Re: [OTlist] hello company...it's misery calling!
Brent, Great comments Do you need an understudy for the sock puppet show? Simply hilarious! Chris -Original Message- From: Brent Cheyne To: OTlist@OTnow.com Sent: Sat, 21 Feb 2009 6:37 pm Subject: Re: [OTlist] hello company...it's misery calling! Ron, Ilene, and Mary Alice and the rest of you I love reading this listserv and enjoy your comments...though somedays reading it makes me want to quit my OT career and join the Circus or start that pumpkin carving business...(maybe not...too seasonal for steady cash flow!;)) <><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><> MARY ALICE: I wanted to respond to you because you have such good comments and DON"T STOP contributing...I agree with you that patients come to rehab and have a lot of preconcieved notions about what efforts/methods will create what results, they think "I just need strengthening" or " I just need to walk".. they don't make the connections about the rehab process that we know so well. So much of the challenge is to educated people on the process of OT, addressing the goals. This requires very good communication skills on the part of the OT. Pt's with chronic illnesses or even subacute health issues are reluctant to attempt the process of adapting to their condition because of denial of the loss function. They really are in phase of wanting to FIX IT NOW back to normal. As we know this is not always possible or realistic. OTs are superior to most other professions at teaching adaptation to "Enable Occupation". In some cases we fix things in an innovative and effective way.The disadvantage is in the OT concepts where ,of course ,we know that occupation is that complex multifactorial phenomena that is the essence of performing daily life and is so much a part of our lives, and so individually subjective. Peeple don't think about it in the same terms we describe it in but they often get the connection when we do our jobs well. It is a tough job but rewarding. <><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><>< RON: I related so well to your well written response to Ilene (Message 4,2/21/09), I have a similar history to you and worked in the SNFs in the late 1990's, but woe is me... I still do today. As you stated the business model doesn't foster the best that OT can be as a profession. It is very inflexible and stifles innovation, creativity, and quality in favor of effeciency, profit, and bureaucratic compliance to Medicare rules and regs which set the system up to be as lame as it is. Some how I have found a way continue in20this practice setting for almost 15 years and have sought out the most high quality employers and facilities with a bit of luck had good results. But I too am growing VERY WEARY of all the issues you so effectively stated. I even spent one week as a Rehab Manager and quit..it made me physically ill, tried o/p hand therapy for 6months and was quite unsatisfied. I have thought of leaving the SNF setting, but every now and then I get a patient or case or two that goes so well and is so satisfying that it draws me back in...it's like trying to leave the Mafia :), Ron do you think home health is the best OT practice setting? <>><><><><><><>><><><><><><><><><><><><><><><><><><>><><><><><><>< ILENE: I could totally relate to you comments about SNF and goal setting and treatment ideas. Isn't this such a challenging population. SPEAKING OF THEORIES:My theory is that people who know the value of occupation to health status "practice what they preach" in that they engage in meaningful occupations and enjoy a high quality of life and health status, and when they do get sick or have issues they are quick to self -treat with the motivation, and goal-oriented mind set to get back to living and and the flexibility to adapt to their condition. And they use their OT as a reso urce to achieve goals. I see a few of these kinds of patients in SNFS, BUT, the greater majority of the SNF patient's I see have an ongoing Occupation deficit which correlates with their poor health status and issues and lack of ability to adapt. We are often faced with the toughest cases, with people who's prior level of occupation is so dysfunctional/deficient or co-dependent on a caregiving relationship that they just don't have a OT-like outlook. Many clients "outsource" their occupation by expecting spouses, neighbors, hired caregivers, meals on wheels, etc..to provided ADL.So I think we are often faced with the most challenging and ill fitting clients for OT at the SNF setting, Hello company...it's misery calling. <><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><>< So should I begin selling snow cones at the north pole, or take my sock puppet show on a national tour as a
Re: [OTlist] Puposeful activity
Joan, No worries at all on the name thing. When you have a double name that starts with Mary, you learn early on to answer to Mary Ann, Mary Beth, etc., etc. If someone calls me the wrong name, I just always say that if that is the worst than anyone calls me then I'm doing pretty good! 8-) I very much appreciated your comments in your earlier post. It's nice to know that people are listening and reading. I am pretty bad about not posting to say that I agree with something as well, so I will try to be more aware of that in the future. I have enjoyed all the discussions lately although we need more people to join in. Please don't be afraid to post! Everyone I've encountered here is very friendly--- although occasionally a bit passionate about their own view! Happy Weekend All! Mary Alice Mary Alice Cafiero, MSOT/L, ATP m...@mac.com 972-757-3733 Fax 888-708-8683 This message, including any attachments, may include confidential, privileged and/or inside information. Any distribution or use of this communication by anyone other than the intended recipient(s) is strictly prohibited and may be unlawful. If you are not the recipient of this message, please notify the sender and permanently delete the message from your system. On Feb 21, 2009, at 5:42 PM, Joan Riches wrote: Back again. I didn't catch all the edits I needed to make in my dictation so I have done that below. I hope you were able to read over them but if not this may help. Also I apologise to Mary Alice for getting your name wrong. Obviously I have a Mary Catherine in my life. Joan Hi Ilene The book Ron Mentioned, "Enabling Occupation: An Occupational Therapy Perspective", as well as "Enabling Occupation II: Advancing an Occupational Therapy Vision for Health Well-being and Justice and Through Occupation" are the official guiding documents for OT in Canada. They are both published and available from www.caot.ca. They are good but do not address the payment and productivity demands of your SNF practice in the US. You wrote "Hi Joan and thanks for your insight! May I ask what you would want an OT to work on with you though before you had sufficient range to fasten your bra behind your back, if increasing the range of motion or adapting the task (i.e fastening in the front) were not options you would want?" Increasing range, strength and stability as well as adapting the task were all necessary and, of course, increasing range strength and stability improved occupational performance in many other ADL and IADL tasks. What I would have wanted from another OT, if I had not been doing it for myself was good task analysis and grading. Analyzing how I pulled up my pants and to what extent that was facilitating internal rotation is an example of grading toward the ultimate goal of fastening my bra at the back. Pulling up the pants can be graded from starting at the front and wiggling into them to gradually moving both hands further back. It was several months before I could pull up my pants with both hands behind my back. It was also a good way to see progress with my Peete exercises (I can't resist leaving this in. I have just begun to be able to dictate to my computer. It has not yet learned what I'm talking about). I guess in my own case I did have multiple goals because I was analyzing all the things that I had to do differently, how I was doing them, how I wanted to do them and how I could grade the movements I was making to lead toward how I wanted to do things rather than falling into bad habits of accommodation, especially the habit of limiting myself in terms of what I was willing to do. Because I had a hip fracture as well I was particularly concerned about not developing an accommodated gait. However my measurable goal for my hip was to be able to cut my toenails on that foot. I can do it now but it is a real struggle and when I can do it easily I think that the stride of both legs will be equal and my gait will be balanced. This example is only applicable to a client with intact cognition who can look forward and see the implications of the difficulties they are having. In other words they will be able to follow the logic of your reasoning. It is a very different matter when you are working with people who have a cognitive deficit. They are unlikely to understand working toward a measurable goal. The goal in that case may be implicit in terms of comfort so your analysis and grading may lead you toward some motions that can be elicited by an activity, such as balloon ball to encourage reaching up. The Canadian Occupational Performance Measure includes those things that a client wants or needs to do as well as those things that someone else needs or wants wants you to do. In the SNF setting treating a shoulder injury may have the goal of improving comfort during mechanical transfers so the want or need will be expressed by the caregivers not the client. As y
Re: [OTlist] Puposeful activity
Back again. I didn't catch all the edits I needed to make in my dictation so I have done that below. I hope you were able to read over them but if not this may help. Also I apologise to Mary Alice for getting your name wrong. Obviously I have a Mary Catherine in my life. Joan Hi Ilene The book Ron Mentioned, "Enabling Occupation: An Occupational Therapy Perspective", as well as "Enabling Occupation II: Advancing an Occupational Therapy Vision for Health Well-being and Justice and Through Occupation" are the official guiding documents for OT in Canada. They are both published and available from www.caot.ca. They are good but do not address the payment and productivity demands of your SNF practice in the US. You wrote "Hi Joan and thanks for your insight! May I ask what you would want an OT to work on with you though before you had sufficient range to fasten your bra behind your back, if increasing the range of motion or adapting the task (i.e fastening in the front) were not options you would want?" Increasing range, strength and stability as well as adapting the task were all necessary and, of course, increasing range strength and stability improved occupational performance in many other ADL and IADL tasks. What I would have wanted from another OT, if I had not been doing it for myself was good task analysis and grading. Analyzing how I pulled up my pants and to what extent that was facilitating internal rotation is an example of grading toward the ultimate goal of fastening my bra at the back. Pulling up the pants can be graded from starting at the front and wiggling into them to gradually moving both hands further back. It was several months before I could pull up my pants with both hands behind my back. It was also a good way to see progress with my Peete exercises (I can't resist leaving this in. I have just begun to be able to dictate to my computer. It has not yet learned what I'm talking about). I guess in my own case I did have multiple goals because I was analyzing all the things that I had to do differently, how I was doing them, how I wanted to do them and how I could grade the movements I was making to lead toward how I wanted to do things rather than falling into bad habits of accommodation, especially the habit of limiting myself in terms of what I was willing to do. Because I had a hip fracture as well I was particularly concerned about not developing an accommodated gait. However my measurable goal for my hip was to be able to cut my toenails on that foot. I can do it now but it is a real struggle and when I can do it easily I think that the stride of both legs will be equal and my gait will be balanced. This example is only applicable to a client with intact cognition who can look forward and see the implications of the difficulties they are having. In other words they will be able to follow the logic of your reasoning. It is a very different matter when you are working with people who have a cognitive deficit. They are unlikely to understand working toward a measurable goal. The goal in that case may be implicit in terms of comfort so your analysis and grading may lead you toward some motions that can be elicited by an activity, such as balloon ball to encourage reaching up. The Canadian Occupational Performance Measure includes those things that a client wants or needs to do as well as those things that someone else needs or wants wants you to do. In the SNF setting treating a shoulder injury may have the goal of improving comfort during mechanical transfers so the want or need will be expressed by the caregivers not the client. As you well know this is a much more complicated situation in which to try to write a measureable occupational goal. I hope this helps. Please let's continue the conversation. Let the list know if you have been able to apply this. Tell us about your successes or your frustrations and thank you so much for asking. Blessings, Joan -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com No virus found in this incoming message. Checked by AVG - www.avg.com Version: 8.0.237 / Virus Database: 270.11.2/1964 - Release Date: 02/21/09 11:05:00 -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] hello company...it's misery calling!
Ron, Ilene, and Mary Alice and the rest of you I love reading this listserv and enjoy your comments...though somedays reading it makes me want to quit my OT career and join the Circus or start that pumpkin carving business...(maybe not...too seasonal for steady cash flow!;)) <><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><> MARY ALICE: I wanted to respond to you because you have such good comments and DON"T STOP contributing...I agree with you that patients come to rehab and have a lot of preconcieved notions about what efforts/methods will create what results, they think "I just need strengthening" or " I just need to walk".. they don't make the connections about the rehab process that we know so well. So much of the challenge is to educated people on the process of OT, addressing the goals. This requires very good communication skills on the part of the OT. Pt's with chronic illnesses or even subacute health issues are reluctant to attempt the process of adapting to their condition because of denial of the loss function. They really are in phase of wanting to FIX IT NOW back to normal. As we know this is not always possible or realistic. OTs are superior to most other professions at teaching adaptation to "Enable Occupation". In some cases we fix things in an innovative and effective way.The disadvantage is in the OT concepts where ,of course ,we know that occupation is that complex multifactorial phenomena that is the essence of performing daily life and is so much a part of our lives, and so individually subjective. Peeple don't think about it in the same terms we describe it in but they often get the connection when we do our jobs well. It is a tough job but rewarding. <><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><>< RON: I related so well to your well written response to Ilene (Message 4,2/21/09), I have a similar history to you and worked in the SNFs in the late 1990's, but woe is me... I still do today. As you stated the business model doesn't foster the best that OT can be as a profession. It is very inflexible and stifles innovation, creativity, and quality in favor of effeciency, profit, and bureaucratic compliance to Medicare rules and regs which set the system up to be as lame as it is. Some how I have found a way continue in this practice setting for almost 15 years and have sought out the most high quality employers and facilities with a bit of luck had good results. But I too am growing VERY WEARY of all the issues you so effectively stated. I even spent one week as a Rehab Manager and quit..it made me physically ill, tried o/p hand therapy for 6months and was quite unsatisfied. I have thought of leaving the SNF setting, but every now and then I get a patient or case or two that goes so well and is so satisfying that it draws me back in...it's like trying to leave the Mafia :), Ron do you think home health is the best OT practice setting? <>><><><><><><>><><><><><><><><><><><><><><><><><><>><><><><><><>< ILENE: I could totally relate to you comments about SNF and goal setting and treatment ideas. Isn't this such a challenging population. SPEAKING OF THEORIES:My theory is that people who know the value of occupation to health status "practice what they preach" in that they engage in meaningful occupations and enjoy a high quality of life and health status, and when they do get sick or have issues they are quick to self -treat with the motivation, and goal-oriented mind set to get back to living and and the flexibility to adapt to their condition. And they use their OT as a resource to achieve goals. I see a few of these kinds of patients in SNFS, BUT, the greater majority of the SNF patient's I see have an ongoing Occupation deficit which correlates with their poor health status and issues and lack of ability to adapt. We are often faced with the toughest cases, with people who's prior level of occupation is so dysfunctional/deficient or co-dependent on a caregiving relationship that they just don't have a OT-like outlook. Many clients "outsource" their occupation by expecting spouses, neighbors, hired caregivers, meals on wheels, etc..to provided ADL.So I think we are often faced with the most challenging and ill fitting clients for OT at the SNF setting, Hello company...it's misery calling. <><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><>< So should I begin selling snow cones at the north pole, or take my sock puppet show on a national tour as a new career? What Say you RON? (LOL) Brent -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Occupation as THE goal: Does it matter
I totally agree with you Chris. Very well said! ** A Good Credit Score is 700 or Above. See yours in just 2 easy steps! (http://pr.atwola.com/promoclk/100126575x1218822736x1201267884/aol?redir=http:%2F%2Fwww.freecreditreport .com%2Fpm%2Fdefault.aspx%3Fsc%3D668072%26hmpgID%3D62%26bcd%3DfebemailfooterNO6 2) -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Puposeful activity
Hi Ilene The book Ron Mentioned, "Enabling Occupation: An Occupational Therapy Perspective", as well as "Enabling Occupation II: Advancing an Occupational Therapy Vision for Health Well-being and Justice and Through Occupation" are the official guiding documents for OT in Canada. They are both published and available from www.caot.ca. You wrote "Hi Joan and thanks for your insight! May I ask what you would want an OT to work on with you though before you had sufficient range to fasten your bra behind your back, if increasing the range of motion or adapting the task (i.e fastening in the front) were not options you would want?" Increasing range, strength and stability as well as adapting the task were all necessary and, of course, increasing range strength and stability improved occupational performance in many other ADL and IADL tasks. What I would have wanted from another OT, if I had not been doing it for myself was good task analysis and grading. Analyzing how I pulled up my pants and to what extent that was facilitating internal rotation is an example of grading toward the ultimate goal of fastening my bra at the back. Pulling up the pants can be graded from starting at the front and wiggling into them to gradually moving both hands further back. It was several months before I could pull up my pants with both hands behind my back. It was also a good way to see progress with my Peete exercises (I can't resist leaving this in. I have just begun to be able to dictate to my computer. It has not yet learned what I'm talking about). I guess in my own case I did have multiple goals because I was analyzing all the things that I had to do differently, how I was doing them, how I wanted to do them and how I could grade the movements I was making to lead toward how I wanted to do things rather than falling into bad habits of accommodation, especially the habit of limiting myself in terms of what I was willing to do. Because I had a hip fracture as well I was particularly concerned about not developing an accommodated gait. However my measurable goal for my hip was to be able to cut my toenails on that foot. I can do it now but it is a real struggle and when I can do it easily I think that the stride of both legs will be equal and my gait will be balanced. The movie a black, This example is only applicable to a client with intact cognition who can look forward and see the implications of the difficulties they are having. In other words they will be able to follow the logic of your reasoning. It is a very different matter when you are working with people who have a cognitive deficit. They are unlikely to understand working toward a measurable goal. The goal in that case may be implicit in terms of comfort so your analysis and grading may lead you toward some motions that can be elicited by an activity, such as balloon ball to encourage reaching up. The Canadian Occupational Performance Measure includes those things that a client wants or needs to do as well as those things that someone else needs or wants wants you to do. In the SNF setting treating a shoulder injury may have the goal of improving comfort during mechanical transfers so the want or need will be expressed by the caregivers not the client. As you well know this is a much more complicated situation in which to try to write a measureable occupational goal. I hope this helps. Please let's continue the conversation. Let the list know if you have been able to apply this. Tell us about your successes or your frustrations and thank you so much for asking. Blessings, Joan -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Puposeful activity
It is hard for me to answer such questions because I do not work in a skilled nursing facility, and I have not worked in one for over 7years. I cannot really comment on changing practice patterns in nursing home any longer because I do not work in that reality. I should only comment on changing practice patterns in the acute rehab setting, because this is where I have changed my practice patterns. I think that the skilled nursing environment is one of the most diffiult settings to work in for OTs based on productivity, payment level structures, and the motivation level of most patients. To have a patient get out of bed for the day is someimes a major victory in OT. I would love to hear how OTs whom actually work in SNF have been able to move from pegs to occuaption. Is is actually possible? -Original Message- From: bbh1...@comcast.net To: OTlist@OTnow.com Sent: Sat, 21 Feb 2009 11:52 am Subject: Re: [OTlist] Puposeful activity Hello Ilene, Your post was satisfying to me, as I work in the same setting and am faced with the same concerns re tx. Put my reaction down to "misery loves company", although I am not miserable in my position. What I do with patients may not be strictly OT as defined by most of those who contribute to this site, but I have made peace with that because I know that I am definitely helping my patients heal and return to20a higher level of function in their daily lives. I, too, have been asking for more concrete suggestions as to how this is done in the SNF/subacute world which is so focussed on profit. Thanks for sharing a similar concern. It is so easy to feel alone, and not good enough with regard to the cones and pegs controversy! Barb Howard COTA - Original Message - From: ocil...@comcast.net To: otlist@otnow.com Sent: Wednesday, February 18, 2009 7:00:20 PM GMT -05:00 US/Canada Eastern Subject: Re: [OTlist] Puposeful activity Hi Joan and thanks for your insight! May I ask what you would want an OT to work on with you though before you had sufficient range to fasten your bra behind your back, if increasing the range of motion or adapting the task (i.e fastening int he front) were not options you would want? IMO, when therapists resort to cones, etc, it is not because they are lazy, it is because they don't know what else to do, either because they only have experience in work settings where cones and pegs were used, or they are in a subactute setting where they are seeing multiple people at once. Of course that is not ideal, but it is reality. I for one would like to move into this more ideal realm and change the way I practice, but there is precious little practical "how to's" for doing this, especially in settings like mine, where there is no kitchen, ADL suite, etc, and it is impossible to see everyone one on one for ADL's. There is no course that I can find on taking OT back to the functional in today's money-driven practice settings, in fact I have never seen a shoulder course for OT that doesn't focus on increasing range and other medically-based PT-type interventions. Even here, many people say "do this" but very few say specifically HOW or offer any practical ideas for the therapists stuck in peg/cone world who want to be more functional but are up against a practice world that just wants numbers. If you or anyone can offer any practical advice, point to a book or course to help therapists work more functionally with patients (who often, in a nursing home setting, can't even come up with goals of their own or answer "nothing" or "watch TV" when asked what they would like to be able to resume doing) I would be most appreciative. Thanks, Ilene Rosenthal, OTR/L Message: 1 Date: Tue, 17 Feb 2009 11:30:40 -0700 From: "Joan Riches" Subject: Re: [OTlist] purposeful activity To: Message-ID: Content-Type: text/plain; charset="US-ASCII" Greetings to all I couldn't resist this one. In my opinion (like Ron's) all activity has purpose for someone or something (witness the reproduction of plants) .=2 0The OT question re the activities we use as treatment interventions is: Does this activity have purpose and therefore meaning for this client in terms of their explicit and implicit occupational goals? I absolutely agree with Ron's goal formulation where the only goal is some form of OCCUPATIONAL performance. (In the presence of cognitive deficits this becomes a much more difficult question.) Below is my personal physical and OT/PT case example. I've been thinking about it a lot in my present situation and how it plays out. I am still after 14 months working on the stability of the hip that was pinned and the range and strength in the shoulder with a nondisplaced fracture. Although I am determined not to walk or run with the typical 'hip' gait or to limit my reach and ability with my arm I find it very difficult to persist in activities that are not useful and meaningful 'at the time'. E
Re: [OTlist] The Timing of OT...
It is ironic though that the man has muscular dystrophy though and wants to focus only on PT. I wonder if the man realizes the progression of his disease and how aggressive strength training can cause problems. It seems as though the man is in denial about his disease and wants to fight it by building up his body, but in reality the nature of his disease will most likely force him to compensate during his daily occupations. This would be the perfect oppurtunity for early OT to pave the way for this man's unfortunate future to help in his quality of life. I have a feeling that this man will encounter OT again in the future ,but this time he will have a new appreciation for our role. A strong educational program including the neurologist, PT, psycologist, and nursing would alleviate this problem in educating this man on the common progression of the disease and how an OT can help with the occupational issues for the future. -Original Message- From: Ron Carson To: Mary Alice Cafiero Sent: Sat, 21 Feb 2009 8:03 am Subject: Re: [OTlist] The Timing of OT... Hello Mary Alice: Let me be the 1st to say "Thanks" for writing. I understand what you mean about taking time to write and then not getting any responses. But, such is the nature of listserves!. I think you've touched on at least ONE area that can frustrate the OT process. IF an OT is focused on improving occupation but the patient is focused on improving strength/ROM there is inconsistency. Notice that I say FOCUS because as you correctly identified, improving occupation usually results in improving the underlying impairments. But in this case, the patient stated he was doing all he could. OT is a "bizzaro" world! Ron - Original Message - From: Mary Alice Cafiero Sent: Saturday, February 21, 2009 To: OTlist@OTnow.com Subj: [OTlist] The Timing of OT... MAC> I think that patients often equate PT not only with walking, but also MAC> with strengthening. It seems they often feel that the majority of MAC> their problems doing things are because of weakness. If they can just MAC> get stronger, all else will fix itself. I can see this especially MAC> being true with a diagnosis like MS or other progressive neuromuscular MAC> disease. MAC> We, as OTs, can clearly see that learning to do the things you need to MAC> do for yourself has inherent value. It also ends up addressing MAC> strengthening without doing a straight exercise program. I tend to MAC> think that patients often prescribe to the "no pain, no gain" theory MAC> and feel that they have to do multiple reps of an exercise in order to MAC> address weak muscles. MAC> My two cents. I'll be curious to see if anyone responds. The majority MAC> of times that I post a response on this board, no one directly MAC> responds, and my answers just get shuffled over. Not sure of the MAC> reason for that, but it is certainly frustrating. Makes me reluctant MAC> to post because it doesn't seem to add to or lead to further discussion. MAC> Mary Alice MAC> Mary Alice Cafiero, MSOT/L, ATP MAC> m...@mac.com MAC> 972-757-3733 MAC> Fax 888-708-8683 MAC> This message, including any attachments, may include confidential, MAC> privileged and/or inside information. Any distribution or use of this MAC> communication by anyone other than the intended recipient(s) is MAC> strictly prohibited and may be unlawful. If you are not the recipient MAC> of this message, please notify the sender and permanently delete the MAC> message from your system. MAC> On Feb 21, 2009, at 1:21 AM, Ron Carson wrote: I had an interesting experience that I want to share. Last week, I evaluated a middle-aged man with muscular dystrophy. He had recently moved back home with his parent and was started on home health. The man essentially told me that there was nothing I could do for him. He said that PT was all he needed. I explained that as an OT, my job was to teach him to take care of himself as much as possible and desired. But, he still felt that PT is what he needed. I am really perplexed as to why someone might value PT instead of OT? I have some ideas, which I'll share, but I hope readers are willing to discuss this situation. Thanks, Ron -- Ron Carson MHS, OT www.OTnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com MAC> -- MAC> Options? MAC> www.otnow.com/mailman/options/otlist_otnow.com MAC> Archive? MAC> www.mail-archive.com/otlist@otnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] OTlist Digest, Vol 56, Issue 4
Message: 9 Date: Sat, 21 Feb 2009 16:52:49 + (UTC) From: bbh1...@comcast.net Subject: Re: [OTlist] Puposeful activity To: OTlist@OTnow.com Message-ID: < 779914147.963901235235169749.javamail.r...@sz0065a.emeryville.ca.mail.comcast.net > Hi Barb, I'm glad it helped. No, you are definitely not the only one, there are many of us, and while I do think Ron is right about many of the things he answered (not the PT threat thing though, I only work with 1 PT and she is wonderful), I too get frustrated with the "change jobs" answer. I too feel I contribute to my residents in therapy. I do wish though that someone would teach a course on bringing function back in today's settings. Is it just me, or does anyone else feel that 90% (at least) of all adult-based treatment courses with OT as the intended audience, are medical model? Ron, I will look into that book, thanks. I think, regarding your MD patient, that as another poster said, PT is more valued because most people feel is they just get stronger everything else will be fine. I had a parkinson's patient once in subacute rehab who could not feed himself, yet refused OT. ALL he wanted to do, all he cared about was walking, and felt the "what do you want to walk TO, and what do you want to DO there" part would come automatically. I also once had a woman with cognitive declines so severe she could not make a cup of tea or dial 911 on a phone...yet conversationally you'd never know she had a problem, it only came into play with motor tasks involving planning, sequencing, multiple steps. I documented like crazy, yet once she was walking 200 feet independently, her HMO sent her home alone from rehab. I went to her care conference and despite my reports to her family and the Dr., she was deemed fine to go home. All I could do was write a HUGE cover-my-butt progress note in the chart saying I didn't agree with the DC plan and that I told everyone concerned. This mindset that if you can walk, you're fine, seems almost systemic, and although I wish it would change, I don't hold out a huge amount of hope! ~Ilene Rosenthal, OTR/L Hello Ilene, Your post was satisfying to me, as I work in the same setting and am faced with the same concerns re tx.? Put my reaction down to "misery loves company", although I am not miserable in my position.? What I do with patients may not be strictly OT as defined by most of those who contribute to this site, but I have made peace with that because I know that I am definitely helping my patients heal and return to a higher level of function in their daily lives.? I, too, have been asking for more concrete suggestions as to how this is done in the SNF/subacute world which is so focussed on profit.? Thanks for sharing a similar concern.? It is so easy to feel alone, and not good enough with regard to the cones and pegs controversy! Barb Howard COTA -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Occupation as THE goal: Does it matter
Seems like in your example of occupation that the UE is left out of the equation, although through some improvement it can lead to improvements in the patient's personal goals of occupation. Just because there is no function in the flaccid UE does not mean there will not be any improvement 6 months down the road, especially with intentional focus on the issue. I can make the UE treatment focus on occupation just like you state, but it will take much longer. Instead of writing patient will improve AROM by 30 degrees in order to assist with self feeding I can simply write patient will reach for a glass of water from table using his involved arm. The problem is it might take 6 months to a year to achieve this occupationally written goal, but it only might take 2-3 months to show 30 degrees of progress if the patient has good rehab potential in arm function. The structure of insurance re-imbursement is set up on showing immediate progress, otherwise we are told to DC a patient or set more achievable goals. Even though we as neuro OTs might wright goals that focus on body impairments, it does not mean that we are not looking at occupation. It only means that we want to continue to work with the patient that has the potential of using their arm in occuation again, but unfortunately we need to be able to document improvements relatively quickly for insurance to foot the bill. This sytem of billing does not match up with the natural progression of improvement in a patient's arm after a stroke.The road to recovery for a stroke patient's flaccid arm is a long and painful one, in which sometimes the road does not lead to a positive outcome. How can we justify seeing them for an entire year, and then finally one day we state that the patient is not appropriate for OT any longer. There needs to be incremental steps along the way to occupation showing that the patient is making progress towards that goals that we predicted would eventually be achievable. And let me tell you, when that area of occupatiion is finally achieved after such time and effort from the therapist and patient, there is not greater feeling in OT. I wish we could see them for an entire year, following one occuaptionally based goal and not having to worry about the measurements of tone, strength, ROM, coordination, but with the system that we bill under now, we have to follow the rules. Your examples of training in sit to stands, balance retraining, functional transfers are on the mark of occupation. However these areas of impairment are often easier to demonstrate improvements in occupation simply showing the assist level of improvement (patient inproved from a total assist to a supervision when toileting). These areas of occupation are more certainly easier to treat in the timeframe we are given to show progress. The area of impairment involving the flaccid UE is much more complex and difficult to show immediate progress. It is impossible to write goals that focus on occupation because it would be impossilbe to show incremental progress on the actual occupation when the patient wants to incorporate he flaccid arm into occuaption again. If the patient is a total assistance with reaching for a glass of water using the hemi arm, it would be impossible to demonstrate in a months time that the patient is at a maximal assistance, moderate, or minimal assistance for the task while using the hemi arm. The assist levels do not quantify the small incremental improvement. I can certainly document that the patient is using their arm more duing occupation through the use of activity journals, or subjective surveys that the patient fills out based on their perceptions, but it is near impossible to visually recognize that a patient improved from a total assistance to a maximal assist with the reaching task, because of the limitations of the assist level scales. It is much more quantifiable to use standardized scales that focus on body impairments like the dynamomenter, goniometer, Motor Assessement scales, Wolf Activity Scales, Modified Ashworth Scale, and the like to show these small incremental scales of progress required for changes in the patient's occupational goals. Chris Nahrwold MS, OTR. -Original Message- From: Ron Carson To: cmnahrw...@aol.com Sent: Sat, 21 Feb 2009 5:19 am Subject: Re: [OTlist] Occupation as THE goal: Does it matter Chris, after thinking about your question, I conclude that the best I can offer is a hypothetical situation. So, here goes Take my patient today. A CVA patient. He has a flaccid UE with no functional use. He requires assist for sit/stand and ambulates with a quad cane with supervision. IF the goal is improving the occupation of self-care to the supervision/setup level, treatment might look like this: Therapeutic activity to include: sit/stand and transfer training. Balance trai
Re: [OTlist] The Timing of OT...
Mary Catherine I don't think I have ever replied directly to you before. I want to tell you that I feel the same way about the lack of reaction to most of my posts. I always value your comments and frequently feel, Oh yes, I agree with that. Generally since I have no difference of opinion with you I'm not questioning your comments. I know from my own experience what a difference it would make to you to have the, "O yes I agree with you" come up on your computer. We all seem to wind up debating with Ron or responding to Ron rather than with each other. I have a different thought about the timing of OT, or perhaps it is another contributing factor. Once cognitively intact clients have had a good start in OT methods they begin to make their own adaptations and set their own goals. The PT then becomes a technical assistant to help them achieve their occupational goals. So it is not our job at that point to teach them to take care of themselves but to support them in their own reasoning. Once again where there is a cognitive deficit this is most unlikely to happen. Joan Riches B.Sc.O.T., OT(C) Specialist in Cognitive Disability Riches Consulting High River, Alberta, Canada 403 652 7928 -Original Message- From: otlist-boun...@otnow.com [mailto:otlist-boun...@otnow.com] On Behalf Of Mary Alice Cafiero Sent: February 21, 2009 4:02 AM To: OTlist@OTnow.com Subject: Re: [OTlist] The Timing of OT... I think that patients often equate PT not only with walking, but also with strengthening. It seems they often feel that the majority of their problems doing things are because of weakness. If they can just get stronger, all else will fix itself. I can see this especially being true with a diagnosis like MS or other progressive neuromuscular disease. We, as OTs, can clearly see that learning to do the things you need to do for yourself has inherent value. It also ends up addressing strengthening without doing a straight exercise program. I tend to think that patients often prescribe to the "no pain, no gain" theory and feel that they have to do multiple reps of an exercise in order to address weak muscles. My two cents. I'll be curious to see if anyone responds. The majority of times that I post a response on this board, no one directly responds, and my answers just get shuffled over. Not sure of the reason for that, but it is certainly frustrating. Makes me reluctant to post because it doesn't seem to add to or lead to further discussion. Mary Alice Mary Alice Cafiero, MSOT/L, ATP m...@mac.com 972-757-3733 Fax 888-708-8683 This message, including any attachments, may include confidential, privileged and/or inside information. Any distribution or use of this communication by anyone other than the intended recipient(s) is strictly prohibited and may be unlawful. If you are not the recipient of this message, please notify the sender and permanently delete the message from your system. On Feb 21, 2009, at 1:21 AM, Ron Carson wrote: > I had an interesting experience that I want to share. > > Last week, I evaluated a middle-aged man with muscular dystrophy. He > had > recently moved back home with his parent and was started on home > health. > > The man essentially told me that there was nothing I could do for > him. > He said that PT was all he needed. I explained that as an OT, my job > was > to teach him to take care of himself as much as possible and > desired. > But, he still felt that PT is what he needed. > > I am really perplexed as to why someone might value PT instead of > OT? I > have some ideas, which I'll share, but I hope readers are > willing to > discuss this situation. > > Thanks, > > Ron > > -- > Ron Carson MHS, OT > www.OTnow.com > > > > > -- > Options? > www.otnow.com/mailman/options/otlist_otnow.com > > Archive? > www.mail-archive.com/otlist@otnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com No virus found in this incoming message. Checked by AVG - www.avg.com Version: 8.0.237 / Virus Database: 270.11.1/1962 - Release Date: 02/20/09 19:22:00 -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Puposeful activity
Hello Ilene, Your post was satisfying to me, as I work in the same setting and am faced with the same concerns re tx. Put my reaction down to "misery loves company", although I am not miserable in my position. What I do with patients may not be strictly OT as defined by most of those who contribute to this site, but I have made peace with that because I know that I am definitely helping my patients heal and return to a higher level of function in their daily lives. I, too, have been asking for more concrete suggestions as to how this is done in the SNF/subacute world which is so focussed on profit. Thanks for sharing a similar concern. It is so easy to feel alone, and not good enough with regard to the cones and pegs controversy! Barb Howard COTA - Original Message - From: ocil...@comcast.net To: otlist@otnow.com Sent: Wednesday, February 18, 2009 7:00:20 PM GMT -05:00 US/Canada Eastern Subject: Re: [OTlist] Puposeful activity Hi Joan and thanks for your insight! May I ask what you would want an OT to work on with you though before you had sufficient range to fasten your bra behind your back, if increasing the range of motion or adapting the task (i.e fastening int he front) were not options you would want? IMO, when therapists resort to cones, etc, it is not because they are lazy, it is because they don't know what else to do, either because they only have experience in work settings where cones and pegs were used, or they are in a subactute setting where they are seeing multiple people at once. Of course that is not ideal, but it is reality. I for one would like to move into this more ideal realm and change the way I practice, but there is precious little practical "how to's" for doing this, especially in settings like mine, where there is no kitchen, ADL suite, etc, and it is impossible to see everyone one on one for ADL's. There is no course that I can find on taking OT back to the functional in today's money-driven practice settings, in fact I have never seen a shoulder course for OT that doesn't focus on increasing range and other medically-based PT-type interventions. Even here, many people say "do this" but very few say specifically HOW or offer any practical ideas for the therapists stuck in peg/cone world who want to be more functional but are up against a practice world that just wants numbers. If you or anyone can offer any practical advice, point to a book or course to help therapists work more functionally with patients (who often, in a nursing home setting, can't even come up with goals of their own or answer "nothing" or "watch TV" when asked what they would like to be able to resume doing) I would be most appreciative. Thanks, Ilene Rosenthal, OTR/L Message: 1 Date: Tue, 17 Feb 2009 11:30:40 -0700 From: "Joan Riches" Subject: Re: [OTlist] purposeful activity To: Message-ID: Content-Type: text/plain; charset="US-ASCII" Greetings to all I couldn't resist this one. In my opinion (like Ron's) all activity has purpose for someone or something (witness the reproduction of plants) . The OT question re the activities we use as treatment interventions is: Does this activity have purpose and therefore meaning for this client in terms of their explicit and implicit occupational goals? I absolutely agree with Ron's goal formulation where the only goal is some form of OCCUPATIONAL performance. (In the presence of cognitive deficits this becomes a much more difficult question.) Below is my personal physical and OT/PT case example. I've been thinking about it a lot in my present situation and how it plays out. I am still after 14 months working on the stability of the hip that was pinned and the range and strength in the shoulder with a nondisplaced fracture. Although I am determined not to walk or run with the typical 'hip' gait or to limit my reach and ability with my arm I find it very difficult to persist in activities that are not useful and meaningful 'at the time'. Especially now that the physical limitations are only apparent when I'm challenged - trying to walk a distance across a large parking lot quickly to keep an appointment for instance or helping to unload plywood from the truck or screwing a light bulb into a ceiling fixture - it is easy to have 'life' push out the daily excercises. I am not of the generation the 'works out for the sake of'. I have a brilliant and understanding PT. He knows the 30 to 45 straight minutes a day will just not get done. He knows that I want to recover not adapt. So he knows what I need to do and collaborates with me to find ways to incorporate the movements into my regular activities such as mindfully using the stairs, varying pace, not using the railings to pull myself up etc. The stairs themselves cue me as do the top shelves in the kitchen where I store at least three things that I use for breakfast each morning. My morning routine now in
Re: [OTlist] The Timing of OT...
Hello Mary Alice: Let me be the 1st to say "Thanks" for writing. I understand what you mean about taking time to write and then not getting any responses. But, such is the nature of listserves!. I think you've touched on at least ONE area that can frustrate the OT process. IF an OT is focused on improving occupation but the patient is focused on improving strength/ROM there is inconsistency. Notice that I say FOCUS because as you correctly identified, improving occupation usually results in improving the underlying impairments. But in this case, the patient stated he was doing all he could. OT is a "bizzaro" world! Ron - Original Message - From: Mary Alice Cafiero Sent: Saturday, February 21, 2009 To: OTlist@OTnow.com Subj: [OTlist] The Timing of OT... MAC> I think that patients often equate PT not only with walking, but also MAC> with strengthening. It seems they often feel that the majority of MAC> their problems doing things are because of weakness. If they can just MAC> get stronger, all else will fix itself. I can see this especially MAC> being true with a diagnosis like MS or other progressive neuromuscular MAC> disease. MAC> We, as OTs, can clearly see that learning to do the things you need to MAC> do for yourself has inherent value. It also ends up addressing MAC> strengthening without doing a straight exercise program. I tend to MAC> think that patients often prescribe to the "no pain, no gain" theory MAC> and feel that they have to do multiple reps of an exercise in order to MAC> address weak muscles. MAC> My two cents. I'll be curious to see if anyone responds. The majority MAC> of times that I post a response on this board, no one directly MAC> responds, and my answers just get shuffled over. Not sure of the MAC> reason for that, but it is certainly frustrating. Makes me reluctant MAC> to post because it doesn't seem to add to or lead to further discussion. MAC> Mary Alice MAC> Mary Alice Cafiero, MSOT/L, ATP MAC> m...@mac.com MAC> 972-757-3733 MAC> Fax 888-708-8683 MAC> This message, including any attachments, may include confidential, MAC> privileged and/or inside information. Any distribution or use of this MAC> communication by anyone other than the intended recipient(s) is MAC> strictly prohibited and may be unlawful. If you are not the recipient MAC> of this message, please notify the sender and permanently delete the MAC> message from your system. MAC> On Feb 21, 2009, at 1:21 AM, Ron Carson wrote: >> I had an interesting experience that I want to share. >> >> Last week, I evaluated a middle-aged man with muscular dystrophy. He >> had >> recently moved back home with his parent and was started on home >> health. >> >> The man essentially told me that there was nothing I could do for >> him. >> He said that PT was all he needed. I explained that as an OT, my job >> was >> to teach him to take care of himself as much as possible and >> desired. >> But, he still felt that PT is what he needed. >> >> I am really perplexed as to why someone might value PT instead of >> OT? I >> have some ideas, which I'll share, but I hope readers are >> willing to >> discuss this situation. >> >> Thanks, >> >> Ron >> >> -- >> Ron Carson MHS, OT >> www.OTnow.com >> >> >> >> >> -- >> Options? >> www.otnow.com/mailman/options/otlist_otnow.com >> >> Archive? >> www.mail-archive.com/otlist@otnow.com MAC> -- MAC> Options? MAC> www.otnow.com/mailman/options/otlist_otnow.com MAC> Archive? MAC> www.mail-archive.com/otlist@otnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] The Timing of OT...
I think that patients often equate PT not only with walking, but also with strengthening. It seems they often feel that the majority of their problems doing things are because of weakness. If they can just get stronger, all else will fix itself. I can see this especially being true with a diagnosis like MS or other progressive neuromuscular disease. We, as OTs, can clearly see that learning to do the things you need to do for yourself has inherent value. It also ends up addressing strengthening without doing a straight exercise program. I tend to think that patients often prescribe to the "no pain, no gain" theory and feel that they have to do multiple reps of an exercise in order to address weak muscles. My two cents. I'll be curious to see if anyone responds. The majority of times that I post a response on this board, no one directly responds, and my answers just get shuffled over. Not sure of the reason for that, but it is certainly frustrating. Makes me reluctant to post because it doesn't seem to add to or lead to further discussion. Mary Alice Mary Alice Cafiero, MSOT/L, ATP m...@mac.com 972-757-3733 Fax 888-708-8683 This message, including any attachments, may include confidential, privileged and/or inside information. Any distribution or use of this communication by anyone other than the intended recipient(s) is strictly prohibited and may be unlawful. If you are not the recipient of this message, please notify the sender and permanently delete the message from your system. On Feb 21, 2009, at 1:21 AM, Ron Carson wrote: I had an interesting experience that I want to share. Last week, I evaluated a middle-aged man with muscular dystrophy. He had recently moved back home with his parent and was started on home health. The man essentially told me that there was nothing I could do for him. He said that PT was all he needed. I explained that as an OT, my job was to teach him to take care of himself as much as possible and desired. But, he still felt that PT is what he needed. I am really perplexed as to why someone might value PT instead of OT? I have some ideas, which I'll share, but I hope readers are willing to discuss this situation. Thanks, Ron -- Ron Carson MHS, OT www.OTnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Occupation as THE goal: Does it matter
Chris, after thinking about your question, I conclude that the best I can offer is a hypothetical situation. So, here goes Take my patient today. A CVA patient. He has a flaccid UE with no functional use. He requires assist for sit/stand and ambulates with a quad cane with supervision. IF the goal is improving the occupation of self-care to the supervision/setup level, treatment might look like this: Therapeutic activity to include: sit/stand and transfer training. Balance training without UE support. Hemi dressing techniques training IF the goal is improving UE ROM to increase ability to perform self-care with supervision/setup, the treatment might look like this: Therapeutic exercise to the affected UE. Self-care training in hemi-dressing. = For the record, the patient verbalized mixed goals. Of course he said he wants to get his arm working but he also wants to reduce the strain on his wife by increasing his ability to sit/stand without assistance from her. Look forward to feedback and comments from you and EVERYONE else! In my opinion, the issues and topics being discussed are too important to not be involved! Ron - Original Message - From: cmnahrw...@aol.com Sent: Monday, February 16, 2009 To: OTlist@OTnow.com Subj: [OTlist] Occupation as THE goal: Does it matter cac> Ron, cac> Great outline.? Can you next explain how the treatment will differ? cac> Chris cac> -Original Message- cac> From: Ron Carson cac> To: OTlist@OTnow.com cac> Sent: Mon, 16 Feb 2009 7:52 am cac> Subject: [OTlist] Occupation as THE goal: Does it matter cac> Hello All: cac> What follows are thoughts and opinion about using occupation as *THE* cac> goal for OT treatment. cac> Here's is the premise for my arguments: cac> (1) When occupation is *THE* goal, outcome statements may be written in cac> concise occupation-based outcomes. For example: cac> Patient will safely and independently ambulate to/from toilet cac> with RW and perform all hygiene without assistive equipment. cac> Patient will transfer from w/c to bed using slide board cac> transfers cac> Patient will dress self using adaptive equipment as necessary cac> (2) Conversely, when occupation is not *THE* goal, outcomes may be cac> written so that occupation is a desired outcome but is based on cac> improving underlying impairment(s). For example: cac> Patient will increase UE elbow ROM to 115 degree active flexion cac> to all for donning/doffing of shirt cac> Patient will increase standing endurance/balance to allow them cac> to safely and independently carry out toileting hygiene. cac> cac> Some argue there is little difference in the above approaches. However, cac> I believe these approaches frame patient problems very differently. This cac> is important because how we frame a problem drives our treatment. cac> The first example clearly identifies that occupation is the goal. There cac> is no expressed concern for underlying factors impairing occupation. cac> However, and this if often overlooked, it is IMPLIED that all factors cac> impairing the goal will be treated within the therapist's abilities. cac> This is true because occupation includes the following factors: cac> Physical, emotional, mental environmental, behavioral, social cac> Thus, as OT's and within our scope of practice, occupation-based cac> outcomes address all factors impairing the desire occupations. cac> While the second example does include occupation as an outcome, only cac> factors addressed in the goals are included for treatment. This severely cac> limits treatment and cac> in my opinion indicates that remediation of cac> underlying impairments is the real goal. The implication is that if cac> underlying impairments are remediated, occupation will improve. However, cac> is inconsistent with OT theory because occupation is ALWAYS more than cac> physical. In my opinion, the second example is much more like a PT cac> rather than an OT goal! cac> In closing, writing occupation-based goals is important for us and for cac> the patient. These goals allow us to focus on occupation's many elements cac> and complexity to best enable our patients. cac> Thanks, cac> Ron cac> -- cac> Ron Carson MHS, OT cac> www.OTnow.com cac> -- cac> Options? cac> www.otnow.com/mailman/options/otlist_otnow.com cac> Archive? cac> www.mail-archive.com/otlist@otnow.com cac> -- cac> Options? cac> www.otnow.com/mailman/options/otlist_otnow.com cac> Archive? cac> www.mail-archive.com/otlist@otnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.co
[OTlist] The Timing of OT...
I had an interesting experience that I want to share. Last week, I evaluated a middle-aged man with muscular dystrophy. He had recently moved back home with his parent and was started on home health. The man essentially told me that there was nothing I could do for him. He said that PT was all he needed. I explained that as an OT, my job was to teach him to take care of himself as much as possible and desired. But, he still felt that PT is what he needed. I am really perplexed as to why someone might value PT instead of OT? I have some ideas, which I'll share, but I hope readers are willing to discuss this situation. Thanks, Ron -- Ron Carson MHS, OT www.OTnow.com -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
