I have always liked the idea if the SticKids program for making sensory plans and handouts, and now I actually get to use it! While I do have some issues with how the SticKids software works, I still think they make my job easier with the products I can create for students. Sometimes though, only your own picture will do. (this was an activity we had safety tested in the classroom)
A flashback to begin the story: when I was in high school (not all that long ago) I often had this feeling of being overextended, existing in a state of mild panic at most times. Totally unassigned time (especially that which was not merely procrastination) was rare. Looking back, I was doing A LOT. Probably too much. As a sampling (just of items I can quickly remember, which probably neglects a few) I was involved in 2 sports, at least 5 extracurriculars (not including special events such as talent show) and a part time job while carrying a not-wussy list of classes. I say this not to brag, but to give some perspective of who I was/am. My freshman year of college was completely opposite- I went to class, I goofed off with my friends, I took midday naps, maintained my (very) part time job, and I did not care about much else. This actually had a reverse effect of sometimes making me feel anxious and somewhat empty at times.
I added activities back in and out around the MOT program. I added in AOTA and SOTA my first year in the program and my state association soon after. Responsibilities grew over time. After graduation, I was again pretty inactive at first, which was justified in my mind by moving to a new town, starting a new job, and getting married all in quick succession. But again, I added items back in, even doing extra program development for work in my free time.
So as the years have passed, I have added activities in and out as it suits me. Things tapered off with the move to Baltimore but have increased again now that I've been settled awhile. The most noticeable time commitment is work, which with my poor balancing act between productivity and completing notes has led to me taking work home frequently.Inpatient staff is doing more covering of outpatients while also handling staffing shortages of our own. This has created a baseline level of stress for me, trying to stay on top of the daily grind and being unhappy that I can't seem to squeeze it all into an 8 hour day. I also had a level I student recently, which was fun despite the time involved and seemed to work out even a little better than last time. Just leaving me at a baseline level of exhausted.
In addition to work, I have taken a more active role in my state association. I was 'elected' as VP of Advocacy Relations for MOTA and have been involved in monthly business meetings and bimonthly legislative reviews with our bill review team and our lobbyist. It is a great group of individuals, I feel like we have a diversity on the group that allows to have insight into almost all the issues. It seems that no matter what the bill of concern, if we say, how do the OTs in that field feel, we will always have a representative. Our Lobby Night event went well, we've also had several members present testimony to various committees in support of bills. Legislative activity rolls by quickly, so it's kept me quite busy trying to keep the pace.
My other new OT activity is very concentrated in the amount of effort but will only be officially meeting twice a year. I got to go to California last week for a 2 day NBCOT conference developing simulation questions. First of all, I did not even know that they had added these type of questions to the exam since I took it. It is truly a challenge for your critical thinking skills. Looking at the example I was sent, I wasn't sure that I could take the test, let alone write it. I met a great group of OTs, in and out of academia and in all ranges of practice. Everyone I met was intelligent, friendly, and committed to giving back to the OT community. If it's any consolation to the students out there, as hard as you will work studying to take the exam, others are working just as hard to write it according to the blueprint and keep it fair for entry level OTs. I haven't had the feeling of brain jello for a long time, but we worked to exhaustion on those items.
Last major OT activity is the upcoming AOTA Conference. I am certainly looking forward to it, but I've got enough stuff on my plate that I'm not frequently thinking of it as a 'getaway' or anything like that. I'm excited because it's close enough to drive, and I will get to go with my best friend. I've gone to 3 conferences in past years, but never with a buddy, so that will be nice. I'm trying to cool it on the overscheduled program and see if I can take things at a calmer pace for once. I think that it's interesting in how things are scheduled at the conference. Last year, I felt like there were more NICU courses, so it's hard to tell if that was a passing trend, more people holding out for the NANT conference, or just a random event. This year, I saw 4 interesting acute care courses- all scheduled at the same time, so that's a major bummer. I've noticed that I selected more stroke related courses this year, including one that I tried to attend LAST year and the presenter didn't show up for. I'm disappointed that I didn't do more with my new-found knowledge last year, so I'm going to take off the day after to see if I can synthesize some things before heading right back into the workplace.
With all these new roles and responsibilities, I have had difficulty keeping up with other tasks. My google reader has completely overflowed to something like 500 unread items, I haven't been able to get the state association legislative webpage up and running yet, and I won't even tell you how long this post has been sitting in drafts. I have 2 AJOTs that haven't even been opened, let alone read. I have about 300 pages left in The Count of Monte Cristo and really would like to spend a solitary day finishing that. Concert season is coming up too. Obviously, there will be things that get left behind. I'm trying to prioritize and find a dozen extra hours in the day. Until then, I'm just doing what I can and hopefully will stumble into some occupational balance.
All three of the individuals were over 80 years old, with moderate dementia. They were all admitted with altered mental status caused by pneumonia and concurrent urinary tract infections. They were all living with family members prior to admission, who have each made a goal to keep the individual at home as long as possible. They are each oriented only to person at this time, but recognize their family members who were at bedside. Each person required max assist for bed-chair transfer and max assist for ADLs during OT eval.
Patient “Alan” lives with his also elderly brother. They have been living together almost their entire lives, and until about 5 years ago were very active in several community activities. I think it is fair to say that they are brothers and also best friends. Alan has been declining in recent years however. He is normally able to walk at home but is very unsteady, requires a lot of assist on the steps to the upper floor, and has had multiple falls at home endangering him and his brother. Alan's brother tearfully states that he is unable to help him after falling, which is becoming more frequent. Alan has not been able to leave the house for some time, and his brother is only able to go out for short trips to the grocery store, which he recognizes still poses a safety risk by leaving Alan alone. They have a 2 story home, good DME setup, and some rare support from friends (no remaining family).
Patient “Betty” is a very pleasant woman, always smiling, happy and friendly. Her daughter is a retired pediatric nurse, but is frustrated with herself for not knowing more about geriatric care. She noticed a cough developing earlier in the week but did not expect that illness would cause such a drastic change in her mother's personality and abilities. Normally Betty is able to walk w/o device and perform ADLs with supervision. However, Betty is very afraid of falling in the hospital environment, actually fighting the transfer, and requires max assist of 2 for chair to bed. She is still able to follow 1 step commands as long as they are not about transfers. Betty's daughter is well educated on devices, but has a bad back and cannot lift >10 pounds. Per pt's daughter, Betty did well in rehab previously after a hip replacement.
Patient “Carol” is lethargic and minimally responsive during the evaluation. She responds best to her daughter, and will follow 1 step commands from her. She has severe retropulsion in sitting. I could not transfer her, but her daughter was able to in a less than fully safe method. Daughter reports that there are multiple family members that live in the home with Carol, and others that assist in rotating care duties. They have good DME setup at home and 24 hour assist with various caregivers. Carol clearly responds best to her family members over the staff at the hospital.
Who gets to go where? There are few hard and fast rules in discharge planning. Because OT is committed to being client and family-centered (and because care for a person with moderate dementia requires a high level of commitment from the family), discussions regarding each option were provided to the families of the patients. These are the decisions we made together, though it is certainly possible that other therapists or case managers may have tried to elicit a different response.
Alan was recommended for a trial of inpatient rehabilitation at a subacute level to attempt to progress in ADLs and transfers. The plan was to select a facility that also provides long term care, as Alan's brother could no longer care for him at home. Special consideration was given to make this place close to their home so that Alan's brother could make frequent visits.
Betty was recommended for inpatient rehab at a subacute level at a facility she had been to previously. Betty's daughter would not be able to care for her currently, but was open to the idea of family training and purchase of lifting devices if needed to allow for her to return home after rehab. She also had a good connection with home therapists as well.
Carol was recommended to return home with home health therapy to address safety in transfers and additional adaptive equipment assessment for best safety at home for her and the family. She was unlikely to fare well in any facility cognitively or with physical progress. The family was ready to continue 24 hour assist and try whatever was necessary to provide for Carol.
Discharge planning is not always easy. Therapists, MDs, case managers and the family do not always reach agreement. But this was a situation where even though there were difficult decisions, each family unit got what was best for them, I think.
CDC Health Disparities and Inequalities Report- this lengthy report is broken down into several important subsections, such as access to health insurance, air quality, housing, and preventable hospitalizations. Another tool that could be very useful if you're looking for materials to justify OT services for an area.
As an occupational therapist, I enjoy your products and have been excited about their potential applications for rehabilitation. I own a system myself, and while experimenting with it, noticed some features that could easily be improved to better suit the Wii's use in rehab. WiiFit, WiiPlay, and WiiSports are the games considered for this review.
Therapists love being able to control and alter activities and the environment to provide the "just-right" challenge for their clients. Wii games would be much more usable by therapists if there was more input to grade the activities. This could be automatic grading within the game, where it would adapt to the skill level of the user, or ability to manually adjust sensitivity, speed, and degree of difficulty for games. Additionally, having either a "low vision/contrast enhanced" option for games or ability to decrease some of the visual stimulation would often be helpful.
In general, it would be more efficient to be able to set up multiple games in Sports or WiiFit prior to a session. It would be best if new profiles and avatars were not required to setup and save routines, since this takes up extra valuable therapy time and is a potential privacy violation. Being able to set a timer for specific games, such as making a 5 minute boxing session, would also assist in achieving aerobic status during activity.
I love the balance board for WiiFit. A user can get an objective report of balance that can be reviewed from session to session, and the devices marketed to rehab professionals for this are MUCH more expensive than a Wii system. But a bariatric board would be very beneficial for those who practice with adults in the hospital or SNF. Also, an optional bar to provide support while standing would be appreciated by many adults while they are trying to feel secure in standing. I don't know if the hardware could be altered to allow for better tests of sitting balance while the board was supported on an adjustable mat, but this is a common intervention for a neurological population who would likely appreciate being able to participate in the games as if they were standing.
In closing, I appreciate that these products have great applicaiton to rehabilitation. The system has surely benefitted from all the positive press regarding its use for therapy and activity for people with disabilities. There are endless possibilities for improvement into the therapy arena, and I would encourage you to partner with some pediatric and geriatric therapy practitioners to maximize your products' usefulness and appeal. And given that the Kinect is getting a lot of attention but you could provide a more affordable solution for clinics everywhere, I think it would be worth your time.
Thank you and I hope you will show a renewed interest in collaboration with rehabilitation services in the future.
For this review, I looked at 3 systematic reviews and 1 prospective uncontrolled intervention that was not included in the prior reviews. Of the reviews, one was from an OT publication, one from a PT publication, and one from a physiatry publication, so I feel that all relevant parties were represented. I focused only on articles that emphasized adults, and preferably the lower extremity since that was most relevant to my case. Annotated bibliography at bottom of page.
WHAT IS THE RATIONALE FOR SERIAL CASTING?
There are multiple theories for the effectiveness of serial casting and as per Lannin, Novak & Cusick, there is no strong evidence to state clearly which is the correct reasoning. (Categories by Lannin, Novak & Cusick though 1 or more are expressed in each article, further references as noted)
1. Neurophysiological (includes NDT)- casting prevents changes in muscle length, which eliminates excitatory input of muscle spindles and decreases spasticity. The concepts of neutral warmth, proprioceptive input to the limb, and even/constant pressure are also considered to play a part (Saracco Preissner). Per Mortenson & Eng, little evidence exists for the concept of neutral warmth providing the decreased spasticity.
2. Biomechanical- a low-load, long-duration stretch can prevent or correct contractures. By stretching, the Golgi Tendon Organs are stimulated, which stimulate the Ib afferent fibers and then inhibit the alpha motor neurons (Mortenson & Eng).
3. Motor Learning- support proximal joints until control is gained distally. Per Mortenson & Eng, no evidence to support this. I question how this can be applied to LE casts, since they are predominantly applied to the ankle and toe ROM is not a desired outcome. Also, though I have never casted a knee, it seems that if you were working off of this principle to give support proximally until distal control is given, then it might be easier to apply a bledsoe brace locked in position than a serial cast.
WHAT OUTCOMES ARE EXPECTED TO IMPROVE WITH SERIAL CASTING?
Mortenson & Eng outlined these well as: reducing abnormal tone, increasing ROM/reducing contracture (usually PROM is what is measured), and function. Measurement of these effects has been inconsistent across studies. Some studies give a very subjective therapist rating of tone, others use tools such as the Ashworth Scale. ROM was typically measured using standard goniometry, though Mortenson & Eng bemoaned the reliability of ankle goniometry. Mortenson & Eng also disucssed that increases in ROM do not necessarily correlate with increases in function, similarly, Saracco Preissner mentioned that abnormal tone did not necessarily indicate lack of function. "Function" is defined very loosely between studies and various outcome measures are used. Singer et al used the Transfer Dependency Scale, and other studies referenced the FIM. From my own limited experience in research, it would make sense that you would need an adequately sensitive measure and control for confounding factors (concurrent therapy, practice effect, time) to truly indicate whether improvement would be due to casting. I can think of several appropriate measures for UE functional improvement but don't know what has been researched in this direction arleady.
WHAT IS THE ACCEPTED PROTOCOL FOR SERIAL CASTING?
As indicated in the systematic review articles, there is no consistent protocol for serial casting. Lannin, Novak & Cusick identifies a key problem in a consistent protocol- namely that your background rationale will affect your decisions regarding casting time and limb positions. This article listed known indicators and contraindications to tx along with the level of evidence for each, however, a confounding variable to this information is that some factors that were exclusion criteria for some studies were inclusion criteria for others. Given the wide variability, comparison of RCTs was unable to be performed in this review.
Timing is a decision that has wide variability in each study. Saracco Preissner states (but does not reference) that there is no indication how long after injury casting is effective or when a person is too far removed from injury to benefit. It is stated that "most" advocate casting sooner for increased effectiveness, but again this is unreferenced. Length of time wearing the cast was highly variable as well, with the most relevant results being from a study by Pohl in 2002 (referenced in the following section) that showed no difference in results when casts were worn 1-4 days vs 5-7 days.
Protocol was specified for the Singer et al study, and stated to be "standard guideline." Briefly, casts were applied by 2 therapists w/ pt. in prone and knee flexed to 90* after gel pads were applied to bony prominences at risk for breakdown. They were able to insert a custom molded support for metatarsals if clawing of the toes was present. Casting was postponed if pressure areas or skin breakdown was present. Casts were discontinued when no change in PROM was seen over 3 casts, skin breakdown present, or if there was a need to emphasize other treatment prior to discharge.
INDIVIDUAL STUDIES AND RESULTS OF NOTE:
*Singer et al performed a prospective uncontrolled intervention with 16 adults after aquired brain injury. Statistically significant increases in PROM were noted, and 13/16 improved their transfer ability. However, transfer skills were measured by "4 randomly selected scores" not admission/discharge scores, and could have been affected by concurrent cognitive increases. Of note, 3/4 patients who had limited response had brainstem dysfunction and decerebrate positioning. I believe it is clinically accepted that decerebrate and decorticate positioning is an indicator of poor prognosis medically and with therapy, but I can understand including these patients in this study to just add to that evidence. The authors suggested that the severity of injury rather than the severity of the ankle deformity was the more important predictor of success.
(The following articles were referenced in one or more of the main articles, but I did not follow up to read the full article. Slightly irresponsible, I know, so just take this info at that level)
*Pohl 2002- this study compared 2 groups who were casted for different lengths of time between cast changes- 1-4 days vs 5-7 days. All groups showed an increase in PROM with no difference between groups. Gains were maintained 1 month after cast removal. The Lannin, Novak & Cusick review stated that since there were slightly fewer complications with the group who got casts changed more frequently, there might be an advantage to more frequent changes, however, cost does not appear to have been considered as a factor.
*Mosley 2006- this was an RCT focused on adults with serial elbow casts vs PROM for 1 hr/day. The casting group decreased contracture 22* compared to stretchers when casts were removed, but this decreased to 11* the next day, and the improved effect had almost disappeared by 42 days.
*Booth 1983- This was a retrospective study of 39 patients who had casts s/p head injury. 37% showed and increase in ROM and decreased tone. They observed that pts with brainstem lesions got their casts longer out from injury and took longer to show progress than those who had cortical lesions. Per this study, traditional treatments (PROM, splinting, weight bearing, and PAMs) did not do enough to make an impact on spasticity compared to casting. I'm not sure why this study was given such prominence in the Saracco Preissner article since it was a retrospective study, a bit dated at this time, and its rather unclear how they drew such sweeping consclusions, but again, I did not review the actual article
*Hill 1994- a double-crossover design between traditional tx (PROM, static stretching, splinting) and casting. Improvements were seen for ROM in 14/15 participants and spasticity in 11/15. Stated conclusion is that casting was more effective than the traditional tx, but the gains did not translate into functional gains.
WHAT ARE THE OVERALL RECOMMENDATIONS FOR SERIAL CASTING?
Per Lannin, Novak & Cusick, "There is insufficient evidence to either support or refute the effectiveness of upper limb casting ... There is no evidence of long-term benefits or long-term adverse effects." But this article also stated that there is Level Ib evidence that casting an adult's elbow s/p brain injury increases available extension 1 day after cast removal.
Per Sarraco, since immobilization (such as with spasticity) can cause physiological changes that would impair ADLs, and these changes are reversible, we should treat as able for spasticity. Serial casting has shown some effectiveness in improving ROM and spasticity.
Mortenson & Eng issued "grade" ratings for practice, which I am not familiar with. They say that there are inconsistent measures of "function," so no recommendation can be made on that front. A "Grade C" rating is given to using casts to reduce spasticity secondary to decreased rigor in measurement tools. A "Grade B" rating is given to using casting to improve or prevent loss of PROM, and they state that this is the only outcome with enough evidence to be considered a "best practice." Their studies showed gains of 10.4-26* improvement in ankle ROM, which is statistically significant, however they cautioned that ankle goniometry is not always reliable.
WHAT SHOULD BE ADDRESSED IN FUTURE RESEARCH RELATED TO SERIAL CASTING?
As with nearly all therapy research, there are many questions that need to be addressed. A summary from all articles would include the following, but it is not an exhaustive list:
How does casting work? Is it a biomechanical effect, neurological effect, or both?
What is the best protocol for serial casting? Included in this would be inclusion criteria, positioning of casts, length of time worn, concurrent therapy, post-casting program (including splints and exercises).
What is the comparison to other treatments or lack thereof (especially no stretching)?
How long are gains maintained?
How do improvements after casting translate into function? What specific functinoal gains are seen? Are these gains cost effective and best practice?
Randomized controlled trials comparing the above are also needed.
FULL DISCLOSURE: I am not a professor or professional researcher and do not claim that this is an exhaustive review of the literature surrounding this topic, but a review that I undertook relevant to a specific case. I am not an expert clinician. I do not intend to diminish the efforts or quality of research produced by any of the referenced articles. I would encourage you to do your own review and get necessary training prior to performing this intervention, which may not constitute entry-level practice for all practitioners. Please feel free to comment on additonal relevant research.
Singer, B. J., Jegasothy, G. M., Singer, K. P., & Allison, G. T. (2003). Evaluation of Serial Casting to Correct Equinovarus Deformity of the Ankle After Acquired Brain Injury in Adults. Archives of Physical Medicine and Rehabilitation, 84, 483-491.
A single study in Australia looking specifically at casted ankles in an adult brain injury unit.
Lannin, N. A., Novak, I., & Cusick, C. (2007). A systematic review of upper extremity casting for children and adults with central nervous system motor disorders. Clincal Rehabilitation, 21, 963-976.
A review focusing on UE casts but somewhat confounding as it includes many studies on children with CP
Mortenson, P. A. & Eng, J. J. (2003). The use of casts in the management of joint mobility and hypertonia following brain injury in adults: a systematic review. Physical Therapy, 83(7), 648-658.
Looks at adults after TBI and CVA only but includes studies involving wrist and elbow casting as well.
Preissner, K. S. (2001). The effecs of serial casting on spasticity: a literature review. Occupational Therapy in Health Care, 14(2), 99-106.
This review focuses mainly on management of spasticity, less on ROM gains.