Exodus

There have been so many farewells here lately, and it's quite frustrating!

In the space of ~1-2 months, we are losing a lot of people at work. One of the front office staffers, 3 PTs (who all sit in my cubicle row) and likely 3 great rehab techs. Also, one girl from my row is likely to go out on maternity leave any day now. I don't want it to get quiet and lonely in my area, or lose contact with good friends. And now, I'm seeing goodbyes in the blogosphere. One of the leaders from Hospital Impact is onto other projects, though the blog will continue. OT Advocacy made what was to me a shocking announcement of retirement, after a relatively short but productive run and a feature in OT Practice. And debate continues for the future of OT Students... though understandable, I would hate to lose access to the outlook of a cherished virtual friend.

And another thing! What happened to our OT Blog Carnival?! 2-3 issues and then poof?

I don't really think of fall as a time for changes... more as a time to hunker down and stay the course. Plus, I'm usually too distracted by football season to want to shake up life in any other way. Maybe some new and interesting things will pop up, but it's no fun to be saying goodbye all the time.

My First WiiHab

So our hospital has a Wii (actually 2, one lives solely in the burn unit) which I have thought was interesting since I didn't know how well it could be used in acute care. I missed the inservice but figured I could go ahead with my session since I have a Wii at home and am somewhat familiar with the games.

The way I see it, for the Wii to be used in acute care, you have to have a client who is sticking around for a few days, has the required cognitive capabilities to understand the system, and has deficits that can be addressed using the system. We currently have 3 games- the basic sports game, Wii Play, and Wii Fit. The first client that I had who would have been appropriate (since the program starting) was a cute little lady who was extrememly active prior to her stroke- walking 3 miles a day. Her only deficits were upper-level balance issues, but I was off after her evaluation so I didn't get to implement that plan. But I was able to use the Wii with another lady on the stroke floor. Sorry the case study isn't more in-depth, but several weeks have passed now...

Ms Z was getting an extensive neuro workup for several symptoms, including visual dysfunctions, L-sided paralysis, mental status changes, seizures. Original possible diagnoses were PRES vs an unlikely conversion disorder. Her visual problems were very odd, starting out where she could only see shadows, then she could identify broad swaths of color and light/dark, to where her acuity was markedly improved at which time the optometrist diagnosed a L hemianopsia. She also had a L hemiparesis. As our sessions progressed, she regained hand movement progressing to intermittant elbow and shoulder control. She also progressed to verbal cues only for supine to sit, and was then able to transfer to a chair with min assist of 2, needing her L knee blocked. Once we could transfer her to an appropriate chair, she could come down to our gym to use the Wii.

I thought she would be a good Wii candidate since her controlled ROM of the LUE was intermittant. I hoped that given a distracting BUE task that the control might become more consistent. This was my plan on Friday... when I came in on Monday we had to cut the session short due to LP, and then on Tuesday Ms Z had full ROM of her LUE! Not from anything I did, but just part of the strange waxing and waning of symptoms. She then had some RUE control deficits. I decided that since her coordination was still off that the Wii session could continue. We worked on Wii boxing to address standing balance, endurance, and UE ROM control. Our first day, Ms Z was unable to tolerate a full "round" vs the computer opponent (3 minutes) while standing. However, she persevered while seated and did complete 2 bouts. Our second day, she was able to complete a full bout while standing (10 minutes in parallel bars with contact guard support from PT). We then added in additional challenges, using different punches (inspired by TurboJam), and trying to better facilitate weight shifting both front-back and right-left.

I was happy with how the boxing activity worked out... my next session was going to be more visually-spatial based and require more refined isometric control of the shoulder, but Ms Z was discharged that night to rehab. Even though her initial reaction to the wii was "this doesn't apply to me because I do not play sports," she did get very active and involved in the activity, progressing on performance components she needed for independence. The novelty of the activity was also good since she was getting frustrated with an extended hospital stay. It was a worthwhile therapy experience for both of us.

I feel that I learned a lot from these sessions, and I went home and reevaluated my wii games (sports and play... don't have a wii fit). That brought me to a gigantic list of things that could be better about the games from a therapy perspective. It is a LONG list, I will share it hopefully this week and would love to hear others' thoughts on using the Wii in rehab. For more thoughts on the subject, you can check out a blog dedicated to WiiHab here.

Thoughts Spurred by Malcolm Gladwell

At the suggestion of my dad, I read Malcolm Gladwell's books over the summer, and have some OT-related thoughts from them.

As a disclaimer, before someone jumps in to attack my lack of critical reading skills, I am well aware that none of the concepts in Gladwell's books are his own research, but there is a limit to how many individual research articles any one person is going to read in a given lifetime. So these are distilled stories with ready-made inferences, but interesting and thought provoking nonetheless. Here are some OT-related thoughts from the books The Tipping Point (TP), Blink (B), and Outliers (O).

Reading the Face (B 197) The final chapter of Blink discusses the work of Paul Ekman and ability to read emotions through expressions and micro-expressions. While I think it would be interesting to see when people are lying, frustrated, or scared, I think I would have better use to just be more aware of my own expressions and the message that I am subconsciously sending.

Fusiform vs Temporal gyrus (B 219)- After discussing visual tracking during a movie between persons w/ and w/o autism, he touches on a study indicating that most people picture and view faces using the fusiform gyrus. However, an autistic individual uses the inferior temporal gyrus to view faces, which is the same location that most people use only for objects. I wasn't really aware of that specific neurological difference but think that it would make an interesting principle to guide treatment.

10,000 hour rule (O 35)- This concept is presented as one of the precursors to mis-named overnight success. Several examples were given of people who started working in an unpopular field and had logged 10,000 hours of practice by the time that the field was ready for rapid growth. This number is referred to as the number of hours of practice needed to become an expert in the field. This would be a little over 5 years of full time work. How many OTs work their first 5 years uninterrupted, let alone in the same practice area? Just a thought. Also makes the hours needed for board and specialty certification seem almost doable.

Culture of Honor (O 161)- There was a mention of how a cultural importance of honor in highland areas has continued into the Appalachian region, giving some reasoning behind the number of feuds in the past century. This concept is also of high importance to many urban residents, especially in places where gang culture is rampant. I just thought it was an important tip to promote developing rapport with your clients and deferring to be more formal and respectful until you have a well developed relationship with your client and can be more informal.

Parenting styles (O 104)- A study is referenced that talks about 2 parenting styles: "concerted cultivation" vs "accomplishment of natural growth." I don't have full definitions for these, but they are associated with high and low SES families, respectively. The former is where the parent would encourage social skills and talent development through modeling and empowering the child. This was associated with higher confidence and better interactions with adults. The latter is a style that is more passive, leaving some of the development left up to teachers, coaches, therapists, etc. I definitely saw both types of parents when I was working with peds. In my experience, the latter style makes it hard to have home program carryover.

Levels of mitigation in speech (O 194)- The levels are restated here, and were discussed in the book in relation to studies about plane crashes. The author of that link also references an article from a person in a different power-index culture, which was interesting. I would be very interested to see a study on what terminology was used in ERs for trauma or in ICUs in critical moments between the various staff members. I may write up my observations on the language that is used at the interdisciplinary care meetings. But as far as client-therapist interactions, I think you have to balance your styles based on the client and family cultural and learning preferences. As an OT I want to give options, not take them away, however as safety concerns become larger, I do get more commanding.

Transactive Memory (TP 187) I scoured my in-depth books on cognition and found no mention of this concept, however, there is some research on this concept in the fields of relationship studies and also in computer science. This is where a couple or a group have certain tacitly designated tasks or things to remember. I never know where the various charger cords or electronic devices are, but/because my husband always does. This can happen sometimes in workplaces as well, where you have specialists and go-to guys/gals for specific tasks or theories. I think this also accounts for some of the memory impairment that I see in hospital patients as well. If you're used to sharing memory tasks it's not the same when you're out of your environment and out of touch with those you are close to.

The Tipping Point (TP 9)- Obviously this is the main idea of the first book, the idea that at some point change becomes unstoppable due to the momentous force behind it. My question here is- when is OT going to reach a tipping point? When are we going to be highly demanded in multiple fields? When are we going to be the go-to professionals for daily living, low vision, home mods, driving rehab, etc etc ad nauseum? When are we going to be respected by legislation, hospital policies, and other professions? I AM READY TO TIP! I know this is implicit in the Centennial Vision, and I would love for us as a profession to tip by that time. So I guess I'm still at the phase of tipping that I am becoming the best OT I can be so that when consumers have my services they come away with a great message about the purpose and power of OT. Just important to try your best every day since you don't know who you encounter that will be talking about you later.

Hope that's enough inspiration to help me get through the week! Anyone else have Gladwell-related thoughts?