Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even
Arley. Good points. Thanks for bringing me back to reality. -Original Message- From: Johnson, Arley To: OTlist@OTnow.com Sent: Fri, 24 Apr 2009 8:17 pm Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Having some experience with a RAC review a few years ago, they will go after anything to deny payment. I don't know if CMS fixed their incentive loophole, but they would get a percent of whatever amount they denied. If the facility appealed the denials(80% turnover rate) and won, the RAC would still get paid their cut. At the time, my OTs did plenty of UE ther ex (which I disliked, but that's another convo) with the joint replacement patients, but the RAC never mentioned that in our reason for denials. That leads me back to my initial statement that they will hunt for anything in the chart to get a denial. To expand, they were inconsistent with their reviews. One patient had unstable hgb levels, UTI and newly diagnosed diabetes. They said she did not demonstrate a need for 24 hr medical supervision,but yet they approved a straight forward unilateral TKR with no acute illnesses. Go figure. To conclude, we shouldn't get so bent on that one experience as the fall of OT. :-) These reviewers aren't always the sharpest pencils in the bunch. Arley Johnson, MS, OTR/L Site Manager, Pennsylvania Hospital Rehabilitation Services From: otlist-boun...@otnow.com on behalf of cmnahrw...@aol.com Sent: Fri 4/24/2009 5:04 PM To: OTlist@OTnow.com Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even PatJoan, I do not think you understand. Medicare (our government payor source for the elderly)is now not allowing general debility patients into acute rehab period. We used to have this 75% rule in which 75% of our cases had to match a certain diagnois (stroke, spinal cord, etc), and the other 25% could be whatever diagnosis. Now Medicare CMS is auditing charts and making rehab facilities pay back millions of dollars finding that the patients were not appropriate to be there. Several cases she explained was that the OT did not have enough documentation to support that they truly needed OT. Her claim was that a general debility patient would not need OT for arm exercises. When a person has 5/5 strength and the therapists complete UE exerise and group therapy all day long that is totally inapproriate. We need to complete ADLs during the first three days of their stay to document the need for skilled OT and then actually work on those issues during their stay to demonstrate improvement on the FIM. The funny thing is the patients improve much faster when we take an occupational approach. It is not rocket science. Bottom line is that patients need to get up of the the wheelchair and get moving by engaging in their daily occuapations in the way they plan on completing them at home. We OTs need to speak up to the OTs who are screwing our profession up. I am sure AOTA is aware of these issues because these Medicare RACK audits is a hot topic in rehab right now. -Original Message- From: Joan Riches To: OTlist@OTnow.com Sent: Fri, 24 Apr 2009 2:32 pm Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Have you reported this with names and details to AOTA for follow-up? What was the result of the debate? Will this person continue the blanket refusal of all OT? Targeted refusals of UE exercise without specific rationale and a UE diagnosis might go a long way to changing practice. I wonder how widespread this is in Canada. I did see it 25 years ago as a student. It definitely does not happen in this area. All the OTs are far too busy too waste time that way. 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 cmnahrw...@aol.com Sent: April 23, 2009 8:12 PM To: OTlist@OTnow.com Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Listened to a medicare teleconference describing why CMS is denying debility patients from acute rehab stays. When asked why this is so, the medicare communicater stated that they did not have medical necessity for occupational therapy. When debating this issue and how occupational therapy works on a debility patient's occupations, the communicator stated that she thought that all we did was UE exercise. I guess from all of her chart audits she has concluded this over the years. I am starting to slowly see Ron's point of view even clearer now. I now am recognizing that this is more of a standard practice than I thought. I think we really need to focus on occupations when the goal is to get the patient home or to improve their quality of life. I think it is ok to work on UE strength, fine motor control to an extent esp
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even
Having some experience with a RAC review a few years ago, they will go after anything to deny payment. I don't know if CMS fixed their incentive loophole, but they would get a percent of whatever amount they denied. If the facility appealed the denials(80% turnover rate) and won, the RAC would still get paid their cut. At the time, my OTs did plenty of UE ther ex (which I disliked, but that's another convo) with the joint replacement patients, but the RAC never mentioned that in our reason for denials. That leads me back to my initial statement that they will hunt for anything in the chart to get a denial. To expand, they were inconsistent with their reviews. One patient had unstable hgb levels, UTI and newly diagnosed diabetes. They said she did not demonstrate a need for 24 hr medical supervision,but yet they approved a straight forward unilateral TKR with no acute illnesses. Go figure. To conclude, we shouldn't get so bent on that one experience as the fall of OT. :-) These reviewers aren't always the sharpest pencils in the bunch. Arley Johnson, MS, OTR/L Site Manager, Pennsylvania Hospital Rehabilitation Services From: otlist-boun...@otnow.com on behalf of cmnahrw...@aol.com Sent: Fri 4/24/2009 5:04 PM To: OTlist@OTnow.com Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even PatJoan, I do not think you understand. Medicare (our government payor source for the elderly)is now not allowing general debility patients into acute rehab period. We used to have this 75% rule in which 75% of our cases had to match a certain diagnois (stroke, spinal cord, etc), and the other 25% could be whatever diagnosis. Now Medicare CMS is auditing charts and making rehab facilities pay back millions of dollars finding that the patients were not appropriate to be there. Several cases she explained was that the OT did not have enough documentation to support that they truly needed OT. Her claim was that a general debility patient would not need OT for arm exercises. When a person has 5/5 strength and the therapists complete UE exerise and group therapy all day long that is totally inapproriate. We need to complete ADLs during the first three days of their stay to document the need for skilled OT and then actually work on those issues during their stay to demonstrate improvement on the FIM. The funny thing is the patients improve much faster when we take an occupational approach. It is not rocket science. Bottom line is that patients need to get up of the the wheelchair and get moving by engaging in their daily occuapations in the way they plan on completing them at home. We OTs need to speak up to the OTs who are screwing our profession up. I am sure AOTA is aware of these issues because these Medicare RACK audits is a hot topic in rehab right now. -Original Message- From: Joan Riches To: OTlist@OTnow.com Sent: Fri, 24 Apr 2009 2:32 pm Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Have you reported this with names and details to AOTA for follow-up? What was the result of the debate? Will this person continue the blanket refusal of all OT? Targeted refusals of UE exercise without specific rationale and a UE diagnosis might go a long way to changing practice. I wonder how widespread this is in Canada. I did see it 25 years ago as a student. It definitely does not happen in this area. All the OTs are far too busy too waste time that way. 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 cmnahrw...@aol.com Sent: April 23, 2009 8:12 PM To: OTlist@OTnow.com Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Listened to a medicare teleconference describing why CMS is denying debility patients from acute rehab stays. When asked why this is so, the medicare communicater stated that they did not have medical necessity for occupational therapy. When debating this issue and how occupational therapy works on a debility patient's occupations, the communicator stated that she thought that all we did was UE exercise. I guess from all of her chart audits she has concluded this over the years. I am starting to slowly see Ron's point of view even clearer now. I now am recognizing that this is more of a standard practice than I thought. I think we really need to focus on occupations when the goal is to get the patient home or to improve their quality of life. I think it is ok to work on UE strength, fine motor control to an extent especiallly when the imparment is effecting the individual on a disability level, but the focus needs to be on the skills that will allow the patient to go home safelyl. I believe that this move by medicare CMS will slowly trickle down into other
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even
Have you reported this with names and details to AOTA for follow-up? What was the result of the debate? Will this person continue the blanket refusal of all OT? Targeted refusals of UE exercise without specific rationale and a UE diagnosis might go a long way to changing practice. I wonder how widespread this is in Canada. I did see it 25 years ago as a student. It definitely does not happen in this area. All the OTs are far too busy too waste time that way. 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 cmnahrw...@aol.com Sent: April 23, 2009 8:12 PM To: OTlist@OTnow.com Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Listened to a medicare teleconference describing why CMS is denying debility patients from acute rehab stays. When asked why this is so, the medicare communicater stated that they did not have medical necessity for occupational therapy. When debating this issue and how occupational therapy works on a debility patient's occupations, the communicator stated that she thought that all we did was UE exercise. I guess from all of her chart audits she has concluded this over the years. I am starting to slowly see Ron's point of view even clearer now. I now am recognizing that this is more of a standard practice than I thought. I think we really need to focus on occupations when the goal is to get the patient home or to improve their quality of life. I think it is ok to work on UE strength, fine motor control to an extent especiallly when the imparment is effecting the individual on a disability level, but the focus needs to be on the skills that will allow the patient to go home safelyl. I believe that this move by medicare CMS will slowly trickle down into other areas of our care. We need to start now to force our other therapists to treat as occupational therapists not cone and peg pushers. Managers need to initiate policies that address these issues now, No virus found in this outgoing message. Checked by AVG - www.avg.com Version: 8.0.238 / Virus Database: 270.12.4/2078 - Release Date: 04/24/09 07:54:00 -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even
Hey Ron and group, Here is a case I had this week in home health. Brief history includes a significant emotional trauma about 4 years ago. Apparently the pt. got mixed up in a multi-level/pyramid scheme of some sort and lost lots of money. According to her husband, shortly after she had an emotional break down and has never recovered. Fast forward to the referral... now she has fallen at home with a displaced femoral neck fx. and surgical repair. She is only 68 yo and now has a dx. Of Alzheimer's type dementia for which she is taking Aricept and depression (taking Zoloft). The husband reports the med's have not helped. She is very impulsive, has the "lithium/trazadone stare", is not able to talk and will only occassionally follow directions/cues of any kind. The husband is the primary caregiver and is providing excellent care. What would you do to serve her occupational needs? P Please consider the environment before printing this e-mail The information contained in this electronic document from Advanced Home Care is privileged and confidential information intended for the sole use of otl...@otnow.com. If the reader of this communication is not the intended recipient, or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the person listed above and discard the original.-Original Message- From: otlist-boun...@otnow.com [mailto:otlist-boun...@otnow.com] On Behalf Of Ron Carson Sent: Thursday, April 23, 2009 9:25 PM To: ocil...@comcast.net Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Hello Ilene: I appreciate your message! In this case, the pain was caused by probably joint misalignment resulting from paralysis of the shoulder girdle. I believe I did assist this patient by providing him my opinion on his shoulder pain, and referred him to an ortho MD. I am pretty confident that this patient understood occupation and OT. Well, at least it was explained to him. In fact, he was discharged because his only stated goal was, "walking like a man". Thanks again! Ron - Original Message - From: ocil...@comcast.net Sent: Wednesday, April 22, 2009 To: otlist@otnow.com Subj: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even ocn> Ron, IMO there were many things an OT could have done to assist ocn> that patient even without directly treating his arm. Pain disrupts ocn> occupational function in all areas. We can work with chronic pain ocn> patients to learn relaxation techniques. We can educate them and ocn> their caregivers on how to prevent further pain and deformity (many ocn> times CVA patients do make things worse because of dysfunctional ocn> strageties they develop to perfom self-care, poor arm placement ocn> during transfer, etc) We can help them learn how to find a chronic ocn> pain support group or how to find assistive devices on the ocn> internet. I think patients really have no idea all that OT offers, ocn> nor often what "occupation" really is. The best way to get OT's out ocn> of the "UE" box, is to show them what we CAN do for them, rather ocn> than say "there is nothing we can do, refer to PT" for a patient like that. ocn> ~Ilene Rosenthal, OTR/L ocn> From: Ron Carson < rdcar...@otnow.com > ocn> Subject: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even ocn> Possible? ocn> To: OTlist@OTnow.com ocn> Date: Monday, April 20, 2009, 4:06 PM ocn> Hello All: ocn> A couple weeks ago, I worked with a CVA patient who despite having ocn> multiple occupational deficits, he was unwilling to verbalize any ocn> OT-related goals. And after a couple of weeks, the patient was d/c'd. ocn> The patient's UE and LE were compromised by the CVA. He had almost no ocn> active movement in his affected arm. His shoulder was extremely painful ocn> during any AROM. ocn> I initially told the patient that as an OT, I would address his most ocn> important occupations but that I could do nothing about his arm. Over ocn> the? course of? treatment, his wife reported having difficulty bathing ocn> under the patients arm. After doing some gentle PROM, I concluded that ocn> there was a possible impingement. I believed an orthopedic appointment ocn> was necessary. I conferred? with the PT and? she concurred. I ocn> also ocn> confirmed that the treating PTA would address ocn> the shoulder ocn> ROM/Pain. ocn> -- ocn> Options? ocn> www.otnow.com/mailman/options/otlist_otnow.com ocn> Archive? ocn> 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] Breaking the Bonds of Upper Extremity OT; Is it even
Listened to a medicare teleconference describing why CMS is denying debility patients from acute rehab stays. When asked why this is so, the medicare communicater stated that they did not have medical necessity for occupational therapy. When debating this issue and how occupational therapy works on a debility patient's occupations, the communicator stated that she thought that all we did was UE exercise. I guess from all of her chart audits she has concluded this over the years. I am starting to slowly see Ron's point of view even clearer now. I now am recognizing that this is more of a standard practice than I thought. I think we really need to focus on occupations when the goal is to get the patient home or to improve their quality of life. I think it is ok to work on UE strength, fine motor control to an extent especiallly when the imparment is effecting the individual on a disability level, but the focus needs to be on the skills that will allow the patient to go home safelyl. I believe that this move by medicare CMS will slowly trickle down into other areas of our care. We need to start now to force our other therapists to treat as occupational therapists not cone and peg pushers. Managers need to initiate policies that address these issues now, -Original Message- From: Ron Carson To: ocil...@comcast.net Sent: Thu, 23 Apr 2009 8:24 pm Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Hello Ilene: I appreciate your message! In this case, the pain was caused by probably joint misalignment resulting from paralysis of the shoulder girdle. I believe I did assist this patient by providing him my opinion on his shoulder pain, and referred him to an ortho MD. I am pretty confident that this patient understood occupation and OT. Well, at least it was explained to him. In fact, he was discharged because his only stated goal was, "walking like a man". Thanks again! Ron - Original Message - From: ocil...@comcast.net Sent: Wednesday, April 22, 2009 To: otlist@otnow.com Subj: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even ocn> Ron, IMO there were many things an OT could have done to assist ocn> that patient even without directly treating his arm. Pain disrupts ocn> occupational function in all areas. We can work with chronic pain ocn> patients to learn relaxation techniques. We can educate them and ocn> their caregivers on how to prevent further pain and deformity (many ocn> times CVA patients do make things worse because of dysfunctional ocn> strageties they develop to perfom self-care, poor arm placement ocn> during transfer, etc) We can help them learn how to find a chronic ocn> pain support group or how to find assistive devices on the ocn> internet. I think patients really have no idea all that OT offers, ocn> nor often what "occupation" really is. The best way to get OT's out ocn> of the "UE" box, is to show them what we CAN do for them, rather ocn> than say "there is nothing we can do, refer to PT" for a patient like that. ocn> ~Ilene Rosenthal, OTR/L ocn> From: Ron Carson < rdcar...@otnow.com > ocn> Subject: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even ocn> Possible? ocn> To: OTlist@OTnow.com ocn> Date: Monday, April 20, 2009, 4:06 PM ocn> Hello All: ocn> A couple weeks ago, I worked with a CVA patient who despite having ocn> multiple occupational deficits, he was unwilling to verbalize any ocn> OT-related goals. And after a couple of weeks, the patient was d/c'd. ocn> The patient's UE and LE were compromised by the CVA. He had almost no ocn> active movement in his affected arm. His shoulder was extremely painful ocn> during any AROM. ocn> I initially told the patient that as an OT, I would address his most ocn> important occupations but that I could do nothing about his arm. Over ocn> the? course of? treatment, his wife reported having difficulty bathing ocn> under the patients arm. After doing some gentle PROM, I concluded that ocn> there was a possible impingement. I believed an orthopedic appointment ocn> was necessary. I conferred? with the PT and? she concurred. I ocn> also ocn> confirmed that the treating PTA would address ocn> the shoulder ocn> ROM/Pain. ocn> -- ocn> Options? ocn> www.otnow.com/mailman/options/otlist_otnow.com ocn> Archive? ocn> 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] Breaking the Bonds of Upper Extremity OT; Is it even
Hello Ilene: I appreciate your message! In this case, the pain was caused by probably joint misalignment resulting from paralysis of the shoulder girdle. I believe I did assist this patient by providing him my opinion on his shoulder pain, and referred him to an ortho MD. I am pretty confident that this patient understood occupation and OT. Well, at least it was explained to him. In fact, he was discharged because his only stated goal was, "walking like a man". Thanks again! Ron - Original Message - From: ocil...@comcast.net Sent: Wednesday, April 22, 2009 To: otlist@otnow.com Subj: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even ocn> Ron, IMO there were many things an OT could have done to assist ocn> that patient even without directly treating his arm. Pain disrupts ocn> occupational function in all areas. We can work with chronic pain ocn> patients to learn relaxation techniques. We can educate them and ocn> their caregivers on how to prevent further pain and deformity (many ocn> times CVA patients do make things worse because of dysfunctional ocn> strageties they develop to perfom self-care, poor arm placement ocn> during transfer, etc) We can help them learn how to find a chronic ocn> pain support group or how to find assistive devices on the ocn> internet. I think patients really have no idea all that OT offers, ocn> nor often what "occupation" really is. The best way to get OT's out ocn> of the "UE" box, is to show them what we CAN do for them, rather ocn> than say "there is nothing we can do, refer to PT" for a patient like that. ocn> ~Ilene Rosenthal, OTR/L ocn> From: Ron Carson < rdcar...@otnow.com > ocn> Subject: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even ocn> Possible? ocn> To: OTlist@OTnow.com ocn> Date: Monday, April 20, 2009, 4:06 PM ocn> Hello All: ocn> A couple weeks ago, I worked with a CVA patient who despite having ocn> multiple occupational deficits, he was unwilling to verbalize any ocn> OT-related goals. And after a couple of weeks, the patient was d/c'd. ocn> The patient's UE and LE were compromised by the CVA. He had almost no ocn> active movement in his affected arm. His shoulder was extremely painful ocn> during any AROM. ocn> I initially told the patient that as an OT, I would address his most ocn> important occupations but that I could do nothing about his arm. Over ocn> the? course of? treatment, his wife reported having difficulty bathing ocn> under the patients arm. After doing some gentle PROM, I concluded that ocn> there was a possible impingement. I believed an orthopedic appointment ocn> was necessary. I conferred? with the PT and? she concurred. I ocn> also ocn> confirmed that the treating PTA would address ocn> the shoulder ocn> ROM/Pain. ocn> -- ocn> Options? ocn> www.otnow.com/mailman/options/otlist_otnow.com ocn> Archive? ocn> 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] Breaking the Bonds of Upper Extremity OT; Is it even Possible?
Hello Carmen: Thanks for the information on the DASH (Disabilities of the Arm, Shoulder and Hand). I don't really see this as on occupation-based assessment, but I like what it attempts to do. It's much better than ROM, MMT, etc. However, I wonder how patients and referring ortho doctors would view this assessment/outcome. In my experience, ortho MD's are only concerned about ROM, decreased pain, etc. They are not SPECIFICALLY concerned with many of the items listed on the DASH. Has anyone ever used the DASH as the only outcome measure with UE ortho patients? With this particular patient, there really is no hope at this time for regaining lost occupation caused by the arm dysfunction. Additionally, the patient does have other occupational dysfunction which could have been restored, but he did not desire to do so. Thanks, Ron ~~~ Ron Carson MHS, OT www.OTnow.com - Original Message - From: Carmen Aguirre Sent: Wednesday, April 22, 2009 To: otlist@otnow.com Subj: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? CA> There is a tool called The DASH, an occupationally- based CA> assessment tool that attempst to merge physical dysfuntion and CA> decreased occupational engagement. I would have use it in the CA> scenario you presented. There is an area of occupation we many times CA> don't address: Health Maintenance skills. CA> Perhaps looking a increased competency in this area may increase CA> your comfort level in treating it as it relates to occupational CA> dysfunction. I know that is what i did to be able to understand the CA> implications of the hemi shoulder and then begin to explore the many CA> possibilities to enhance occupation. CA> i had to start with the components of arm use before before CA> addressing the actual task at the begining but pretty soon most of CA> the treatments become occupationally based . CA> Carmen CA> -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible?
There is a tool called The DASH, an occupationally- based assessment tool that attempst to merge physical dysfuntion and decreased occupational engagement. I would have use it in the scenario you presented. There is an area of occupation we many times don't address: Health Maintenance skills. Perhaps looking a increased competency in this area may increase your comfort level in treating it as it relates to occupational dysfunction. I know that is what i did to be able to understand the implications of the hemi shoulder and then begin to explore the many possibilities to enhance occupation. i had to start with the components of arm use before before addressing the actual task at the begining but pretty soon most of the treatments become occupationally based . Carmen > Date: Tue, 21 Apr 2009 20:22:34 -0400 > From: rdcar...@otnow.com > To: OTlist@OTnow.com > Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even > Possible? > > Hello All: > > I thought some more about this situation and I'm more comfortable with > my decision to not treat this patient's shoulder. It is true that his > wife said she was having difficulty bathing under the arm, and that's > why I initiated contact with the PT. But, if I would have treated the > patient what is an appropriate goal? > > Based on my treatment philosophy, ALL goals must be occupational. So, in > this case, my goal would have been: "Pt will be able to bathe under > right arm pit with assistance and no self-reported pain". To me, this is > a great OT goal. But, when this goal is reached, which probably wouldn't > take too long, what would be the outcome of the patient's shoulder. He > may have gained 20 - 30 degrees of pain free passive ROM, allowing him > to bathe under his armpit, but by my goal, the OT would have stopped. > > Is that really what is best for this patient? I don't think so. What I > think he needs is SKILLED and focused treatment on his UE to reduce the > pain and increase his PROM. But, for me, this is NOT the role of OT, > it's the role of PT! > > Thanks, > > Ron > > ~~~ > Ron Carson MHS, OT > www.OTnow.com > > ----- Original Message - > From: Ron Carson > Sent: Tuesday, April 21, 2009 > To: Audra Ray > Subj: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? > > RC> Thanks for writing. > > RC> Maybe this is one of the cases were I was over zealous about NOT > RC> treating someone's arm. But, I truly feel that PT is much better trained > RC> and in my case, licensed, to treat bio-mechanical issues. It just floors > RC> me that a PT would refer back to OT for shoulder treatment. > > RC> Here's some things to consider: > > RC> 1. Why do OT's treat arms and not legs? > > RC> 2. Aren't MOST PT's better trained to treat physical dysfunction? > > RC> 3. Where is the line between focused treatment on an UE and focused > RC> treatment on occupation? Can both co-exist with the same > RC> patient/therapist? > > RC> This is a very confusing case for me! > > RC> Ron > > > -- > Options? > www.otnow.com/mailman/options/otlist_otnow.com > > Archive? > www.mail-archive.com/otlist@otnow.com _ Rediscover Hotmail®: Get e-mail storage that grows with you. http://windowslive.com/RediscoverHotmail?ocid=TXT_TAGLM_WL_HM_Rediscover_Storage2_042009 -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even
Ron, IMO there were many things an OT could have done to assist that patient even without directly treating his arm. Pain disrupts occupational function in all areas. We can work with chronic pain patients to learn relaxation techniques. We can educate them and their caregivers on how to prevent further pain and deformity (many times CVA patients do make things worse because of dysfunctional strageties they develop to perfom self-care, poor arm placement during transfer, etc) We can help them learn how to find a chronic pain support group or how to find assistive devices on the internet. I think patients really have no idea all that OT offers, nor often what "occupation" really is. The best way to get OT's out of the "UE" box, is to show them what we CAN do for them, rather than say "there is nothing we can do, refer to PT" for a patient like that. ~Ilene Rosenthal, OTR/L From: Ron Carson < rdcar...@otnow.com > Subject: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? To: OTlist@OTnow.com Date: Monday, April 20, 2009, 4:06 PM Hello All: A couple weeks ago, I worked with a CVA patient who despite having multiple occupational deficits, he was unwilling to verbalize any OT-related goals. And after a couple of weeks, the patient was d/c'd. The patient's UE and LE were compromised by the CVA. He had almost no active movement in his affected arm. His shoulder was extremely painful during any AROM. I initially told the patient that as an OT, I would address his most important occupations but that I could do nothing about his arm. Over the? course of? treatment, his wife reported having difficulty bathing under the patients arm. After doing some gentle PROM, I concluded that there was a possible impingement. I believed an orthopedic appointment was necessary. I conferred? with the PT and? she concurred. I also confirmed that the treating PTA would address the shoulder ROM/Pain. -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible?
Hello All: I thought some more about this situation and I'm more comfortable with my decision to not treat this patient's shoulder. It is true that his wife said she was having difficulty bathing under the arm, and that's why I initiated contact with the PT. But, if I would have treated the patient what is an appropriate goal? Based on my treatment philosophy, ALL goals must be occupational. So, in this case, my goal would have been: "Pt will be able to bathe under right arm pit with assistance and no self-reported pain". To me, this is a great OT goal. But, when this goal is reached, which probably wouldn't take too long, what would be the outcome of the patient's shoulder. He may have gained 20 - 30 degrees of pain free passive ROM, allowing him to bathe under his armpit, but by my goal, the OT would have stopped. Is that really what is best for this patient? I don't think so. What I think he needs is SKILLED and focused treatment on his UE to reduce the pain and increase his PROM. But, for me, this is NOT the role of OT, it's the role of PT! Thanks, Ron ~~~ Ron Carson MHS, OT www.OTnow.com - Original Message - From: Ron Carson Sent: Tuesday, April 21, 2009 To: Audra Ray Subj: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? RC> Thanks for writing. RC> Maybe this is one of the cases were I was over zealous about NOT RC> treating someone's arm. But, I truly feel that PT is much better trained RC> and in my case, licensed, to treat bio-mechanical issues. It just floors RC> me that a PT would refer back to OT for shoulder treatment. RC> Here's some things to consider: RC> 1. Why do OT's treat arms and not legs? RC> 2. Aren't MOST PT's better trained to treat physical dysfunction? RC> 3. Where is the line between focused treatment on an UE and focused RC> treatment on occupation? Can both co-exist with the same RC> patient/therapist? RC> This is a very confusing case for me! RC> Ron -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible?
Lets face the facts. Most PTs do not know how to treat stroke shoulder dysfunction. Most OTs do not know how to properly treat stroke shoulder dysfunction. They think they can, but most of them do a botched up waste of time job. It is a specialized skill, that warrents continued education. It is beyond crazy busy for an OT with education in this area, because most clinicians in both the field of OT and PT do not feel comfortable with it and will gladly refer their patients to you. -Original Message- From: Carmen Aguirre To: otlist@otnow.com Sent: Tue, 21 Apr 2009 6:12 pm Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? I think treating the shoulder seemed to be warranted given the limitations it brough about to pt's and caregiver routines at home. It seemed to be related to safety, prevention of further limitation in his adl's or caregivers ability to care for him appropriately. Techniques applied such as bilateral integration, re-education during those adl tasks the caregiver seemed to be having difficulty with. Thanks Carmen Date: Mon, 20 Apr 2009 19:06:29 -0400 From: rdcar...@otnow.com To: OTlist@OTnow.com Subject: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? Hello All: A couple weeks ago, I worked with a CVA patient who despite having =0 A> multiple occupational deficits, he was unwilling to verbalize any OT-related goals. And after a couple of weeks, the patient was d/c'd. The patient's UE and LE were compromised by the CVA. He had almost no active movement in his affected arm. His shoulder was extremely painful during any AROM. I initially told the patient that as an OT, I would address his most important occupations but that I could do nothing about his arm. Over the course of treatment, his wife reported having difficulty bathing under the patients arm. After doing some gentle PROM, I concluded that there was a possible impingement. I believed an orthopedic appointment was necessary. I conferred with the PT and she concurred. I also confirmed that the treating PTA would address the shoulder ROM/Pain. Last Friday, I received a new referral for this same patient. When I questioned it, I was told that: "...[PT saw the patient] and he has some issues so nursing went back in and she felt OT needed back in also so we received an order to do an eval and treat." Based on this my ever so sweet scheduler made an appt with the patient. At this point I had no idea why OT was called back in but suspected it was an arm "thing". Just by coincidence, before my scheduled appointment, I ran into the treating PTA. When I asked her about the referral she confirmed that the PT wanted OT to address the patient's arm. The PTA said that they thought a different OT than myself would be sent to the patient. And if fact, I was later called by my homehealth office and "advised" that I didn't need to see the patient because it was an shoulder thing and they understood that I don't do shoulders. I've written countless paragraphs about breaking the 'band of UE therapy', but at this point, I'm thinking it may not even be possible. What is the message when one OT says "no" to focused shoulder treatment while others cordially say "yes". Heck, at this point I'm confused! Sadly yours, 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 _ Windows Live™ Hotmail®:…more than just e-mail. http://windowslive.com/online/hotmail?ocid=TXT_TAGLM_WL_HM_more_042009 -- 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] Breaking the Bonds of Upper Extremity OT; Is it even Possible?
I think treating the shoulder seemed to be warranted given the limitations it brough about to pt's and caregiver routines at home. It seemed to be related to safety, prevention of further limitation in his adl's or caregivers ability to care for him appropriately. Techniques applied such as bilateral integration, re-education during those adl tasks the caregiver seemed to be having difficulty with. Thanks Carmen > Date: Mon, 20 Apr 2009 19:06:29 -0400 > From: rdcar...@otnow.com > To: OTlist@OTnow.com > Subject: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even > Possible? > > Hello All: > > A couple weeks ago, I worked with a CVA patient who despite having > multiple occupational deficits, he was unwilling to verbalize any > OT-related goals. And after a couple of weeks, the patient was d/c'd. > > The patient's UE and LE were compromised by the CVA. He had almost no > active movement in his affected arm. His shoulder was extremely painful > during any AROM. > > I initially told the patient that as an OT, I would address his most > important occupations but that I could do nothing about his arm. Over > the course of treatment, his wife reported having difficulty bathing > under the patients arm. After doing some gentle PROM, I concluded that > there was a possible impingement. I believed an orthopedic appointment > was necessary. I conferred with the PT and she concurred. I also > confirmed that the treating PTA would address the shoulder > ROM/Pain. > > Last Friday, I received a new referral for this same patient. When I > questioned it, I was told that: > > "...[PT saw the patient] and he has some issues so nursing > went back in and she felt OT needed back in also so we received > an order to do an eval and treat." > > Based on this my ever so sweet scheduler made an appt with the patient. > At this point I had no idea why OT was called back in but suspected it > was an arm "thing". > > Just by coincidence, before my scheduled appointment, I ran into the > treating PTA. When I asked her about the referral she confirmed that the > PT wanted OT to address the patient's arm. The PTA said that they > thought a different OT than myself would be sent to the patient. And if > fact, I was later called by my homehealth office and "advised" that I > didn't need to see the patient because it was an shoulder thing and they > understood that I don't do shoulders. > > I've written countless paragraphs about breaking the 'band of UE > therapy', but at this point, I'm thinking it may not even be possible. > What is the message when one OT says "no" to focused shoulder treatment > while others cordially say "yes". Heck, at this point I'm confused! > > Sadly yours, > > 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 _ Windows Live™ Hotmail®:…more than just e-mail. http://windowslive.com/online/hotmail?ocid=TXT_TAGLM_WL_HM_more_042009 -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible?
Thanks for writing. Maybe this is one of the cases were I was over zealous about NOT treating someone's arm. But, I truly feel that PT is much better trained and in my case, licensed, to treat bio-mechanical issues. It just floors me that a PT would refer back to OT for shoulder treatment. Here's some things to consider: 1. Why do OT's treat arms and not legs? 2. Aren't MOST PT's better trained to treat physical dysfunction? 3. Where is the line between focused treatment on an UE and focused treatment on occupation? Can both co-exist with the same patient/therapist? This is a very confusing case for me! Ron - Original Message - From: Audra Ray Sent: Monday, April 20, 2009 To: OTlist@OTnow.com Subj: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? AR> Ron, AR> AR> I would have been one of those OTs that treated the patient. His AR> caregiver had a goal to bathe under the patient's arm. As an OT AR> trained in physical disabilities, I know how to treat a shoulder AR> impingement and would have. I know I'll probably get railed at, but AR> this is how my treatment plan would have gone: the patient has AR> pain with ROM, so treat the pain; strengthen what can be AR> strengthened to also reduce pain and probably fix a possible AR> subluxation; patient/caregiver education to continue home exercise AR> program to maintain what is gained. By doing these things, the AR> patient/caregiver is now able to meet his occupational goal of washing under his arm. AR> The goal would have been written as follows: The patient/caregiver AR> will bathe under affected arm without pain or discomfort. AR> AR> I had a patient recently discharged that came to me saying her AR> arm/neck was killing her. Her goals were as follows: AR> -decrease pain. AR> -be able to use arm in daily occupations without discomfort. AR> I helped her do just that. We used PAMs to decrease her pain, which AR> took over a month to do. She used to have a flat affect and slept AR> alot because of all the pain medicine she took. Now she is smiling, AR> going to activities frequently, and has 0/10 pain with daily occupations. AR> I did my job as an OT to make someone's life better. AR> AR> Audra Ray, OTR/L AR> AR> What I don't understand is why you only follow one Model: MOHO? AR> There are many models that we base treatment on. AR> AR> --- On Mon, 4/20/09, Ron Carson wrote: AR> From: Ron Carson AR> Subject: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? AR> To: OTlist@OTnow.com AR> Date: Monday, April 20, 2009, 4:06 PM AR> Hello All: AR> A couple weeks ago, I worked with a CVA patient who despite having AR> multiple occupational deficits, he was unwilling to verbalize any AR> OT-related goals. And after a couple of weeks, the patient was d/c'd. AR> The patient's UE and LE were compromised by the CVA. He had almost no AR> active movement in his affected arm. His shoulder was extremely painful AR> during any AROM. AR> I initially told the patient that as an OT, I would address his most AR> important occupations but that I could do nothing about his arm. Over AR> the course of treatment, his wife reported having difficulty bathing AR> under the patients arm. After doing some gentle PROM, I concluded that AR> there was a possible impingement. I believed an orthopedic appointment AR> was necessary. I conferred with the PT and she concurred. I also AR> confirmed that the treating PTA would address the shoulder AR> ROM/Pain. AR> Last Friday, I received a new referral for this same patient. When I AR> questioned it, I was told that: AR> "...[PT saw the patient] and he has some issues so nursing AR> went back in and she felt OT needed back in also so we received AR> an order to do an eval and treat." AR> Based on this my ever so sweet scheduler made an appt with the patient. AR> At this point I had no idea why OT was called back in but suspected it AR> was an arm "thing". AR> Just by coincidence, before my scheduled appointment, I ran into the AR> treating PTA. When I asked her about the referral she confirmed that the AR> PT wanted OT to address the patient's arm. The PTA said that they AR> thought a different OT than myself would be sent to the patient. And if AR> fact, I was later called by my homehealth office and "advised" that I AR> didn't need to see the patient because it was an shoulder thing and they AR> understood that I don't do shoulders. AR> I've written countless paragraphs about breaking the 'band of UE AR&g
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible?
Audra/Ron I appreciate Ron that you feel as OT's we should not look at UE exclusively e.g. to increase ROM or reduce pain, but is it ever exclusive?? As, with Audra's example the outcome of addressing reduced ROM and pain is likely to be an increase in independence, quality of life and participation in occupations. Effective UE's are the pre-requisite for participating in activities so if not addressed, alongside functional goals we miss a huge area of potential in our patients. There are times that the pain and movement issues need to be addressed before we can attempt effective participation in activities. Certainly in the UK we have OT's working in critical care ensuring patients are positioned and passively moved through ROM to reduce contractures, and to maintain ROM with the expectation that this gives them the optimal chance of participating in occupation in the future, once they are medically stable I am seeing a lady who has had a stroke currently who has made great progress from being bed bound, disorientated and flat affect - walking short distances with no aid, completeing personal care tasks independently and preparing and planning simple meals. She has memory, behavioural and cogntive deficits which we are developing strategies to manage and she has reduced ROM in her shoulder, reduced fine motor control and sensation in her hand. This is limiting her ability to reach up to cupboards, shelves (e.g. when shopping), she struggles to dry and dress herself and it affects her ability to write. Now that many of this lady's deficits have been addressed (rehabbed or compensated for) it is apparent that the reduced efficiency of her UE is playing an important part in her continued deficits. In order for her arm and hand to be effective her shoulder needs to be stable, and strengthened, she currently is following a program of shoulder exercises in supine, provided by Physio and OT in collaboration. Along with this she continues to be encouraged to use her Right UE in functional activities, and activities are set up to encourage reach, grip and fine motor control, and normal movement is promoted. In this case do you feel Ron that it is the physio's role to work on the base of UE strength and ROM, and the OT to take over and promote normal movement in functional activities?? I am not sure, in my experience joint OT/PT working is often effective (if possible!), certainly this lady requires specific UE exercises as purely using arm in function is not making a significant difference. Kind Regards Lucy Simpson For Quality Stationery and Greetings Cards check out this website: www.phoenix-trading.co.uk/web/lucysimpson Save it in your favourites for the next time you need cards. --- On Tue, 21/4/09, Audra Ray wrote: From: Audra Ray Subject: Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? To: OTlist@OTnow.com Date: Tuesday, 21 April, 2009, 3:17 AM Ron, I would have been one of those OTs that treated the patient. His caregiver had a goal to bathe under the patient's arm. As an OT trained in physical disabilities, I know how to treat a shoulder impingement and would have. I know I'll probably get railed at, but this is how my treatment plan would have gone: the patient has pain with ROM, so treat the pain; strengthen what can be strengthened to also reduce pain and probably fix a possible subluxation; patient/caregiver education to continue home exercise program to maintain what is gained. By doing these things, the patient/caregiver is now able to meet his occupational goal of washing under his arm. The goal would have been written as follows: The patient/caregiver will bathe under affected arm without pain or discomfort. I had a patient recently discharged that came to me saying her arm/neck was killing her. Her goals were as follows: -decrease pain. -be able to use arm in daily occupations without discomfort. I helped her do just that. We used PAMs to decrease her pain, which took over a month to do. She used to have a flat affect and slept alot because of all the pain medicine she took. Now she is smiling, going to activities frequently, and has 0/10 pain with daily occupations. I did my job as an OT to make someone's life better. Audra Ray, OTR/L What I don't understand is why you only follow one Model: MOHO? There are many models that we base treatment on. --- On Mon, 4/20/09, Ron Carson wrote: From: Ron Carson Subject: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? To: OTlist@OTnow.com Date: Monday, April 20, 2009, 4:06 PM Hello All: A couple weeks ago, I worked with a CVA patient who despite having multiple occupational deficits, he was unwilling to verbalize any OT-related goals. And after a couple of weeks, the patient was d/c'd. The patient's UE and LE were comp
Re: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible?
Ron, I would have been one of those OTs that treated the patient. His caregiver had a goal to bathe under the patient's arm. As an OT trained in physical disabilities, I know how to treat a shoulder impingement and would have. I know I'll probably get railed at, but this is how my treatment plan would have gone: the patient has pain with ROM, so treat the pain; strengthen what can be strengthened to also reduce pain and probably fix a possible subluxation; patient/caregiver education to continue home exercise program to maintain what is gained. By doing these things, the patient/caregiver is now able to meet his occupational goal of washing under his arm. The goal would have been written as follows: The patient/caregiver will bathe under affected arm without pain or discomfort. I had a patient recently discharged that came to me saying her arm/neck was killing her. Her goals were as follows: -decrease pain. -be able to use arm in daily occupations without discomfort. I helped her do just that. We used PAMs to decrease her pain, which took over a month to do. She used to have a flat affect and slept alot because of all the pain medicine she took. Now she is smiling, going to activities frequently, and has 0/10 pain with daily occupations. I did my job as an OT to make someone's life better. Audra Ray, OTR/L What I don't understand is why you only follow one Model: MOHO? There are many models that we base treatment on. --- On Mon, 4/20/09, Ron Carson wrote: From: Ron Carson Subject: [OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible? To: OTlist@OTnow.com Date: Monday, April 20, 2009, 4:06 PM Hello All: A couple weeks ago, I worked with a CVA patient who despite having multiple occupational deficits, he was unwilling to verbalize any OT-related goals. And after a couple of weeks, the patient was d/c'd. The patient's UE and LE were compromised by the CVA. He had almost no active movement in his affected arm. His shoulder was extremely painful during any AROM. I initially told the patient that as an OT, I would address his most important occupations but that I could do nothing about his arm. Over the course of treatment, his wife reported having difficulty bathing under the patients arm. After doing some gentle PROM, I concluded that there was a possible impingement. I believed an orthopedic appointment was necessary. I conferred with the PT and she concurred. I also confirmed that the treating PTA would address the shoulder ROM/Pain. Last Friday, I received a new referral for this same patient. When I questioned it, I was told that: "...[PT saw the patient] and he has some issues so nursing went back in and she felt OT needed back in also so we received an order to do an eval and treat." Based on this my ever so sweet scheduler made an appt with the patient. At this point I had no idea why OT was called back in but suspected it was an arm "thing". Just by coincidence, before my scheduled appointment, I ran into the treating PTA. When I asked her about the referral she confirmed that the PT wanted OT to address the patient's arm. The PTA said that they thought a different OT than myself would be sent to the patient. And if fact, I was later called by my homehealth office and "advised" that I didn't need to see the patient because it was an shoulder thing and they understood that I don't do shoulders. I've written countless paragraphs about breaking the 'band of UE therapy', but at this point, I'm thinking it may not even be possible.. What is the message when one OT says "no" to focused shoulder treatment while others cordially say "yes". Heck, at this point I'm confused! Sadly yours, 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
[OTlist] Breaking the Bonds of Upper Extremity OT; Is it even Possible?
Hello All: A couple weeks ago, I worked with a CVA patient who despite having multiple occupational deficits, he was unwilling to verbalize any OT-related goals. And after a couple of weeks, the patient was d/c'd. The patient's UE and LE were compromised by the CVA. He had almost no active movement in his affected arm. His shoulder was extremely painful during any AROM. I initially told the patient that as an OT, I would address his most important occupations but that I could do nothing about his arm. Over the course of treatment, his wife reported having difficulty bathing under the patients arm. After doing some gentle PROM, I concluded that there was a possible impingement. I believed an orthopedic appointment was necessary. I conferred with the PT and she concurred. I also confirmed that the treating PTA would address the shoulder ROM/Pain. Last Friday, I received a new referral for this same patient. When I questioned it, I was told that: "...[PT saw the patient] and he has some issues so nursing went back in and she felt OT needed back in also so we received an order to do an eval and treat." Based on this my ever so sweet scheduler made an appt with the patient. At this point I had no idea why OT was called back in but suspected it was an arm "thing". Just by coincidence, before my scheduled appointment, I ran into the treating PTA. When I asked her about the referral she confirmed that the PT wanted OT to address the patient's arm. The PTA said that they thought a different OT than myself would be sent to the patient. And if fact, I was later called by my homehealth office and "advised" that I didn't need to see the patient because it was an shoulder thing and they understood that I don't do shoulders. I've written countless paragraphs about breaking the 'band of UE therapy', but at this point, I'm thinking it may not even be possible. What is the message when one OT says "no" to focused shoulder treatment while others cordially say "yes". Heck, at this point I'm confused! Sadly yours, 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
