23 May 2010

Evidence-based practice, practitioner versus student, smack-down.

I recently received a comment with constructive criticism regarding how I present OT to the masses. I wanted to write about my perspective regarding how I share OT. First I'll start by addressing Anita's comments, then go into further detail.

I was a little worried when I saw that you wrote:Β  “I am going to try a TENS unit on the forearm in the acupuncture points of Li3 and Li10 I think it is??” I don't know about TENS or acupuncture, so I'm not telling you what is right or wrong. What I thought when I read this was “what evidence is this based on? What knowledge and skills does this OT have here?” etc. This was because the way you wrote this left me with the impression that you might simply try it and see without having done any research to know if it would be appropriate for a person with post-burns pain. Of course this wouldn't be the case at all, I just worry that a lay person might read this and think “wow, I could do what an OT does, it sounds very eclectic, and really quite simple”.

I could see after Anita pointed it out, how what I wrote looked as if I was saying “I have no idea, let's try this”. That's one of the down-sides of blogging, it rarely occurs to me people will read things in a spirit quite differently than intended. In reality, I have taken a special course in physical agent modalities that included the use of TENS [transcutaneous electrical nerve stimulation] for multiple uses, including pain reduction, based on the gate theory of pain. It is appropriate for the use of pain reduction in a post-burns pt as long as I'm not directly covering the burns with the electrodes. TENS units, to the best of my knowledge, do have supportive evidence to back their use as a common physical agent modality. Anecdotally, using the TENS units on specific acupuncture points (such as Li3 and Li10 which are located on the upper extremities), helps more than just using the TENS in random locations. A very experienced physical therapist I work with has used the TENS units specifically on acupuncture points with great success in pain reduction. When I used the question marks in “Li3 and Li10 I think it is??”, I was referring to not remembering the NAMES of the two specific acupuncture points – I knew exactly where to place them, just wasn't positive I had properly remembered their names. Regarding evidence-based practice, using the TENS was warranted, and whether it was on an acupuncture point or not may HELP but would not harm. I should check to see if any evidence-based articles exist regarding the use of TENS on acupuncture points.

As a new practitioner with somewhat limited local resources due to my geographic area, I try hard to be evidence-based when approaching new areas of practice (new to me). For example, I recently had a pt with chemotherapy-induced peripheral neuropathy, and I found three different articles in medical journals that I had the library get for me. I read those to get a better understanding of what to expect/know about this specific issue, and that is where I learned about pseudo-athetosis and severe sensory ataxia, both of which were relevant to what I was handling. I've also researched and gotten multiple (I think SIX?) articles on shoulder subluxation after stroke, to better grasp best treatment protocols. For basic treatment, I often rely heavily on what I have seen other therapists perform, or what I have received advice about, or learned while in school, or observed in fieldwork, etc….I do not approach each treatment with “I didn't find an article on this so I have no idea if it's evidence-based”….I rely on clinical judgment and the professional expertise of others, my research/resources from schooling, fieldwork, and recent experiences, to determine whether I am providing basic appropriate treatment. When I get into more new issues or want to explore alternate routes, I start researching.There are times when I want to explore what would happen if I took a common treatment protocol in one area and applied it to another – for example, taking the surgical brushing of the Wilibarger protocols of sensory integration, and determining whether it would be a feasible or appropriate treatment for the peripheral neuropathy….hard to know in cases like that. I definitely never experiment on my pts in harmful ways.

Anita also commented that when I blog I often do not act as if I have solid evidence-based foundations to draw from, and am rather just experimenting. She suggested I approach blogging in a more professional manner in regards to presenting questions about interventions.

When it comes to my blogging as a new practitioner, I do tend to have a very student-like approach of trying to “learn out loud', pondering my options, looking through my books, asking questions of others. I do tend to be very informal in my presentation, and I guess it can appear that OT is an easy/simple profession where we just use common sense. It's not my intention to make it sound like OT is not a skilled profession (you have to have at least a Master's degree now) – but it is my intention to make OT seem like a possible and fascinating career for perspective OTs. I'm not always so great (okay, NEVER great) about using a lot of professional terminology and acting very professional in my blogging presentations.

I very much like the idea of performing evidence-based research then coming on here and asking for more specific thoughts from other therapists, but realistically it's unlikely. When I do have specific questions of practitioners, I tend to use the OT Connections blog which i know is read almost exclusively by therapists. I tend to use this blog for getting out my jumbled thoughts and for giving the general public an idea of what sorts of things OT might see – it's less for other OTs than for prospective OTs or OT students. I guess some could argue I do the profession injustice/harm by my haphazard blogging as an occupational therapist, but based on the e-mails/comments I've received over the last few years, I've helped many people with making their final decisions to enter the profession or not, and/or to help them determine whether it's potentially a pathway to follow.Β 

I do believe overall it's important to aim for evidence-based practice – evidence of the highest power when possible, such as meta-analysis and systematic review and not just case studies. When I have the time and energy or need to research myself, I do. I also do believe in the anecdotal evidence of more experienced therapists who have used interventions with great success – in those cases there probably is evidence to back up the interventions that I just haven't yet taken the time to research. When I have specific questions I tend to ask on OT Connections, and when I am just sharing my thoughts and letting them flow out my fingers, I tend to come here. If some OTs read this blog and are horrified at my informality and how it may appear that I'm not really sure of what I am doing, then I am sorry because it's not my intention to appear clueless – just learning, the same as I did when I was a student. Even as a new practitioner, I don't see a reason to blog differently than I did as a student, as the learning process is the same – it's just that how I use the information is different as it will be applied to real clients.

So in conclusion I appreciated Anita's comment (which can be found on the post 2 below on the pediatric SI post), and also appreciated Donna's comment on criticism being necessary for growth (see one post below). I'm going to try harder to not sound quite so hesitant or questioning when blogging, and to possibly take her advice and occasionally do my research then ask specific questions. But I'm also still going to write my crazy jumbled rambling posts where I'm pondering what to do wi
th clients – but may try to be better about clarifying I do know my basic practice standards/interventions, and am just trying to decide how to best apply them.

Some days I cringe regarding my blogging jumbles, other days I am proud of them. I do occasionally get critical comments that I can grow from, and then I get a lot of comments that make me happy regarding people realizing how much they love the profession of OT after following my blogs. I'm Facebook friends with several now-OT students who I first met as prospective students through this blog. I love watching their journey, and I love introducing people to OT, and I still need to work on increasing professionalism, but I'm always going to be crazy as well. πŸ™‚ I may not be a very experienced occupational therapist, and I sometimes have fewer local resources than I'd like, but overall I have great relationships with my patients and I work INCREDIBLY HARD to do research and read and prepare for my clients so that they get the best possible treatment.

I got a text the other day from a friend who reads my blog who said he would be horrified if I did in fact use proper grammar in a blog post (like I threatened in this previous post), so hopefully he won't have a heart attack. Not used to GRAMMAR! I'm a txter! Srsly. Anyway – enough being serious….Anita, hope I addressed your comments….I'm going to try to be better, but probably not as good as you hope, as if I have to start behaving myself, it will take too long to write up! Haha.

Now it's time to go cuddle with my hideously ugly cat Lester! I gave him a partial haircut today, it's very ripply. Maybe I'll write again tomorrow with new thoughts on things (I want to do some more research on hand and trunk dysfunction from a hand dysfunction book I found, plus I found an OT goals book that had great goals in it I want to use for pediatric pts!)

Category: Occupational Therapy | Comments: 7

21 May 2010

Critical comments…ouchful yet necessary on my OT journey!!

Part of the fun of having a blog is all the sweet comments. Part of the yuckiness is the critical comments – some deserved, some not. I choose whether to allow comments and sometimes its tempting to not allow people to see the ones criticizing me, but I also think it's really important to grow from the criticism and share the struggle/journey with readers.

Β In this case, one of my blog readers Anita wrote a very thoughtful comment on a recent post criticizing some of the way I present information and it was very valid, although for some of it I do have legitimate reasons and/or things get misunderstood, I think……

I reallllly want to write a long blog post explaining but as it is I'm getting ready for work so no time. But this weekend, get prepared for an evidence based practice vs anecdotal vs experience vs student/practitioner vs blog, kinda post! Who knows, I may actually use proper grammar, so get excited. So go read her comment, think about it, and come back soon for a discussion. If you do agree with Anita and want to join on the criticism bandwagon, please maybe wait until my next post, as if I get a whole ton of posts telling me I suck I'm going to be really sad! Not that Anita said I suck and she also said I didn't have to post it – I REALLY appreciate her comments so I can think about it and grow.

Now I better get to work!!

Category: Occupational Therapy | Comments: 2

20 May 2010

Pediatric day/SI day for OT!

I was looking at how to make homemade weighted blankets and they were a lot of work. Really only worth it if you love to sew/have lots of patience, and also don't have a lot of money. Weighted blankets provide firm deep pressure that is very calming to most hyperactive children and really most people in general. Think about the lead apron they have you wear at the dentist office and how nice that feels – its for the shield and not the pressure, but when I am having dental procedures done I request they leave the lead apron on the entire time.

I was researching weighted vests today as someone inquired at the clinic about them and they are all so expensive from catalogs. I was looking at Abilitations, Southpaw, Fun and Function, Sammons and Preston, etc. It occurred to me that maybe a walking vest would work just as well – you know, the 10 pound or more vests that people wear while walking to enhance their workout. Anybody tried a walking vest for SI purposes?

Today I prepared a trampoline, tunnel, peanut ball, and host of other items in preparation for a child with ADHD and other similar problems (new phrase I learned today: severe axial hypotonicity, often associated with mitochondrial disorders). Of course the child didn't come – that's what happens when you prepare a lot. Oh well, I'll be ready next week. πŸ™‚

I also pondered how to reduce severe pain after burn (meaning beyond the stage it should be hurting that badly anymore) – I am going to try a TENS unit on the forearm in the acupuncture points of Li3 and Li10 I think it is?? to see if that helps during the actual session. I wrote a burn therapist with some questions regarding severe pain, webspace contractures, etc. I also worked a lot on understanding the Peabody and think I'm pretty close to ready! I understand the basal and ceiling levels and how to calculate ages etc, entry points, now just need to study the instructions on what to say, etc.

I'm trying to think of what else I learned today. I did stare longingly at some “fish sticks” or long chopstick like devices that are great for kids to use like tweezers to pick up items. Speaking of which, my PT partner told me of something her son had to do as a pre-writing skill, which is to use large push pins and use them to trace outlines of objects on a buletin board….ie a simply shaped animal is outlined with many pushpins so the kid has to grab the pushpin and push it in, many times over. Great prewriting muscle work up.

Tme to go shower! Time flies!

Category: Occupational Therapy | Comments: 2

19 May 2010

OT trying to eat healthy, lol

I haven't written on here much this past week. Seems like I stay busy whether I have lots of patients or not. There is just SO MUCH LEARNING and RESEARCH! There will never be enough hours in the day to tackle all the things I want to learn about. And more importantly, retain what I learn….

Lately my week-day life revolves around work, working out, and eating fresh and healthy as much as possible, so a lot of time researching food stuff. Hardcore. Spent like an hour looking at the raw food movement today. Depending on the day also some OT research as well in prep for next day. Weekends I stay out of town usually, getting away from work seeing as how I live on my work campus, haha.

So today…
I started outpatient on campus and had a 9am, 10am, 11am, treatments, all of which lasted full hour with total one on one attention as I still can't seem to let go of my patients, haha, and noon eval….then I was supposed to be inpatient by 1pm but was 15 minutes late for that….oopsies. Luckily inpatient didn't need me to treat much, just one patient, then supervise a student temporarily, then I went back to OP to write up the IP note as well as all the other OP notes…still need to finish the eval. It's orthopedic so it is a challenge for me, I'm more used to neuro!

After work I came home to chill out with my cat and play online and read about raw food (reading blogs is relaxing to me, nothing intense)….worked out at the gym then took a walk…talked to a friend…watched Glee with interns…home to shower/prep for next day. Dinner/dessert was something I'm proud of, are you ready? I never used to eat this kind of stuff….all of this stuff was natural ingredients, minimally processed, that I put together myself.

1. Spinach salad with Belle Chevre goat cheese, avocado, a dollop of hummus, with a combination of roasted zucchini, mushrooms, orange bell pepper, onion and weird curlique peppers…(last night's also had kumquat but I ran out, I love those things!!)
2. Sweet potato fries with nut butter coating
3. Frozen banana with cocoa/agave nectar/cashew butter on it.

So normally I don't randomly talk on my OT blog too much about random topics but I wanted to share today as the healthy food crap is becoming a big part of my life/attention these days, still got a ways to go. I try to NOT spend too much time on OT outside of work or it would drive me insane/burn me out quickly.

Today I saw a PT working on standing tolerance I guess, while having pt work on Mod-Podgeing something, I am sure she got the stuff from rec therapy…I was jealous at the idea! I really get stuck sometimes on inpatient ideas (ie how to be occupation based) when it comes to people who need basic strengthening….I guess I could try to avoid dumbell and machines and stick to laundry, making bed, etc, but that's not always feasible from a time frame, cognition, language barrier, kind of perspective.

BLAH. it's almost midnight and I should not still be online. Lester is snorkeling next to me, what a little dork face. πŸ™‚Β  It's time for people to start taking boards and I'm getting more questions on that so I guess one of my next posts better be about boards!!

Okay Lester just got into my arms making it hard to type, I think it's the sign I needed that it's bedtime seeing as how the temporal cue was clearly not strong enough. I needed a feline tactile cue as well. :0

If any of you OT related peeps out there – no matter how far removed – have some thoughts they want to share on OT, let me know so I can post it!

Loooooooooooooooove, in a like kinda way, so really just Liiiiike, Karen

Category: Occupational Therapy | Comments: none

10 May 2010

Lester's back, wheelchair basketball done, OT coming up for the week, etc

Strokes, paraplegia, peripheral neuropathy, accidents leading to brain injuries, and pediatric clients with sensory issues, CP, ADHD, etc are the bulk of my caseload right now.

I just learned about Cisplatin-induced peripheral neuropathy and how it can start causing symptoms months after treatment stops, and how severe sensory ataxia and pseudoathetosis are frequently seen with this diagnosis. Pseudoathetosis meaning you may see movements of the fingers resembling athetosis and it’s because of damage to the proprioceptive pathway. People with this issue will have a positive Romberg’s sign, meaning that if they put their feet directly together while standing and close their eyes, they lose their balance instantly. Very interesting to me.

Also learning about brain injury and how it can “jog” the cranial nerves and cause vision, hearing, olfactory senses, etc, to go awry.

Also continuously learning more about sensory issues – sensory modulation, sensory registration, etc. Was re-reading Greenspan’s famous book about encouraging growth in kids with special needs and the need for closing “circles of communication” this weekend, ie not just giving your kid what they want right away but rather playing gently dumb to draw out communication. They bang on the fridge and you know they want juice? Play dumber than usual, gently. Ask if they want milk. Ask if they want something else. Draw it out a few times, not to the point of INSANE temper tantrum but enough to frustrate them enough that they communicate more than they would have you just gotten it for them. Then reinforce it. Lots of great idea in Greenspan’s book. I read that he just died, that made me sad. I consider his book one of my OT bibles.

This weekend: Germany just barely beat USA In an exciting world championship game of women’s wheelchair basketball. Saturday evening was a party at my friend’s house and she and her husband are AMAZING cooks – he smoked pork and turkey and chicken and corn on the cob, she made an amazing four layer Paula Deen chocolate mousse cake + pasta salad etc. It was my first gluten challenge in over a month and it went surprisingly well. I think maybe I’m more sensitive to carbs and processed foods and sugars than I am necessarily to just gluten, but I’m still going to try and stay predominantly gluten free + processed food free. with occasional splurges. Today my friend and I went on a hike in the forest trails surrounding the Institute here – I knew VAGUELY how to get to a waterfall but wasn’t positive. A few turns and mistakes and ponderances here and there and we finally ended up at the waterfall, it was nice and beautiful and I took pics to come later maybe. We got semi lost coming back too – never off a marked trail but lost in the sense of which trail to get back home. We eventually figured it out and so the roughly 1 hour trip took us more like 3ish….when we were on the final part back to my house which is PAVED, after several hours of carefully navigating, I guess I stopped being careful since it was familar ground again, and I slipped off the paved part with my ankle into the dirt part and kind of sprained it. I had to sit down on the path, I couldn’t walk on it, it was hurting. My friend is a girl scout and so she cracked me up with pouring out the ice in the water bottle and putting it into the plastic bag we had the bottles in, to put on my ankle and elevate for a few mins. When I could walk again we finished getting home, I felt so sheepish!! It was fine a while but now it’s a little swollen and I’m hobbling. Following the RICE principles + drugs. When I got my drugs, I had to give my cat some treats because when he hears the bottles rattling he is like a little junkie and his ears perk up. He thinks bottles rattling = treats. Yep I have my adorable special needs kitty back for about a month. I love me some Lester. πŸ™‚ He snores like a truck driver. Okay that was way off topic.

I’m just procrastinating. I really need to shower and go to bed.

Oh, this Friday I’m taking an OT shoulder course through Summit continuing ed I think! Yay! Well boo since I’m not a fan of shlders, but yay because I need the training.

Category: Occupational Therapy | Comments: 2

6 May 2010

OT filled life

My blog reader/friend Ananannanifhaihadiaiaiaiai ( looong name) just got into OT school!!!!!!! YAY!!!!!!!!!!!!!!!!!

Such an exciting journey to begin! Hard work but if you're passionate, usually pretty fun.

I have a blog reader/FB friend named Wendy who is constantly posting OT school statuses and I love reading them. I get the impression she is busy and at times overwhelmed, but overall still loving it. πŸ™‚

I was talking to a dude in the gym today about OT and he was saying how he wished he had found a profession he loved.

I need to go prep for peripheral neuropathy, 2 strokes, and paraplegia tomorrow! Yep I still do a lot of prep work and research. I wish I could remember all the stuff I learn.

And I found a few more pieces of the Peabody today. Man, it's all over the place.

I just got back from a work-out/going in and out of the Germany vs Great Britain women's world wheelchair basketball tournament. Germany slammed Great Britain. In the last 5 minutes of games I swear girls fell out of their chairs like 10x. It was intense. Two more days!!

This post could use a dose of Ritalin.

Category: Occupational Therapy | Comments: 2

5 May 2010

Women's World Wheelchair Basketball Championships!!

The women's WORLD wheelchair basketball tournament is here this week in Warm Springs, GA! Tonight at 6pm I watched Germany vs Netherlands and it was strangely reminiscent of the movie Murderball (quadriplegics etc playing rugby!). There was a lot of crashing. I stumbled across one of the players in the weight room tonight, ODDLY ENOUGH AN OCCUPATIONAL THERAPIST FROM CANADA!!!!! What are the odds. She was on the Stairmaster and was able to do 15 minutes (If I do 5 minutes I am elated) and I was like um, you play wheelchair basketball? She explained the point system to me and how she can, for example, do the stair climber and elliptical but can't do impact sports because of so many ACL tears she has had. She is considered high level and is assigned a high point ranking while others with less function are at a lower point ranking and somehow the combination of players on the court has to equal a certain number of points….by the way I've never seen so many young females with prosthetic legs in one place! Lots of chicks rambling around with double prostheses and stuff, and not the fake cosmetic ones but the sticks! One thing i love about this campus is how open and accepting it is to people with disabilities…

The teams here are Great Britain, Canada, Mexico, the Netherlands, USA, Germany…..tomorrow night at 6pm is Mexico vs USA I think. CINCO DE MAYOOOOOO. There are games at 9am, 11am, 2pm, 4pm, and 6pm, between these six world teams, every day meaning today, Weds, Thurs, Fri….

SATURDAY MORNING is the CHAMPIONSHIP game of world women wheelchair basketball πŸ™‚ I am going to try and take my camera tomorrow and take some pics and maybe a little video for you all to see. VERY cool. Inspiring. Man those women had BUFF arms too. In June, we have the men world wheelchair basketball tournaments!!

They all stay at Camp Dream on Lake Dream which is part of our campus here at the Roosevelt Institute. It's a beautiful camp and extremely accessible, as it dates back to when President Franklin Roosevelt had this as a polio haven. For example, in the apartment I live in on campus, my toilet is so high I have to be on tiptoe and I have an arm rail and back rail and the bathroom is wide.

I GOT A CONFIDENTIAL comment on FB regarding my blog post on energy conservation and how it was helpful (confidential in that I won't explain details!) – glad to know it helped even one person.

I really really need to focus on pediatrics this week! More later, I'm sweaty (I just went down to the entrance of campus and back which is hilly and about a mile total) – I've been gluten free and very healthy more or less since Easter now, and my energy level has definitely done a lot better.

After my shower i may go peruse Jan Davis's Facebook page for more treatment tricks for my patients with strokes, and also look at a few books I brought home to look at about development of hand skills etc. I'm a dork….I love OT.

Hey, one of the PTs today took a patient – newly wheelchaired – down to the wheelchair basketball games going on today as part of her treatment session, I thought that was a great inspirational idea. πŸ™‚


Category: Occupational Therapy | Comments: 1

4 May 2010

Great basic stroke videos made by Jan Davis :)

it's midnight but I'm up watching videos made by Jan Davis,
She has some GREAT basic videos up regarding stroke care! Also great ideas about cheap ways to incorporate ADLs and intrumental ADLs into treatment, such as washing/shining a car, shining shoes, squeezing orange juice, making chocolate milk or powdered tea, etc. Really enjoyed what I saw, now to convince her she needs me to have ALL her videos for free so I can review them for you all and tell you guys how much you need to buy them. From what I saw, very impressive. πŸ™‚ Great for a new practitioner like me, I am excited to try some of her ideas.


Category: Occupational Therapy | Comments: 2

2 May 2010

Basic energy conservation for household management

A lot of times OTs see people with disabilities that cause them to fatigue easily. Household management can be very hard! So some tips to help conserve energy or make household cleaning easier. In all cases use your best judgment and safety and get professional assistance as needed.

1) Make your bed while you are still in it. While lying down, pull up all the sheets, then CAREFULLY get out of bed, ie dont let your feet get tangled.

2) Vacuuming: either delegate, have dark carpets that don’t show the dirt as much, or try to find a lightweight propelling vacuum that doesn’t require so much energy on your part. Also try to break it up – maybe vacuum a room a day instead of the entire house.

3) House cleaning in general: Consider getting house cleaned professionally if you can afford it, so that you can save your energy for other things you enjoy more. If not weekly, maybe have them come in once a month for a deep clean so you don’t have to worry so much the rest of the time.

4) Laundry: Front-loading is best, you can have them on blocks or pallets or something to raise their height so you aren’t having to stoop or bend as much (CHECK CODES AND ASK PROFESSIONALS BEFORE YOU DO THIS!! I don’t want to be responsible for anything bad happening!!). This can make a big difference for back pain.

5) Mopping: People like the Swiffer or similar products a lot as it takes away alot of the hardest work. Try to use a grid pattern for more efficient moving around, and to help avoid getting into slippery areas.

6) Dishwasher: Ideally this would be higher, but that’s a hard one to change if it’s not like that to begin with. Consider delegation or unloading/loading over a longer period of time. Hmm, must research this one further for more ideas.

7) Doing dishes manually: Either open the cabinet and prop a foot up on the ledge, or get a small step in front of you, so that one leg is on the step. You can alternate legs and shift weight around to help with back pain.

8) Stovetop cooking: If you’re in a wheelchair, having a tilted mirror over the top of your stove (again, be careful about safety here, have professionals assist) will help you see inside to know whether its boiling, burning, etc.

9) Prioritize, pace, etc…only do what you have to do, and don’t necessarily do it all in one sitting. Think about what you are about to do before you do it to try and decide how to make it easier and less energy consuming for you.

10) Chime in and tell me what you do to conserve energy while managing the household. Besides eating bonbons while watching your children do it all πŸ˜‰

Category: Occupational Therapy | Comments: none

2 May 2010

OT for massage?

i was reading an old ladies home journal – dont laugh, my grandma gets it for me – and there was a blurb on massage in the march 2009 issue and one of the parts was which therapist you should get. It mentioned LMT, OT, PT, and Nurse Massage Therapist. I thought it was kinda bizarre -but cool – she mentioned OT/PT for massage. For OT she mentioned “An OT will occasionally integrate massage into an overall plan for patients they are treating for hand injury or lymphedema”. The writer’s name was Emily Chau.

Category: Occupational Therapy | Comments: 1