And be extremely fit – but not actually doing anything at home!  And you canbe very sure that this happens.  A lot.

The occupational therapist, with a really good ‘ergonomic’ approach, may recommend all sorts of wonderful gadgets, seating and break down the work tasks to ones the person ‘can do’, but the actual tasks the person does is really being established on the basis of what the doctor said about ‘no heavy lifting’.  The person feels pressured because there are lots of other movements that increase pain, apart from ‘heavy lifting’ (what about sitting? or twisting? or going up stairs?) but ‘has’ to do these movements because the doctor didn’t say they were ‘banned’, and there really are not that many tasks at work that the person can do!

And finally the psychologist, who is aware that the person isn’t sleeping, is feeling quite anxious and doesn’t have effective communication skills, works on these – but fails to address the confusion that the person has about what this pain actually means.

These situations are so common as to be the norm.  And while each provider is possibly working to ‘clinical standards’, the models they’re using don’t dovetail, and the person’s real concerns are not identified – and worse, the person gets caught in the middle between all these rather earnest providers who are actually talking past each other!

Now it’s not my plan here to lobby for any specific approach – I think plurality and choice is great in pain management.  But – and you knew there would be a but – there does need to be excellent communication and agreement amongst the providers and the claimant/person as to

1. what the problems are
2. what the hypothesised relationships between various factors are
3. a consistent approach to managing specific beliefs and behaviours

Oh and it does need to be evidence-based.  That means ‘favourite’ treatments that individuals like to do (like acupuncture, pilates, adaptive gadgets and even CBT or mindfulness) need to be justified not only from the literature, but also in terms of how they ‘fit’ for this person in this situation at this time.  That means outcomes need to be measured.

I’m still not convinced that primary care, even secondary care, clinicians talk to each other enough in the same language.  If ACC wants to ‘risk profile’ patients, maybe it also needs to ‘risk profile’ providers.  And maybe providers could be given some further training (maybe even training through a tertiary institute like University of Otago’s postgraduate papers in Musculoskeletal Medicine, Pain, Pain Management etc?!), even psychologists who currently don’t receive any specific training in a cognitive behavioural approach in pain management.

Read this paper – it’s an oldie but a goodie.  Even though some of the recommendations have now moved on, the fundamentals remain.  Psychosocial factors continue to be the most important predictor of disability, and need to be managed from the outset.  After all, people with chronic pain had acute pain in the beginning!

Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, & Reis S (2002). Cognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future. Spine, 27 (5) PMID: 11880850

A landmark study on autism and the use of early intervention, Applied Behavioral Analysis (ABA), and play.  Occupational therapists who work with young kids are all about using play to facilitate therapeutic outcomes, so even though this study isn’t necessarily referencing occupational therapy, it’s good research to know about!

You can read the article by clicking here.

A landmark study on autism and the use of early intervention, Applied Behavioral Analysis (ABA), and play.  Occupational therapists who work with young kids are all about using play to facilitate therapeutic outcomes, so even though this study isn’t necessarily referencing occupational therapy, it’s good research to know about!

You can read the article by clicking here.

Hands up the occupational therapists who like statistics!  Thought not.

What about those who read journal articles comparing one treatment with another?  Use a treatment model consistently – or use a set of hypotheses and test to see which ones apply to the person we’re working with? Hmmm….  Are occupational therapists ‘epistemiphobic[1]’? or simply naive about science.

I recently read an assignment on clinical reasoning written by a very competent and educated occupational therapy graduate.  In it the views of Kuhn, cited in Mattingly and Fleming were described where ‘clinical reasoning within a biomedical frame is like puzzle solving, in that a clearly identifiable correct answer exists (e.g., a pathology, a cluster of physiologic deficits), and the player’s task is to find that answer.’ The argument continued that ‘Occupational Therapists in pain management often find themselves reasoning their work in a scientific and biomedical framework due to the nature of their work environments. This unfortunately often discredits the more difficult unspoken things that are done by the Occupational Therapist to the more recognisable and clearly defined instances that medical terms provide.’

My problem with the statements in this are that it assumes that science ‘discredits’ the ‘difficult and unspoken’ things done by occupational therapists – that somehow, occupational therapy is too complex for ‘science’ to unravel and understand.  Firstly this ignores the complexity of scientific methods such as constructivism, and secondly it suggests that what occupational therapists do is so complicated and unrepresented that no-one truly understands it. I also disagree that the prevailing model within pain management is a biomedical one – it’s clearly accepted that a biopsychosocial model is the one that most of the researchers and clinicians now accept. (Head here for one of the most popular books on pain management...no I’m not advertising OK?!)

I’m going to deal with the first point, that occupational therapists have a limited understanding of science, and as a result misinterpret the multiple ways in which society, culture and indeed health care, has been built on the scientific method.  Then I want to turn to the suggestion that what occupational therapists do within treatment is so incredibly complex and individualised that it can’t be subjected to the kind of systematic scrutiny that other health professions have used, with success.

In the history of health care over the past 100 or so years, there has been a swing from humanism[2] toward empiricist[3] epistemology[4] and more recently, back again towards a constructivist[5] view of what makes up a ‘healthy’ individual.

This has been paralleled within the development of occupational therapy – from the Adlerian view of humans as being essentially self-correcting and requiring simply a context and ‘activity’ within which to flourish (Adler, 1931), through to the reductionist biomedical view of humans as an assemblage of body parts that can be pieced together using artificial limbs and principles of biomechanics (for example, as described by Ice, 2005).  As a reversal of this, the constructivist point of view has focused on the lived experience of individuals, rejecting the idea that data that is grouped together can truly represent what is true for any one person (Toombs, 1995).

Today, it’s not always clear, but plurality in how people define and reach wellbeing, especially while self managing chronic health conditions such as diabetes, rheumatoid conditions and chronic pain, is much more broadly defined than ‘the absence of disease’.  The WHO definition of health was, in my training in the early 1980’s, held up as an ideal rather than a reality.  Today, possibly as a response to the rise of chronic health conditions, the outcomes of health interventions are measured as often in terms of ‘quality of life’ and ‘disability’ than in complete cure.   Incorporating a ‘strengths’ approach within mental health (e.g. Cowger, 1997), looking at resilience within positive psychology (Seligman, 2008), and looking at fostering supported self management (Bycroft & Tracey, 2006), are not just passing fancies – they all have a sizable literature, and one that not only draws upon empirical science including randomized controlled trials, but also builds upon ‘the lived experience’ of individuals in all their complexity.

Science can often get a bad rap in the media.  Members of the public criticize scientists for being equivocal about results, for crying wolf over what may be harmful in one study and helpful in another. It’s not surprising that faith in what science can offer in health is somewhat low.

But occupational therapists are not the ‘general public’. Occupational therapists work within a health system that, for the most part, relies upon considered opinion based on fact.  Cold hard facts, often in the form of cost effectiveness, mean that well-designed scientific studies are needed to demonstrate that treatments are worth paying for.  This makes sense to me – I pay taxes, and I attend for treatment.  I’d much rather know that the treatments my money is spent on are known to work, and for whom; and I’d really like to know that when I need treatment, the options I’m given have data supporting their use rather than that old paternalist attitude of ‘the doctor knows best’.

I think science is misunderstood by many occupational therapists.  It’s seen as something removed from the daily reality of clinical life because it involves strange things like ‘control groups’ and ‘statistics’ and experiments, things that clinicians in everyday practice really don’t often do.  Science might not have even been part of some occupational therapists schooling, either before professional training or even as part of undergraduate training.  Girls and women are found to be fearful of science and mathematics as they go through school (e.g. Stipek, & Granlinski, 1991), particularly higher levels of schooling.  If these attitudes and beliefs continue in senior occupational therapy professionals and educators, it’s likely that undergraduate and newly graduating therapists will remain unaware of the place of science as part of the development of knowledge about our world and cultures.

Maybe it’s time occupational therapists took a second look at ‘science’.

Science simply means the ‘systematic study’ of phenomena to identify how it works, whether it will happen again, how it happened, where it happened, how similar or dissimilar that phenomenon was to another one – and so on.  Most of us are familiar with the ‘hypothetic-deductive’ process of experimenting to find out whether treatment X influences outcome Y.  This represents only one approach to the scientific study of phenomena.  There is more than one way to ‘do science’.  Here’s a very recent discussion about a definition of science.

Most of what we accept as ‘known’ today has developed as the result of years of serendipitous and systematic discoveries.  Serendipitous because we can all probably think of at least one discovery that was simply ‘a happy accident’ – think of Fleming and penicillin.  Systematic because once that finding was made, a concerted effort was made to understand what had happened, and to find out how to do it again – and explore the properties that caused such excitement in the beginning!

The view of science that I take is based on combining both aspects of scientific discovery.  The first is to identify something unusual that occurs – and then to see if it happens again.  Once is simply an aberration, twice may be coincidence, while three or more times starts to look seriously interesting. An example in occupational therapy practice might be to notice that several people with chronic pain describe being very reluctant to do their grocery shopping.  While in one or two people, this might be simply an area to work through to help them achieve independence, if it occurs in many people, especially in people with quite different pain presentations and durations, it might point to something worth investigating.  In the language of science, this is called ‘a phenomenon’, and if it’s demonstrated to be present in many people of different pain presentations and in different cities, then it could be called a ‘robust’ phenomenon.

It’s this first ‘aha!’ experience that is one of the most creative and serendipitous aspects of science – but that creativity need not stop there.  First of all, it’s really important to clearly and fully describe the phenomenon – using any manner of methods to identify who demonstrates it, how it’s portrayed, what settings it appears in, whether it’s simply in large supermarkets or maybe also in small convenience stores, whether there are any relationships between this problem with grocery shopping and any other pain-related phenomenon such as pain-related anxiety and avoidance (fear-avoidance).

The second part is to systematically study to understand how and why that phenomenon occurs. This involves painstaking hypothesis generation and testing, and the hypothesis generation part involves asking multiple ‘why’ questions, testing out with many experiments whether the predictions of that explanation hold true.  It also means a lot of disappointment as a favourite explanation turns out to be inaccurate, or incorrect.   The ‘experiments’ can be good old hypothetico-deductive ones, or more broadly-generated constructivist ones.  And to do this careful examination of evidence for and against any particular explanation means controlling for outside influences and chance.  This is whe re the statistics and other horrid mathematical things can come in handy because they allow us to factor ‘in’ or ‘out’ the amount of variability and trust we want to put into our experiments.  But this approach isn’t the only way – we can also use qualitative methods such as intensive description to examine a phenomenon, but even a constructivist approach to science uses inference to draw conclusions from one situation to help us consider and hopefully understand another situation.

So, science is about being systematic, recognising that each of us views the world slightly differently – but underneath all that, there are some commonalities at some point that we can recognise and then apply to another, similar situation (or by comparing what is dissimilar, use that information to inform a completely different situation).

I was with a group of therapists recently, and mentioned the word ‘model’ to them – to hear them talk, models are irrelevant to the ‘real’ day-to-day work of an occupational therapist.  Who’s got time to do all that reasoning and thinking in the business of helping people do things differently?  Well, whether you are aware of a model or not, everything we do especially within a therapeutic context, relies on the model we use. Models are simply a framework that describes more or less ‘how things work’, or how concepts hang together.  The good thing about a model is how easily it can organise how we gather information and what information is thought to be relevant or irrelevant.  A model is more or less helpful, depending on how well it works to explain the phenomenon we see.  The more accurate a model is, the better it will explain how and why a phenomenon occurs.

When we’re being educated as therapists, we spend time learning about various models, and for the more theoretical amongst us, models bring to life the various ways we can learn to view a ‘problem’.  Occupational therapists are famed for being ‘problem solvers’ because we learn to view a ‘problem’ as something that can be solved or ‘got around’.  Initially it’s not easy to solve various problems, but as we gain experience, see more problems, learn what works and what doesn’t work, we become much more capable of seeing ways to solve problems.  But as we do this, the visibility of our reasoning can slip behind this wonderful thing called ‘intuition’.  Intuition simply means that ‘we don’t know how we do it, but we come up with the right answer’ – or as a psychology lecturer once said, ‘intuition is overlearned skill’. We’ve got to the point where we are unaware of all that background reasoning and those assumptions that we have made because we’ve done it so often.

To give an example: we don’t think much about how we walk, or at least most of us don’t.  By the time we’re adults, walking is ‘intuitive’ – we just do it.  But there was a time when we were learning to walk, and it took all of our attention and we made a lot of mistakes and only after a couple of years did we actually ‘get’ how to walk.  Similarly, for most of us, driving the car is now pretty simple – we ‘intuitively’ know when to change gear, when to apply brakes, when to turn the wheel – but we probably all remember what it was like to learn how to drive!

Why am I raving about this? Well, the models we use in occupational therapy (& indeed in any therapy) initially feel quite difficult, require a lot of thought and we need to concentrate to ensure we collect information on all the relevant areas in that model. The models are based on things we ‘know’ about the world – scientific studies that verify the relationships that we recognise within that model.  For example, if we’re using a biomechanical model, we base this on the physics of movement – lever arms, fulcrum, equal and opposite forces.  We rarely go back and re-test the physics because they’re ‘common sense’.  Ermm… maybe they are now – but there was a time when humans didn’t know this and had to learn it.  So when we’re faced with a problem that appears to be solved using a biomechanical solution, we ‘intuitively’ solve it – but our intuition is based on the accumulated wisdom of all those people who did set out and test the laws of physics.  We just quickly jump to that conclusion because we don’t need to check out those laws any more.

The problem is when we try to use a biomechanical model to solve a problem that isn’t fully understood using a biomechanical model.  A good example might be manual handling.  We have assumed that the problem with back pain is essentially that we lift using poor biomechanics, placing additional loads on structures that shouldn’t be placed under such strain.  The solution seems clear – let’s all learn how to lift using ‘proper’ biomechanics and all will be well.  Sorry – that doesn’t work.

The problem of sore backs is not fully explained by a biomechanical model, but because to many therapists it seems ‘common sense’, other solutions don’t get a look-in. It’s been the work of scientific endeavour that has expanded the range of factors that are known to influence back pain (and more especially disability from back pain) that has started to provide some explanations for how and why some people have trouble managing their pain.  And the solutions derived from this research are not ‘intuitive’ to many therapists yet.  They’re still being examined, and they still need expanding.  But if we’re scientifically illiterate, feel afraid of reading scientific articles, rely instead on ‘intuition’ and either don’t measure outcomes or rely on inaccurate measures of outcome, we might continue to believe the biomechanical model is accurate.

Is occupational therapy so complex that what it does can’t be examined using science? I don’t think so.  If it is, then we’re saying that social systems, cognition, emotions, politics, neuroanatomy and physiology and perception are all much more simple than making a cup of tea in the morning when we get up.   Hmmm.  I don’t think so.  It’s more about looking at aspects of that activity in the light of various models (scientifically validated/tested hypotheses) and coming up with an explanation that can explain the most of what we see, with the least number of assumptions.  And while that might be quite distant from the day to day work of a therapist drafting housing alterations or a therapist establishing whether a person is safe to leave the mental health services and manage alone, the work that both of those therapists does uses models – and relies on assumptions that those models inherit.  To ignore the reality that we simplify our worlds so we can get our heads around them and to call it something woolly like ‘intuition’ does the cognitive work we do a disservice.

Is there anything wrong with simplifying the world? No – psychologists have been doing it for at least a century! The cognitive behavioural model is good example of a simple model that explains part of an individual’s behaviour.  It doesn’t explain everything, but it does provide some useful assumptions that help us help another person make changes.  Put together with other models from within psychology, and others from other disciplines, it starts to explain something about how people ‘tick’.  Maybe that’s the best that we can do at this point in time to understand each other.

So… should occupational therapists know ’science’ – oh yes! both quantitative and qualitative methods too.  And probably some philosophy, and certainly lots of theory-building, and probably more psychology and sociology and biomechanics and anatomy and physiology.  Why not?!! At the very least occupational therapists should have some idea that what they’re doing is not ’simply intuition’ nor ‘common sense’, that they do hold assumptions about how the world works when they view a problem, and their solutions are based on those mental models that we’ve learned.  So science is integral to how we do what we do.  Let’s not be afraid of science, let’s not think it’s irrelevant – let’s honour it and celebrate it and get on and DO IT!

[2] Humanism – humanism is defined as a doctrine which seeks to account for the specificity, uniqueness and dignity of human life (retrieved from http://plato.stanford.edu/entries/jaspers/#PhilRel 7 September 2009 at 9.34am).  Occupational therapy is considered a strongly humanist profession.

[3] Empiricism – this school of philosophy claims that what we experience through our sense is the ultimate source of all our concepts and knowledge.  In other words, unless someone can show us something that is able to be touched, examined or measured, it cannot be known.  By contrast, a rationalist viewpoint suggests that we already know about things, or we can deduce things from what we do know, and it’s a matter of simply uncovering these known things through logic and reasoning. (retrieved from http://plato.stanford.edu/entries/rationalism-empiricism/ 7 September at 9.43am)

[4] Epistemology – the branch of philosophy devoted to studying the nature, sources and limits of knowledge (retrieved from http://plato.stanford.edu/entries/rationalism-empiricism/ 7 September at 9.43am)

[5] Constructivism – Constructivism states that our knowledge about what the world is entirely dependent on the meaning we as individuals make of what we perceive within our cultural context. In health constructivists assert that to call a condition a disease is to make a judgment that someone in that condition is undergoing a specific kind of harm that we explain in terms of bodily processes. But the bodily processes are not objectively malfunctioning; rather, they are merely judged by us to be unusual or abnormal because they depart from some shared, usually culturally specific, conception of human nature. (retrieved from http://plato.stanford.edu/entries/health-disease/#ObjCon 7 September 2009 at 9.48am)

References

Bycroft, J., Tracey, J (2006). Self-management support: A win-win solution for the 21st century, NZ Family Physician, 33(4), 243-248

Cowger, C. (1997). Assessing client’s strengths: Assessment for client empowerment. In D. Saleebey (Ed.), The strengths perspective in social work practice (2nd ed., pp. 59-73). White Plains, NY: Longman.

Ice, GH., (2005). Biological anthropology and aging. Journal of Cross-Cultural Gerontology, 20(2) 87-90

Mattingly, C. & Fleming, M.H. (1994). Clinical reasoning: Forms of inquiry in a therapeutic practice. Philadelphia: F.A. Davis Co. U.S.A.

Seligman, M.(2008). Positive Health, Applied Psychology: An International Review, 57, 3–18

Stipek, D, Granlinski, H (1991) Gender Differences in Children’s Achievement-Related Beliefs and Emotional Responses to Success and Failure in Mathematics, Journal of Educational Psychology , 83 (3) pp. 361-71.

Toombs, S K., (1995) The lived experience of disability. Human Studies, 18(1) 9-23

Ice, G. (2005). Biological anthropology and aging Journal of Cross-Cultural Gerontology, 20 (2), 87-90 DOI: 10.1007/s10823-005-9084-6

Last Wednesday I attended the first College of Occupational Therapists (COT) library day. This was a chance to meet 11 other librarians who support Occupational Therapy and hear about what the Occupational Therapists do to support our students.

It seemed we were all agreed that OT students are very rewarding to work with. They make use of the libraries and are grateful for the help you give.

It was also good to meet other librarians too, it’s so easy to get caught up in the day in day out part of the job but getting out and meeting people who are experiencing the same things and sharing ideas is invaluable. It also made me feel very fortunate to work for a university which is forward looking and supportive of libraries.

The major thing I hope will come out of the day is an ongoing peer group where we can share helpsheets, learning materials and other advice.

Part of the day was spent discussing Information Literacy and the best way of supporting it. One group discussed definitions of IL and agreed the CILIP definition from 2003 was the best:

Information literacy is knowing when and why you need information, where to find it, and how to evaluate, use and communicate it in an ethical manner. (http://www.cilip.org.uk/get-involved/advocacy/learning/information-literacy/Pages/definition.aspx)

My group discussed how we can help students to develop information literacy skills. We agreed one thing that is needed is for students to be able to get all their infomation in the same place, they don’t need to know the library does one thing while Student Services does another. I am proud to say at Brighton we do this already!

It was also agreed it needed to come in a variety of formats from hands on sessions to workbooks and online tutorials.

It was lovely to meet the team from the COT library. They are so helpful and the resources are great.

We spent a good part of the day preparing a gift and card for our current occupational therapist.  Tomorrow will be our last session with her.  We are switching to an occupational therapist at the same practice as our son’s behavioral optometrist. 

We are making this change for two reasons.  One is so that the OT and behavioral optometrist can coordinate their work with our son.  The second reason is that our son is now ready for a change.  The current OT practice has become very large and specializes in working with younger children.  I cannot say enough about the amazing changes we have seen in our son as a result of the sensory integration therapy he has received.   Because of these changes, our son is now ready for a more tailored approach to address his needs.

It is with much sadness that we leave the current OT practice, where we have been going for the past three years.  Our son is very attached to his OT, who has done an amazing job in striking the balance between hard work and fun. 

As one door closes, a new one opens.  More to come on our new OT!

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Doing Daily Life: How Occupational Therapy Can Inform Psychiatric Rehabilitation Practice, Terry Krupa, Ellie Fossey, William A Anthony, Catana Brown, Deborah B Pitts Psychiatric Rehabilitation Journal. Winter 2009. Vol. 32, Iss. 3; pg. 155

Abstract:

TOPIC: This paper provides an overview of occupational therapy in the context of psychiatric rehabilitation and mental health recovery. PURPOSE: The paper delineates practical aspects of occupational therapy’s involvement in the mental health field with a discussion of occupation and the elements of conceptual models that guide the practice of occupational therapy. SOURCES USED: CINAHL, Psych Info, Medline. CONCLUSION: Occupational therapy is a key discipline in the field of psychiatric rehabilitation and brings to the field a strong theoretical and knowledge base along with unique procedures and practices. It is important for the psychiatric rehabilitation field to learn from all disciplines, including occupational therapy.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk