Re: [OTlist] Occupation as THE goal: Does it matter
Sorry Ron but the great debate continue There is a budding branch of research that does support the use of impairment based OT to improve occupational outcomes post stroke. This is a very short list, due to time constraints. I can offer more research to you if you wantme to. I really enjoy research so I can probably dig up tons of info if anyone esle is interested. 1) AOTA said this regarding Constraint Induced movement therapy in their evidenced based bytes after an extensive review of the research: “CIT, then, is strongly effective in improving behavioral outcomes. Its effectiveness on impairments of dexterity, coordination, and strength are most pronounced, whereas its effectiveness on ADL and participation in greater amounts of activity is less. The latter finding needs further study using reliable, objective, and more sensitive measuring instruments. CIT does not appear to be contraindicated for patients who are willing to enter into a behavioral contract to carry out the stringent requirements of this treatment.” (http://aota.org/Educate/Research/EB/Stroke/SFQ/37823.aspx) ***Sure the research states that ADL and participation was a less significant change compared to improvements found when measuring the impairments but non the less it was a significant change. This is at least a start in the research. 2) CITATION: Jongbloed, L., Stacey, S., Brighton, C. (1989). Stroke rehabilitation: Sensor imotor integrative treatment versus functional treatment. American Journal of Occupational Therapy, 43, 391-397 RESEARCH QUESTION How does the effectiveness of two OT approaches to treatment of stroke patients-the functional and sensorimotor integrative approaches-differ? DESIGN Randomized controlled trial (RCT) Subjects were randomly assigned to one of two groups: Sensorimotor Integrative or Functional OUTCOME MEASURES (R = Reliability established; V = Validity established) Barthel Index - R, V Meal Preperation - Reliability and validity not established Eight Sensorimotor integration tests - R, V INTERVENTION DESCRIPTION Group 1: Functional Approach: Emphasizes the practice of tasks, usually activities of daily living (ADL). The emphasis is on treatment of the symptom rather than on the cause of the dysfunction. Two methods are used: compensation and adaptation. Group 2: Sensorimotor Integrative Approach: Emphasizes treating the cause of the dysfunction rather than compensating for, or adapting to, the problem. The principles that guided treatment were: (a) provide planned and controlled sensory input; (b) elicit an adaptive response; (c) enhance organization of brain mechanisms; and (d) facilitate the developmental sequence. INTERVENTION DESCRIPTION Group 1: Functional Approach: Emphasizes the practice of tasks, usually activities of daily living (ADL). The emphasis is on treatment of the symptom rather than on the cause of the dysfunction. Two m ethods are used: compensation and adaptation. Group 2: Sensorimotor Integrative Approach: Emphasizes treating the cause of the dysfunction rather than compensating for, or adapting to, the problem. The principles that guided treatment were: (a) provide planned and controlled sensory input; (b) elicit an adaptive response; (c) enhance organization of brain mechanisms; and (d) facilitate the developmental sequence AUTHORS' CONCLUSIONS The authors concluded that if there are any differences between functional treatment and sensorimotor integrative treatment they are small. The findings suggest that occupational therapists can consider using either approach in planning treatment for CVA patients. -- 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 and others, What follows is a long reply to a message that Chris N. wrote awhile back. I generally don't like the format that I used, but I don't want to take the time to make a more formal looking message. Thanks, Ron -- Ron Carson MHS, OT www.OTnow.com - Original Message - From: cmnahrw...@aol.com cmnahrw...@aol.com Sent: Saturday, February 21, 2009 To: OTlist@OTnow.com OTlist@OTnow.com Subj: [OTlist] Occupation as THE goal: Does it matter cac Seems like in your example of occupation that the UE is left out of the cac equation, although through some improvement it can lead to improvements cac in the patient's personal goals of occupation. Then I guess a PT improving UE function is also helping the patient engage in occupation, right? Also, there is nothing supporting the concept that improving the UE can lead to improvement in occupation. Your statement is strictly hypothetical. Improving UE function may or may not lead to improved occupation. And if it doesn't then there's been no improvement in occupation, so what has been done? cac Just because there is no function in the flaccid UE does not mean cac there will not be any improvement 6 months down the road, cac especially with intentional focus on the issue. Any goal that takes 6 months is not a reasonable goal. cac I can make the UE cac treatment focus on occupation just like you state, but it will take cac much longer. Instead of writing patient will improve AROM by 30 cac degrees in order to assist with self feeding I can simply write cac patient will reach for a glass of water from table using his cac involved arm. Reaching for a glass of water is not occupation. You are contriving occupation to fit your treatment agenda. cac The problem is it might take 6 months to a year to cac achieve this occupationally written goal, but it only might take cac 2-3 months to show 30 degrees of progress if the patient has good cac rehab potential in arm function. I consider rehab of arm function to be PT, regardless if it's a PT or OT doing the rehab. I have a patient who has spent countless hours doing mindless exercises on his flaccid UE. It hasn't helped ANY and his previous OT wasted a lot of valuable time acting like a PT and working on his arm. In my opinion, the PT should have addressed the mans' arm and the OT should have been working on improving his occupational performance. cac The structure of insurance cac re-imbursement is set up on showing immediate progress, otherwise cac we are told to DC a patient or set more achievable goals. There is nothing in Medicare guidelines requiring immediate progress. Progress is REQUIRED, and should be, but there is no specific requirement that it be immediate. Goals must be achievable in a reasonable period of time, but that time is not spelled out. cac Even though we as neuro OTs might wright goals that focus on body cac impairments, it does not mean that we are not looking at cac occupation. Focusing on body impairment does not exclude occupation, it simply places it in hind-sight. And honestly, PT does the same thing. Of course, they call it function, not occupation. cac It only means that we want to continue to work with the cac patient that has the potential of using their arm in occuation cac again, but unfortunately we need to be able to document cac improvements relatively quickly for insurance to foot the bill. If improvement in arm function yields improvement in occupation, then you should be able to document occupational gains. cac This sytem of billing does not match up with the natural cac progression of improvement in a patient's arm after a stroke.The cac road to recovery for a stroke patient's flaccid arm is a long and cac painful one, in which sometimes the road does not lead to a cac positive outcome. How can we justify seeing them for an entire cac year, and then finally one day we state that the patient is not cac appropriate for OT any longer. And this is why we need to focus on occupation. If occupation is the goal then it is 100% clear when the goal has been achieved. Of course, occupational goals are often not achieved but then it's an issue of lack of progress. cac There needs to be incremental steps along the way to occupation cac showing that the patient is making progress towards that goals that cac we predicted would eventually be achievable. Yes, ALL therapy improvement is incremental. A PT doing range of motion on rotator cuff repairs yields incrmental changes over time. An OT doing occupational therapy also yield incremental chnages over time. cac And let me tell you, when that area of occupatiion is finally cac achieved after such time and effort from the therapist and patient, cac there is not greater feeling in OT. I wish we could see them
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! smile Ron - Original Message - From: cmnahrw...@aol.com cmnahrw...@aol.com Sent: Monday, February 16, 2009 To: OTlist@OTnow.com 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 rdcar...@otnow.com 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.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 rdcar...@otnow.com To: cmnahrw...@aol.com OTlist@OTnow.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
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
[OTlist] Occupation as THE goal: Does it matter
Hello All: What follows are thoughts and opinion about using occupation as *THE* goal for OT treatment. Here's is the premise for my arguments: (1) When occupation is *THE* goal, outcome statements may be written in concise occupation-based outcomes. For example: Patient will safely and independently ambulate to/from toilet with RW and perform all hygiene without assistive equipment. Patient will transfer from w/c to bed using slide board transfers Patient will dress self using adaptive equipment as necessary (2) Conversely, when occupation is not *THE* goal, outcomes may be written so that occupation is a desired outcome but is based on improving underlying impairment(s). For example: Patient will increase UE elbow ROM to 115 degree active flexion to all for donning/doffing of shirt Patient will increase standing endurance/balance to allow them to safely and independently carry out toileting hygiene. Some argue there is little difference in the above approaches. However, I believe these approaches frame patient problems very differently. This is important because how we frame a problem drives our treatment. The first example clearly identifies that occupation is the goal. There is no expressed concern for underlying factors impairing occupation. However, and this if often overlooked, it is IMPLIED that all factors impairing the goal will be treated within the therapist's abilities. This is true because occupation includes the following factors: Physical, emotional, mental environmental, behavioral, social Thus, as OT's and within our scope of practice, occupation-based outcomes address all factors impairing the desire occupations. While the second example does include occupation as an outcome, only factors addressed in the goals are included for treatment. This severely limits treatment and in my opinion indicates that remediation of underlying impairments is the real goal. The implication is that if underlying impairments are remediated, occupation will improve. However, is inconsistent with OT theory because occupation is ALWAYS more than physical. In my opinion, the second example is much more like a PT rather than an OT goal! In closing, writing occupation-based goals is important for us and for the patient. These goals allow us to focus on occupation's many elements and complexity to best enable our patients. 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
Re: [OTlist] Occupation as THE goal: Does it matter
Ron, Great outline.? Can you next explain how the treatment will differ? Chris -Original Message- From: Ron Carson rdcar...@otnow.com To: OTlist@OTnow.com Sent: Mon, 16 Feb 2009 7:52 am Subject: [OTlist] Occupation as THE goal: Does it matter Hello All: What follows are thoughts and opinion about using occupation as *THE* goal for OT treatment. Here's is the premise for my arguments: (1) When occupation is *THE* goal, outcome statements may be written in concise occupation-based outcomes. For example: Patient will safely and independently ambulate to/from toilet with RW and perform all hygiene without assistive equipment. Patient will transfer from w/c to bed using slide board transfers Patient will dress self using adaptive equipment as necessary (2) Conversely, when occupation is not *THE* goal, outcomes may be written so that occupation is a desired outcome but is based on improving underlying impairment(s). For example: Patient will increase UE elbow ROM to 115 degree active flexion to all for donning/doffing of shirt Patient will increase standing endurance/balance to allow them to safely and independently carry out toileting hygiene. Some argue there is little difference in the above approaches. However, I believe these approaches frame patient problems very differently. This is important because how we frame a problem drives our treatment. The first example clearly identifies that occupation is the goal. There is no expressed concern for underlying factors impairing occupation. However, and this if often overlooked, it is IMPLIED that all factors impairing the goal will be treated within the therapist's abilities. This is true because occupation includes the following factors: Physical, emotional, mental environmental, behavioral, social Thus, as OT's and within our scope of practice, occupation-based outcomes address all factors impairing the desire occupations. While the second example does include occupation as an outcome, only factors addressed in the goals are included for treatment. This severely limits treatment and in my opinion indicates that remediation of underlying impairments is the real goal. The implication is that if underlying impairments are remediated, occupation will improve. However, is inconsistent with OT theory because occupation is ALWAYS more than physical. In my opinion, the second example is much more like a PT rather than an OT goal! In closing, writing occupation-based goals is important for us and for the patient. These goals allow us to focus on occupation's many elements and complexity to best enable our patients. 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
I believe the first set of goals (occupational based) are the best way to go. This is how I write my goals, as it does leave room for the therapist to address several areas of impairment/need. It is typically the case that more than one factor is limiting the patient from being independent with their i.e. toileting, dressing, etc. ~ Miranda ~ To: OTlist@OTnow.com Date: Mon, 16 Feb 2009 10:28:10 -0500 From: cmnahrw...@aol.com Subject: Re: [OTlist] Occupation as THE goal: Does it matter Ron, Great outline.? Can you next explain how the treatment will differ? Chris -Original Message- From: Ron Carson rdcar...@otnow.com To: OTlist@OTnow.com Sent: Mon, 16 Feb 2009 7:52 am Subject: [OTlist] Occupation as THE goal: Does it matter Hello All: What follows are thoughts and opinion about using occupation as *THE* goal for OT treatment. Here's is the premise for my arguments: (1) When occupation is *THE* goal, outcome statements may be written in concise occupation-based outcomes. For example: Patient will safely and independently ambulate to/from toilet with RW and perform all hygiene without assistive equipment. Patient will transfer from w/c to bed using slide board transfers Patient will dress self using adaptive equipment as necessary (2) Conversely, when occupation is not *THE* goal, outcomes may be written so that occupation is a desired outcome but is based on improving underlying impairment(s). For example: Patient will increase UE elbow ROM to 115 degree active flexion to all for donning/doffing of shirt Patient will increase standing endurance/balance to allow them to safely and independently carry out toileting hygiene. Some argue there is little difference in the above approaches. However, I believe these approaches frame patient problems very differently. This is important because how we frame a problem drives our treatment. The first example clearly identifies that occupation is the goal. There is no expressed concern for underlying factors impairing occupation. However, and this if often overlooked, it is IMPLIED that all factors impairing the goal will be treated within the therapist's abilities. This is true because occupation includes the following factors: Physical, emotional, mental environmental, behavioral, social Thus, as OT's and within our scope of practice, occupation-based outcomes address all factors impairing the desire occupations. While the second example does include occupation as an outcome, only factors addressed in the goals are included for treatment. This severely limits treatment and in my opinion indicates that remediation of underlying impairments is the real goal. The implication is that if underlying impairments are remediated, occupation will improve. However, is inconsistent with OT theory because occupation is ALWAYS more than physical. In my opinion, the second example is much more like a PT rather than an OT goal! In closing, writing occupation-based goals is important for us and for the patient. These goals allow us to focus on occupation's many elements and complexity to best enable our patients. 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 _ See how Windows Mobile brings your life together—at home, work, or on the go. http://clk.atdmt.com/MRT/go/msnnkwxp1020093182mrt/direct/01/ -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/otlist@otnow.com
