Photo Phriday- creative style

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)


Photo Phriday: Mat Man

I love the Handwriting Without Tears products (fortunately my district has plenty) and the concept of Mat Man particularly. I think there is a huge advantage to be gained in spatial awareness, prewriting, and body awareness from teaching Mat Man. There's even a cute online game that even includes the song (requires a free login). I've used the manipulatives and drawing sheets for individuals and groups of preschoolers this fall.

Here's some photo results from kids who used the manipulatives or interactive game first and drew pictures onto frames second. I love the repetition to cement the ideas, and the progressively more empty drawing frames to chain the task.

This drawing is by a child with autism in a 3 year old classroom with just a few prompts for parts. She drew fingers independently. She so often refuses to attempt anything on paper or try anything herself but she loved doing her drawing on her own. I enjoyed the pig nose and muppet eyes, personally.

This one is by a little 4 year old with autism in a special education classroom. He had a couple of cues as well and could write his name on the back too.

This one is by a 5 year old in general education preschool. I only interfered after he drew the first hand. Undoubtedly, this Mat Man will be an excellent piano player.

This one may be my favorite, just because I know the child. He is a 4 year old with autism and severe behavioral issues in a special education class. He loved building the Mat Man and worked really hard to make it match the picture perfectly. And he drew this with only cues for ears. Granted, he has fingers without hands, but I think this is pretty stunning given that he previously would not copy a circle. It was so great to see him calm, happy, and attentive throughout the activity, and he was proud of his work.

I was really pleased with the reception that the Mat Man activity had with the kids, and also with the results. Not everyone had such terrific results, but all these are after one session only, and I think there is great face validity to the concept.


Simulations of Learning Disabilities

It can be very difficult to understand what it's like for a child with a learning disability to participate in classroom activities, especially for a child who can't articulate all they are dealing with. I find it hard sometimes to plan treatments for kids to address some compensation methods or remediation of skills since I am still getting my feet wet. It's also hard to see preschoolers with simultaneous severe physical, visual, and communication impairments as they struggle to pick up on concepts such as identifying themselves, choosing an object, using a switch, etc. Some kids work EXTRA hard to learn, and if you were a good student and good at understanding the system (playing the game, as my Dad said) it's hard to see how something so easy for you can be so hard for someone else. So I encourage you to explore these sites' simulations a bit and try to work through the trials they have set up. Honestly, I could not make it through many of the sections. Just a short exercise to better understand struggling learners- appropriate for teenagers and older.

PBS Site for Misunderstood Minds. Thanks to Teaching Every Student for the link.

Children's Vision Network site for Vision and Reading


Photo Phriday!

So I finally got some pictures off my phone! Here are some OT-related pics that you may find amusing.

It's totally unnecessary for parents to tally scoresheets themselves, but that doesn't mean I don't appreciate it!

Can you tell this backpack belongs to a pediatric OT? This is an awesome dragon puppet that has a multitude of fasteners along his tail. Everyone loves Danny Dragon.

This is a shot of the beading dowel. The little guy who did this had no problem matching colors but was just randomly lucky on getting the right shape (30% or less, all trials. Pretty sure that was the only purple bead too).

This is a picture that the students made after reading "Dog's Colorful Day" where Dog encounters 1 different colored blob during each part of the adventure. Can you tell which child worked on her picture as part of an OT session? And also had a bit of a perseveration problem? lol


Visual Motor Freebie

I found this I Spy sheet on Scribd which can be downloaded for free. Some of the images are a little odd, but whatever. I added a document on Google Docs (here) which has a list of the items in the sheet (notations about which ones look a little odd and might be hard to identify) and has a few searches listed out to better make it into an activity. There's a screen to check the 4 quadrants, a listing of animals, and a few common letters listed out.

Happy visual hunting!


Moving into winter

I'm coming up on my third month of being a school therapist and a homeowner, and had a few other interesting things happen recently. Here's a bit of a recap.

I was feeling very over my head in the past 2 months about the conference presentations I had applied to do. I had my usual procrastination battles and feelings of not being qualified for one reason or another, really kinda getting down about it all. In summary, I was a lot more excited about presenting when I signed up in the spring than when it came time to present in the fall. But things turned around and I think they both went over well. I talked about some options when beginning a pediatric practice in a hospital based on my Baltimore experience getting mentored in the NICU, newborn nursery, pediatrics and antepartum units. I had a crowd of mostly students but there was some interest. I felt kinda old since there were a number of students from my alma mater and I knew none of them, though there was a "small world" I-know-who-you-know moment.

Second presentation was meant to be more of a discussion on social media tools and ethics than an actual presentation. I was expecting 10 or less and I think there were about 30 by the time we ended- it definitely changes the dynamics of your discussion. Based on the audience, we covered things on a much more basic level than I had intended, and it would have been better received with more in-depth time to cover the basics. My favorite tools are in the Google brand of (free) products so if you want to get started in social media and exploring the online world, that's my first suggestion. Get yourself a gmail account and then we'll move from there. And for social media with other OTs, you can't beat OTConnections (also free).<

The final presentation (AOTA '12 !!) is just in the beginning stages right now. I was a little stressed prior to our first discussion (coordinating 5 people across a continent does seem challenging!) but now I think that things will fall into place. I'm excited because we will all get to talk about our specialties and favorite online tools, the "why bother" of social media and what we're passionate about. I also think there will be some good ethical discussions and that is interesting in its own right. We used a Google+ hangout to video chat, which worked really well.

I've been getting used to the school system job, and it has been going pretty well. I have been working primarily with preschoolers, most of whom are in a special education classroom. I feel like things have worked out so well in the past few months. The caseload was very manageable, which was great since I am new to the school system and both IEP and IFSP thinking. I have been privileged to get to spend a lot of time in class with 2 superb special ed teachers who truly love what they do and are excellent at it. I've learned a lot from them and it's been great to be able to push-in for most of those treatments. I'm really going to miss the group of teachers, IAs, and kids that I've gotten so attached to. So I'll be leaving this group and getting older kids with regimented treatment times and all pull outs in the next 2 weeks. I'm trying to build up a good supply of activities for a group that is not so easily entertained by blocks and construction paper.
I hope to get a pinterest account soon to more easily share some of the resources I find- I think that will be a better medium than twitter has been. I love the visuals. (Here are a few cool OT-related pin boards to get you interested if you haven't been over there yet: Funkist, Your therapy source, pediastaff)

So I'll be unpacking and repacking a therapy bag (they gave us rolling duffels, which I think is cool). That means cleaning out the Handwriting Without Tears manipulatives (maybe, have to check ages of kids), the switch toys, the tactile puzzles, the nesting blocks and maybe some of the chewelry. In their place, I can add in some tinier toys for advanced fine and visual motor skills, some things I've made from File Folder Fun, and lots of paper. I'm trying not to freak out about January where there are 3 Mondays without school, the month-ish when I'll be covering 2 caseloads at the same time, or April where there is spring break plus AOTA plus possibly NBCOT. Trying not to freak out, but getting pretty anxious anyway. Change is hard.

I have been using the IPad off and on, we only have 20 apps but I hope to have a review of those soon. I also put some free apps on my Android phone so when I get to do an app entry, I will be able to touch a little on both platforms. There will also be an upcoming entry where I can share some of my phone photos I've taken, mostly of the Mat Men kids have drawn.

We're getting ready for the Maryland legislative session to start again in January, our annual Lobby Night event, and months of hard nosed defense of our scope of practice! It is hard work, but great people on the team, and very worthwhile.

The house has been coming along fairly well. There's been some repair work but it seems mostly under control. My family came out for Thanksgiving and it was nice that the 7 of us didn't have to cram into my Grandmother's 1 bedroom duplex for the first time... maybe ever. Just sent out some cute little holiday cards and hopefully will find the energy to get the tree up today. Wintertime always zaps me a bunch. Been off running since Thanksgiving thanks to a repetitive strain on my IT band that's still aching and I haven't made it back to the pool yet either. Maybe someday I'll find that teleporter or a pause button to get a few extra hours a day, but until then the busy-ness just keeps coming :)



Ben, AKA OTA_Stolinski is the winner of the Dycem giveaway! Congratulations! I see a turtle mat in your future! Email me at otnotes at gmail. I will definitely consider doing more giveaways in the future, (should I have items to do that with) but hopefully there will be more legitimate comments and fewer advertisements for fake universities and/or job search engines.


The Biggest OH NO Moment Yet

Worst moment yet of this job:
We have a high number of kids transitioning out of early intervention and into the IEP system. More than usual. So that has led to tons o' evals, IEPs, and meetings. I've been proud of staying ahead of all that needs done. Monday, I finished up all of the evals and the entirety of the IEPs. And today, at 330pm, I discover everything has been obliterated for 2 IEPs. Completely and utterly gone. And due on Monday.


Tangentially Job-Related Goals

Clearly, with my job in a new field and situation I've never been in before, I have goals. I want to be competent (and if possible, awesome) at what I do. But since there are a whole host of other things going on, here are my goals that are only somewhat related to the job.

  • Learn to Navigate the County: I have never been great at finding my way. GPS was essential in Baltimore since I would likely still be driving around North Street trying to get home. My husband does most of the driving when we're together, so I didn't get a lot of practice. Now we've bought a home in a larger-than-I-thought county and I want to know how to get everywhere. Today I went to the extreme East end, and I will regularly be covering points West and South as well. I want to know short cuts (or at least the basics). Ideally, I will be able to out-navigate my husband. We'll see.
  • Find Awesome Eateries: I still pack my lunch a good bit, or hit the grocery store salad bar. But I want to find cool little unique small business eateries. I want to be a regular at the best dives in the nooks and crannies of town that can provide lunch in 30 minutes or less.
  • Improve Time Management/Job Separation: A major problem at my last job was working extra hours and not being able to "turn off" at the end of the day. A prime factor in our decision to move from Baltimore was to have more family time and take up worthwhile activities during the down time. So this is a crucial personal well being step.
  • Dress Like an Adult: I've worn solely scrubs to work for 4 years. This includes not just cute little outfits, but t-shirts, items scrounged from yard sales, and shirts from my Grammy's own collection. Most people would not consider this wardrobe very fashionable, or even always the right size. Now I wear nice pants and shirts... time to be a grown up and look professional! Also, I get to fix my hair nicely on occasion instead of keeping it pinned back constantly.
  • Find Time for Physical Activity: It's never easy to fit in everything you want to do in a day. So I really want to focus on making time to be active. So far, I've been able to walk to the school closest to my house, and work in some school laps during lunches/breaks. On days that I am at a "campus" or several nearby schools, I hope to be able to walk or bike. Incorporating the activity at work is something I'd like to do, and it demands that I pack efficiently and prepare well for the day, so it's a lot to work on. Ideally, I will also do some things before or after work, but I'm still ironing that out.


The more things change...

So I have been working tonight on an entry about the indecision I have right now about the future and the convoluted OT path I have taken up to now. At one point, it started to seem familiar. I felt as if I had quoted Thomas Merton before, and it turns out, I have, 3 years ago when I was equally wondering what the heck I was going to do with my life. Oh goodness... that's a sign it's time to stop thinking for a little while. :) Sudoku here I come!


Don't forget- World OT Day!

October 27 is World OT Day! Sponsored by WFOT (now on Facebook), it's a great day to proudly raise awareness about the profession. I would rock my Super OT shirt, but I have formal meetings, so I'll wear inner-OT-awesomeness instead. :)

This is the sophomore year for the OT Virtual Exchange and they have once again put together a powerhouse group of speakers for a 24 hour time frame. There is a theme of "Pay It Forward," so you should enjoy the quality talks for free and then share your OT knowledge out in the world as well! Check out the schedule here, and be prepared to tweet using the tag #ot24vx.

Linda from the great blog Daily Living Skills is also running a blog carnival to celebrate! It's been way too long since we had an OT blog carnival, I'm excited to see the entries, and I hope we can keep the energy going.


Our OT Identity

In celebration of World OT Day, we are discussing the Global Identity of Occupational Therapy. It's an interesting topic since there has been a lot of discussion about our national OT identity with the approaching Centennial. I think the best thing that I can share for this topic is my summary of two of the best AOTA sessions from the 2011 conference (and maybe from ever).

Last spring, there were two talks that best fit with the presidential address and stood out as completely awesome. One was "OT Survivor: Protecting Your Turf in a Competitive Healthcare Market" by Pam Toto and the other was "Practicing Authentic OT: Strategies for Becoming a Reflective and Reflexive Practitioner" by Debbie Amini. These ladies are both well recognized in the field. Energy was definitely palpable in both rooms, and I even got to meet (again) Suzanne Peloquin during one session. (If a Slagle lecturer shows up in your room- you know the topic is superb!) By discussing what was reviewed in these sessions, I think we can get great input into our OT Identity.

"What is occupational therapy?"

How often do we hear those words?! Yet Toto points out that each OT area has its own definition. What I do on a daily basis in the school system is nothing like what I used to do in the hospital and that would look nothing like the life of a hand therapist. Even within the hospital, my practice could vary widely from the NICU to the Neuro ICU to the orthopedic floor and so on ad nauseum. Toto said this was like blind men describing an elephant- we tend to describe our practice in a reductionist way of what we regularly do, sometimes missing the big picture of OT. This can lead to confusion from consumers, referrers, and payors. Amini points out that if we want to achieve the Centennial Vision goal of a consistent recognizable image, we much EACH take it as a personal responsibility. The "Authentic" version of OT is client centered and occupation based, with occupation as both an outcome and a treatment. Amini pointed out that this is often an espoused belief of practitioners, but not necessarily an enacted one.

A person may not even realize that they aren't enacting their beliefs until there is an additional level of reflection involved. Amini described reflection as thinking and critically examining yourself, skills, and practice. Reflexive practice takes reflection further by then comparing reflected behavior to espoused beliefs, determine any incongruence, and then act to change the behavior or the belief. This process can be done by personal journaling, mentoring, using the AOTA professional development tool, creating a portfolio, or joining a community of practice. Toto states that one of the best ways to advocate for OT is to practice consistency in areas you address, services provided, assessments and intervention approaches. In doing so, you create an image that others will remember and identify as occupational therapy.

There are perceived challenges to authentic and reflective practice. Amini includes corporate policies, reimbursement, productivity, supply cost, time, and decreased support from peers or supervisors. Toto described threats to our practice: complacency in our documentation (failing to specify our unique practice), viewing OT as a job instead of a career, moving from ADLs to preparatory/adjunctive treatments, accepting the status quo (including that laid down by the boss), and allowing any other service to be a "gatekeeper" to OT. Don't allow other professions to represent you. If your services are special and unique, NO ONE can say OT isn't needed! Remember that documentation is important. It's hard to remember that when you're writing 6 evals a day and don't think they're ever read. But think back to being in school when you learned about how each note was a legal document, the only proof of what really happened with a client. Toto discussed that it is important to use our practice framework language and reference evidence in our documentation. The most skilled part of a person's OT session may not have been the hands-on portion, but the clinical reasoning and decision making you engaged in. And speaking of clinical reasoning- don't short sell our value by saying that it's just "common sense!"

Toto discussed at length the importance of advocacy for OT. We're great at being advocates for our clients to get the best care, but more reluctant to stand up for ourselves. There are a limited number of healthcare dollars, and other groups would love to take our share. We can't be timid and "nice." As Dr. Clark said in her presidential address, if you let others take OT for granted, "it's not playing nice, it's playing dead!" Remember, there is no mysterious "they" who will advocate for you. AOTA and your state association may be able to take action on a government level to defend OT, but without your membership, they are hard pressed to do so. And they certainly won't be coming to all your referrers and coworkers and asserting the OT scope of practice. That falls to each of us. Amini reminds us (especially those AOTA members) to use the official documents as leverage during advocacy efforts.

Toto described that there are two ways to make light- you can be the candle or the mirror. When your client is successful, they need to understand who you were, what you did, and how your intervention has impacted their occupations and participation in life. Discuss and hand out goals. Hand out a business card. Make sure that you identify yourself as an Occupational Therapist and not just an OT or OTA. Have several elevator pitches for different audiences that include evidence. Most importantly, let everyone know the good that you do, so that others may receive your awesome authentic services.

I hope you find these points useful for your daily practice. The field of Occupational Therapy and our consumers will definitely benefit from authentic practitioners. Let's all strive for that in the coming week.


Dycem Product Review

The good folks over at Dycem were kind enough to send me some free samples in exchange for a review. Click through to read (and win a prize!)

Dycem products have expanded since I was in school, learning about their use. They have even made a special section on their website just for OTs. I got a few products and started trying them out in my practice and handing them out to others.

I was a little confused by the mat that had a peel off on both sides. I am 80% sure that it was just like that for easy distribution and cleanliness, not to be adhesive. (There are adhesive strips/mats as well) I tossed one of these in my utensil drawer, because the force from me closing the drawer kept knocking the silverware tray back into the depths. I put it in a few weeks ago, and despite me purposefully slamming the drawer, the tray does not move. The silverware itself keeps trying to run away, but I digress. We will also use some for either the drawer holding baggies or for where the wine glasses are.

One of the rifton chairs at school has a piece of Dycem on the seat to help keep the child from sliding. This does work, but you have to be very conscious that you are positioning the child properly and with a good pelvic tilt since it will be hard for them to readjust themselves.

I like the coaster a lot. It doesn't slide on the surface and the glass doesn't slide either. The downside is that it cannot absorb any liquid, so the glass will get pretty drippy if you have a lot of condensation. I tried to use this in the car to hold my phone (illegally) on the dashboard, but it couldn't quite hold the phone during the turns.

The pediatric mats are quite cute. However, the shape cutouts can make it difficult to get the absolute best fit for the object getting stabilized. I have used the Turtle while in the schools, stabilizing slant boards, the Ipad, blocks etc while on the wheelchair tray or tabletop. The kids seem to like it, but it can be a little distracting. I sent the hippo to my grandma because her little fat dachshund dog is so eager to get her daily food portions that she attacks them and pushes them under the toe kick for the kitchen cabinets. This is annoying for my grandma, who really shouldn't be bending over and digging under the cabinet or all across the floor for these bowls. She swapped the old mat for the dycem one and has not had a problem with the bowls moving at all. I got a text message ("from the dog") that reads- "Dear Cheryl, I like my new mat. I don't have 2 chase my food dish. It is easy for my maid 2 pick up and clean. It doesn't take up as much space. Thank u for thinking of me. love, Annie"
The jar and bottle openers are my favorites by far. The jar opener has worked on everything I could try, and my elderly patients have always liked it. It is listed at $12.75, but really high quality. It is much better than the rubber or silicone trivets/openers I've tried before. The bottle opener is a little redundant, but lets me open my adult beverages without assistance.

Keep in mind, when using any of these products, your results are much better if the surface and the product are both clean and dry. I have to keep the portable mats in boxes so that they can be transported without getting nasty. It just takes soap and water to clean. I tried to use the placemat "off label" as a trivet. I wouldn't recommend it for that. It's better than a towel, but does still transfer the heat as time goes on. I actually checked the specs and material is supposed to be OK up to 50*C, but I like my silicone trivets better for this purpose.

Things I didn't try:
- On the website, you can see small furniture disks to keep chairs from slipping. I would be interested to know whether this provides enough stabilization to someone who is really pushing back hard on the chair (like a person with Parkinson's). I suspect it would depend on the angle of the push- might be ok for a person who pushes straight backward, but most are at an angle that causes the chair to tip back.
- Also on the website, they have a picture of a sheet of Dycem on a hospital bed presumably to keep a person from sliding down the bed. Would this really work? Soft surface of sheet plus either soft hospital gown or skin? I don't know that I would try it.
- I didn't have one of those mats to try out with sit-stand transfers. It would probably work with some, but the ability to adjust the person's feet is sometimes needed. Could still be useful.

If it were me, I would expand the product features in a few ways. I think the openers and the coaster could be more accessible if there was a magnet or clip to attach to the fridge or cabinet drawer. The jar opener could probably be made into a ring only and attached to a keyring for tailgating purposes. Some products could be integrated with others to increase their function. A silverware drawer with Dycem lining on the bottom and insides would be helpful. A coaster that could somehow have a cork middle to be absorbent while still retaining the non-skid would be great. Anything that could tolerate high temperatures, microwaving, or going through the dishwasher would be helpful. And more color choices are always enjoyed.

I really don't know of an alternative better to Dycem. It just works.

Free Giveaway!
Thanks for reading this far! Please leave a comment regarding this entry or the blog in general (polite only please, no email addresses, no spam plugging fake universities, etc). Get these in by 11:59pm (EST) Sunday November 6 and I will use a random number generator to pick a winner(s) and mail you a slightly used but not damaged Dycem product. You can also get brochures and free samples here.


Life is what happens when you're busy making other plans

So, I work in the school system now.

I know, it's a big change. But it's not like I had anything else going on, what with the moving, quitting another job, buying a house, and moving again. Late summer of 2011 is rivaling the entire summer of 2007 for most stressful time of my life... it has already surpassed spring/summer of 2002 and that is really saying something. (sidenote- why does all my stress come in the summertime?!) So to sum up, we moved from Baltimore to have a more stable home/family life, I tried to make it work at a job, and I finally got an offer I had been waiting for, so I made the switch. And I now know that you should NOT EVER switch jobs while trying to purchase a house. Loan people don't like that. It also ended up being a much more prolonged departure from one job to the next.

In 2002, or even 2004, or probably even much of 2007 if someone had told me that I would be working in the school system I would not have believed them. Until I had already taken my first job and kind of fell into the world of outpatient pediatrics, I really didn't know that I could find working with kids interesting, important, and fulfilling. I liked kids in short doses, but it wasn't something that I thought about doing for a career. That opinion played a BIG role in selecting the University I went to for OT... I was completely turned off by a big-time program because of what I felt was an overemphasis on pediatrics. I liked outpatient well enough, but never thought that I'd move to school-based therapy.

For the record, I'm pretty sure my mom brought up school system therapy back when I was still in high school, so as usual, YES Mom, you're right.

I haven't been working in the current situation very long, but so far I have just loved it. Great therapy staff and everyone has been very helpful as I get my feet under me. About a month in and I'm starting to get the rhythm. I think the biggest challenge is the scheduling... I have preschoolers that are only present 2 days/week, and then only for mornings or afternoons, travel between locations, meetings, all that jazz. It's coming together.

I love the resources that are available at work. Lots of different assessments, and multiple copies of the popular ones so you don't have to fight with anyone else to schedule testing. A variety of adapted writing tools and alternate seating surfaces that you can just give away as warranted. I think it's great not to have to jump through hoops to get things ordered or recommend something to the parent and make them have to order it.

Had a great weekend with the NBCOT crew, working on simulation questions. We literally go through each word to make sure that the questions are clear, not trivial, not tricky, and not biased. It can be intense, but I am glad to be with such a good group of people. I enjoyed the time in Memphis, particularly running by the Mississippi river, which I had not seen before. My only regret is not getting to go on a sternwheeler, but I didn't see the Proud Mary anywhere, so it's not like opportunities were abounding.

he house purchase process was overwhelming... which is an entirely separate post. (coming someday! I promise! Already started!) But I have been keeping with the recent change in focusing more on personal health and non-OT stuff for a change. I am still running (mostly regularly) with a 5K at the end of October. We've been hanging out with friends during the week more and settling into our crazy fall routine of traveling almost every weekend. Serious miles are in the near future at a time when rest would be most welcome... oh well. At least there should be fun times with friends upcoming.

I'm going to try not to neglect the blog too much, especially since people have been introducing me as the blog girl, and it would be bad form not to update. :) But patience is always appreciated.


Self Behavior Modification

So as I work on getting in shape, I worry about maintaining motivation. There have been a number of failed attempts prior in my (not that long) life and I'd rather not fail again. So I am busting out behavior modification all over myself to make it work. There are some great tips here, and I've listed out some of my other methods of personal mind control.

(not necessarily in any order)
1) Visibility-I want to be reminded of my goals and what I know I should be doing. So everything stays visible. My box of exercise gear (yoga stuff, balance stuff, aerobics shoes) is right beside the TV, so I always see it. If there's an exercise DVD that I want to concentrate on, I'll prop the case up by the xbox so it's easily seen. We have no garage at the moment, so the bikes are sitting right beside the table. I bought anti-chlorine shampoo for post-swim workouts and put it in the front of my shampoo container so I see it every time I walk in the bathroom. You could also place motivational notes to yourself in various places.

2) Ease of access- Since most things are visible, they're easily accessed. I have Netflix streaming and leave all the workout routines in a block so they're easier to locate. The running shoes stay near the door and untied. I keep my water bottle filled and in the fridge. All the workout clothes are in the same drawer, and if I'm planning on going to the pool I'll put all that stuff in a bag together. Generally keeping necessary accessories (say that 3x fast) together makes life easier, for example, the bike helmet is on the handlebars. I'm a bum, the easier it is, the more likely it is to be done.

3) Guilt- Is this a healthy motivator? I don't know. But I use it. Thinking about the cost of items, and that I really should use them, is sometimes helpful. Thinking about how long it has been since doing an activity is also something I do. And in the part guilt/part competition factor, if my husband/workout buddy is doing something, I will try to go along and keep up.

4) Mental monitoring- A recent study showed that people who just mentally asked themselves "how often will I work out this week?" worked out more often than the control group. (sorry, no link) So I try to think about my exercise schedule, and try to think how I will fit things in for the following day. I also am trying to keep a journal with short entries about what I did and how I feel. Keeping a written record gives me something to look back at for motivation.

5) Rewards- I am all for cheap, easy thrills as rewards. I have a smart phone and use the free CardioTrainer app for my exercise recording. Every time I turn it on, I can see a little activity figure for each day that week I did any kind of exercise. I like the little stick figures and think that they're cute, and like to see a variety of them on that screen. It keeps a full history, so I can look back and see how many total miles I have gone since starting the app and the calories for each. I can also see the maps of my outdoor exercise, which I think is cool. Finally, there's a widget for my screen that turns different colors based on # calories burned/week. I see it frequently when using my phone and always try to keep it in the gold/silver/bronze range. I definitely get a little emotional boost when I see a good color.

So that's a few of the ways that I've been manipulating myself lately. Nice to see that I'm making use of my education. Any other good tricks that you use? Feel free to share in the comments.


Disability or Ability- TV's Alphas

I watch a fair amount of TV. Now that I'm home 2 extra days, I keep it on for noise during the day. One of the shows i have started watching is Alphas from the SyFy channel.

Alphas so far appears to be a fairly standard superheroes kind of show in the line of XMen, Heroes, etc mixed in with some espionage and spy work. I like those kind of shows, so I can tolerate some of the less-than-awesome dialogue and recycled plots. Of the 5 types of Alphas described, even mild comic book or superhero fans could list other characters that fit these types.

What spiked my interest in the show was the character who is a "transducer" and able to act as an antenna to intercept and decode messages. "Gary" is able to read all wavelengths- TV, cell phones, computer traffic on the internet, etc. This is an astounding amount of information to absorb, but he is able to help break codes and find information for the rest of his Alpha team. In daily life however, he appears to be on the autism spectrum (some episodes more severe than others), getting assist from his mom or team members for many daily tasks. In a follow up episode, a new character is introduced who is a human "Rosetta Stone," capable of understanding and translating any language, but also considered autistic by those not familiar with Alpha-skills, since she is unable to make eye contact or communicate except by making seemingly random scratches on her hairbrush and other materials.

I won't say that the depictions offered on TV of a person with autism are entirely realistic. I've only seen 2 episodes, but even within that time frame, Gary's eye contact, speech patterns, social skills, and repetitive motions have changed considerably. Some of this is likely due to the actor becoming comfortable with the character, and the changing demands for different episodes. But I particularly like the concept that a person considered disabled in the context of average humans is valued as a superhuman by those "in the know." Which makes labels like "disabled" or "dysfunctional" worthless, since the ability (especially in this case) is all in how the person is treated and enabled. A not too deep encouragement for us to look past labels and prognoses and focus on abilities.

PS- I believe that Modern Family features a character with autism as well, but despite some of my friends liking the show I have never seen it.


thoughts on starting exercise

So I've gotten on the exercise train for a first time in a long time. And I have boarded a new train heading somewhere quite outrageous...

This is my first announcement in a public forum, but here goes. I intend to compete in a (sprint distance) triathlon next year. I'm not particularly fit at the moment, and can't yet do any of the distances for the 3 disciplines on their own, let alone consecutively. It's a process. My husband has decided to join in the fun, so we are both engaged in these struggles that can be both harrowing and ridiculously funny. There would be plenty of material for a knee-slapping gut-busting book or stand alone blog, but I just don't have time for that (how can I, when I already neglect this blog too often?) so I may share some of these stories in this forum.

On our journey to becoming athletes, we have already had a bike push (definitely couldn't be considered a ride) up and down a rain soaked clay hillside; a 2 hour hike into a canyon that required fording a river and another 2.5 hours to get OUT of the canyon; and a realization on my husband's part that swimming after a long bike ride is puke worthy. He has a serious strength advantage on me, and much greater skills in biking by extension, but I have the advantage in swimming thanks to years of lessons at the YMCA (thanks mom & dad!). So I learned a lot of technique as a child that I am now trying to impart to him as an adult. It makes for an interesting take on the difference between learning styles based on age.

The biggest technique piece so far has been introducing rotary breathing. It's a difficult concept for a novice swimmer. Those words were like poison to me for the entirety of 1994. It took me what seemed like a lifetime of 1x/week screaming by unpleasant swim instructors to be able to put my face in the water and master this concept. So even as an adult, when I (prior to the past few weeks) swim only 1x/year, I still can pull that out easily, like riding a bike. Since my husband wants to be able to finish the triathlon too, it was a skill he needed to learn.

As a child, (obviously I wasn't paying the greatest attention to instructional detail at the time) the instructors specialized in breaking down the steps to the task and repeating the practice in various ways. Blocked practice. First, kicking on the side and blowing bubbles. Then, kicking with the kickboard and doing head turns to one side. Then putting it all together into the crawl stroke, which you now have to do since we've thrown you into the deep end of the pool. (I'm having terrible flashbacks trying to write this, even now). Ultimately, until I got a new teacher and went from weekly practices to daily practices, progress was minimal at best.

My husband doesn't really have the attention span to do nothing but work on breathing for an entire hour in the pool, and approaching this from that angle might mean that he would never master it. So I gave him a few tips about how to turn his head while taking a stroke. (In retrospect, this probably shouldn't have taken place in the ocean, but like I said, we are having quite the funny journey). Then I would either answer his questions ("am I supposed to breathe out at some point?") that I hadn't covered earlier or offer some technique feedback. More of a contemporary motor control theory for learning, letting him practice and try on his own. After a few sessions (<5) he feels like he has a rhythm, and even if it doesn't look perfect, he is still able to crank out lots of laps while taking in more air than water.

So what did we learn here? Obviously, having an OT for an instructor is terrific! :) Personally, I think that learning the skills as a child made them well ingrained into my muscle memory and expect that to be unforgettable. It took a lot longer time for me to be able to learn and integrate that skill though as a child than it took my husband as an adult. But I think that the longer time to learn will make it harder to forget. It was easier for me to teach refinements to an adult than for Ms Pam to teach basics to a scared child who could barely stand up in the shallow end. I could compare this to different motor learning theories, but my books are all in boxes anyway. :-/

Well that was a bit rambling.
Personally, I am trying to take a balanced approach in this fitness plan. I really don't want to get an injury or derail this plan in the first month. Trying to add in workouts for flexibility, core, and overall strengthening into this plan. It's really hard to find time and motivation for all of this (and I have no kids and a 3 day/week job) so the ultimate goal seems very daunting at this time. Hopefully I can pull this into line (along with the rest of my life... house shopping, OT presentations, new job, other endeavors etc). And if I come up with things that are potentially interesting or tangentially related to OT, I'll try to share.


In the throes of ... lots of non-OT stuff

Life goes marching on...

Since the move, we have been trying to focus on more family time, and that has transitioned into an increase in athletic endeavors, which has been also going along with work on healthier eating. So there have been a lot of changes that we are trying to turn into healthy habits... a personal "lifestyle redesign" project, if you will. I'm not being super smart about things though since I've made lots and lots of goals, too many to focus on all at once, and no time frames. Also trying to buy a house, which is an insanely-detailed process.

I've only worked 4 days at my new job (a 3 day week and a week long vacation does make it hard to accumulate time, haha) but I feel like I'm starting to get the hang of things. There are computer and written portions of the documentation. It's a new computer program for me, and it will be interesting to see how all the documentation moves to computer (I consider it only a matter of time for all sites... it is the 21st century after all). There have definitely been some great moments with the residents and I hope that things will go well.

Ultimately, I would like to start a Lifestyle Redesign styled program in the assisted living facility. I have gathered some research to use in marketing, but need to review how to do a needs analysis, decide whether to pursue grants, etc etc. I would REALLY LOVE FEEDBACK on getting this started.

I've been keeping busy on my "off" days, which is kind of bad since I have plenty of OT things to be doing during that time, but there is a lot of ebb and flow right now. things will likely get done, just a little off the ideal schedule.


I'm Alive!

It has been WAY too long since I last wrote. Here is an abbreviated update:
1. I moved
2. I'm starting a new job
3. I have irons in the fire.
For more details...
I had to say goodbye to Baltimore. Logically, I know it's the right choice, but it has been crummy. I love the friends that I have made and the excitement that Baltimore offers, and there were so many cool OT opportunities as well. But from a personal and family standpoint, it was just not sustainable in the long term. Commutes were too long (60+ for me and 85+ for my husband) and we needed 3 days off to get home and back since we were so far away. So with potentially wanting to start our own family (in the next few years) something had to change. But knowing that logically doesn't mean that it's been easy or something that makes me happy the whole time, so I have been withdrawing a bit and trying not to put my foot in my mouth.

By extension, since we are moving a significant distance, I have to change jobs. I am at a point of conflict, since I feel like I've learned a lot from working in the hospital and am good at what I do, but it doesn't always make me happy. I don't always get to spend the time I would like to with the patients, and fighting for the appropriate recommendations really wears me down. Sometimes, there's this feeling of standing in a vacuum screaming without anyone hearing. With such little time to work with people, sometimes I wonder about making a difference. This had been better lately on the neuro floor, but it's still frustrating. I still like the hospital environment, but I don't see myself returning to it full time, maybe just prn sometime in the future.

So in thinking about what I'd like to do long term and think that an outpatient environment might be a better fit. I hate making this change without my awesome outpatient buddy from my last 2 jobs directly by my side but hope that we'll be able to keep in touch. The job I'll be starting is a unique outpatient setting that is small relatively new- only been in existence for a few months. I'm excited to help with growing the program and learning how to navigate the new environment. It's a part time job, so that will be flexible enough to let me have time to keep up with my OT extracurriculars and other activities.

On the irons in the fire list, I submitted to 3 conferences in June. 2 presentations will be similar, so that will be helpful. I get to work with an awesome group of OTs for the AOTA presentation on social media, so I hope that will work well. I have been dealing with the whole host of lame stuff that has to be done when you move, including living out of suitcases and sleeping bags for awhile, cleaning, unboxing, tons of laundry. Definitely not my favorite things to do, and having to mooch internet from Cosi was not particularly convenient for updates. I had a crushing crescendo of activities and deadlines that culminated with my last day of work and a week at the beach, and I was so wiped out. Disconnecting from the computer and internet was needed so I could recharge physically and mentally. I am feeling better now.

I intend to have at least 1 post per week now that I have some scheduled days independent of work. I hope to cover some of the following topics, and if interest is expressed I can try to speed it up:
new acute care book on AOTA press
portrayal of mental illness in Broadway's Next to Normal
new shows with characters who have disabilities
thoughts about Lifestyle Redesign program


random thoughts of an insomniac OT

Can't sleep and it's before six a.m. on a day I have off. Awesome. But here are some of my thoughts on things that have been happening recently.

First off, and rather obviously to anyone who has been with me in person, I am under a lot of stress lately. For an OT, I certainly exhibit a lot of poor patterns in dealing with stress when it gets to a high level. I retreat into comfortable things, procrastinate on other tasks (hello blog), and have a thousand questions running through my head all the time. I'm also increasingly more distracted, which feeds back into the procrastination. I've been waking up around 5 for the past several weeks, but for the most part I just stay in bed in a semi-dozing anxiety spree until the alarm actually goes off. Very stressed. Likely to get worse before it gets better.

Since I'm not concentrating well, I haven't been reading as much lately. But I have been attempting to get through a couple books that may be of interest to others. One is strictly a book for work: Yes/No Medical Spanish. I haven't had a chance to use it in person, but I love the concept and found just about everything I would need for an eval (adult or pediatric) included. Since I haven't had the time/motivation/follow through to sit and intensely improve my Spanish (and it would take a lot of classes before I could be fluent for medical things) this is a great resource. I may eventually make a master sheet out of several sections so that I could just carry a small paper for home setup and basic questions and hopefully by that time the interpreter would show up! But definitely a useful book, though not therapy based. The other book I picked up because I saw an interview on Daily Show or Colbert and thought it would be thoroughly interesting: Beyond Boundaries: The New Neuroscience of Connecting Brains with Machines---and How It Will Change Our Lives. The interview was very interesting, and the scientist discussed his research using brain-machine interfaces and talking about how they would make it possible for paralyzed people to walk using their brain power, really innovative stuff. I don't think it's only due to my attention problems, but I have been really struggling through this book both with the reading level and finding things that are interesting in it. I have renewed it twice at the library, it's do or die time now. I finally just skipped several chapters and am reading only about the actual experiments, so it's a little better that way.

I feel proud since 2 of my completely not related to OT goals that I set for myself are coming along nicely. I am progressing well as a user of chopsticks (still much better with wooden ones than smoother surfaces) and I have been able to complete 3 medium difficulty sum sudoku puzzles. Everyone needs something to aspire to and in this instance, something that has nothing to do with a career. But yay... good achievements thus far since I started as a complete novice with both this year.

I had a really interesting person s/p TBI the past few weeks, and he would make a great case study if I can strip enough identifiers eventually. I had a man with a severe hemorhage that was hospitalized for several weeks and made terrific progress exponentially near the end of his stay. I also saw a man with an intriguing stroke presentation (basically a subtly expanding stroke over >1 week) who is now at the local IRF and doing wonderful per report. These people made me actually sad when they were discharged, since they were great people and their cases were interesting. It's difficult in acute care since stays are so short, ability to do treatments is rare, and you get no follow up on what has happened to the person. It's nice when you get to see someone make progress. And speaking as someone who has interests across the lifespan, it's nice to have something so interesting because I need some beacons to figure out where I need to go and focus with my career.

Some odd moments of feeling out the boundaries between therapy comrades. I was scheduled to see a child with torticollis and was interested to try out a new approach I had seen online. But then I found myself wondering if there was good OT justification for that approach. Usually, I don't feel that I'm the 'infringer' so to speak on the other practice domains, but that case made me wonder if it was a treatment true to OT practice. I think there are probably some ways that it potentially could be (use as a feeding position, etc) but it was odd to get that squeamish feeling. Kid never showed up anyway, so really a moot point, but made for some pondering.

I had several moments lately that made me proud to be an OT and do what I do. Despite being the 'young pup' of our current floor group, I am pretty much the only one with an interest in neuro, and people have been counting on me to various degrees for their own education, which makes me feel really great to have that level of respect from others. I got a nice sincere thank you from an elderly man whose wife had a stroke... he had been disappointed that I couldn't see her daily in the hospital but so grateful that I came back. I was not expecting it since the session had been very difficult for the pt and he had watched her struggle along with BADLs. I spent a lot of time with the family of the man with TBI, and they seemed appreciative of the resources given, and even mentioned to the SLP that they felt really prepared following our sessions. I was able to make a connection with a young Hispanic couple really unfamiliar with the health care system and things like inpatient rehab, and I could tell that they were happy to see me even passing in the hallway, so that was great.

I'm trying to really enjoy these happy and proud moments, really appreciate the little things. I have a tendency to be so pessimistic and do want to remember that there are good moments even when I'm in the midst of mounds of work and disappointing myself on other fronts. I'll get a semi-needed computer respite this long weekend and see if that helps things. Words of encouragement appreciated, and I hope to be through the rough spot soon. :)


still learning to deal...

I've been feeling pretty stressed lately, so I've been spending more time away from the computer. Plus, I did get to have a crazy amount of fun in April (1-2 awesome things per week) but things are finally calming down for May. Several entries in the works, but it's going to take some time to bring them online and keep me sane. MOTA readers (anyone?) can now check out the MOTA website for the updated legislative advocacy page.


OT in HD: Presidential Address

AOTA President Florence Clark opened the 2011 AOTA Conference with an excellent presidential address describing the need for OTs to compete.

(Photo credit to Cheryl Crow, videographer extraordinaire, from the OT Connections Gallery)

We live in a world of competition. Especially now, in a time of health care reform where decisions are being made about what services are necessary in the future, we as occupational therapy practitioners need to be engaging competition with (not against) others to ensure our role in promoting occupational fulfillment to the public. Competition needs to be acknowledged. It drives innovation and can improve practice. It's not going away, so get comfortable with it. Victories are won often by teamwork, but always by competition. But, as Dr. Clark said, "let's face it- we're nice." OT attracts people who are cooperative and kind. But if you let others take OT for granted, "it's not playing nice, it's playing dead!"

"HD OT" requires power, and we as a profession need to embrace our collective power. We can't stand alone, but together, we have a power that can't be ignored. As a group, we are witnesses to the "transformative power of occupation" and this must be shared with the public! The public mindset is shifting toward wellness and participation, which is a foundation concept to OT. One example is the case of Congresswoman Giffords. Per Dr. Clark, it was not so much of a question of 'would she walk again?' but one of 'would she run again- for Congress?' People are concerned with the ability to fulfill a role- one of the things that makes life worth living!

Dr. Clark drew some analogies to Rocky, who demonstrates caring and competitiveness, sensitivity and toughness. We have to be "in the ring" during the healthcare debates. We have to bring our "playbook." That includes evidence on our effectiveness, increased grants, decreased hospital readmissions and documentation. Our documentation should not over-emphasize motor-based components, but embrace our multifaceted approach dedicated to the whole person, environment, and occupation. We need to be intensely involved in advocacy to make the message heard- that Occupational Therapy helps people LIVE LIFT TO ITS FULLEST!

A recurring theme of President Clark's address was to strive for "arete," an ancient Greek concept referring to excellence, effectiveness, fulfillment. We each need to strive for everyday excellence in our work, with our clients, and how we represent ourselves. Fire up your competitive juices!

Dr. Clark's message goes hand in hand with 2 other excellent sessions I attended and will share at a later date. I hope that the call to "arete" resonates with you.


AOTA Conference 2011

The 2011 AOTA Conference: OT in HD is in full swing!

Wow. This has been a truly awesome experience thus far. I know people want updates, and it's so hard to encapsulate because there are a million wonderful things going on in all facets of OT practice. Deciding where to begin is difficult.

First off, I think it has been great to be able to come with a friend. My best friend (also an OT, how convenient) got to come this year and this is her first conference, so it's been exciting to see things through her eyes and have someone to bounce ideas off of and be interested in similar things. It's also nice to have someone to sit in the big sessions with and go out in the evening together. So her presence has made this conference an improvement over others in that regard.

Another "people power" effect is that since I have become more involved in OTConnections, my state association, and NBCOT, I have met a lot of people and it's very fun to get to meet them in person or see them again. I also have at least a fair memory for names and faces, so I will see someone's name badge or recognize them from a photo and say hello. I've had a couple of people spot my badge and ask about various people at the hospital and life in Baltimore and I enjoy those chance meetings. I have gotten to see several of my former professors and had time to catch up with them, which is great. There are such terrific people in the field that by just talking to others in your sessions you can find out great things and see that there are OT revolutionaries all around.

I have been to some very informative sessions on a wide range of topics thus far. Started with a course on Infant Driven Feeding in the NICU, also got to see some ground breaking research on Contemporary Motor Control with guidelines for practice. Today I had GREAT sessions which have warranted their own posts at a later date- a session on being a Survivor in a tough market which segued well into the presidential address outlining benefits of being competitive. I got to be part of an intensive discussion on telehealth with (dare I say it?) other OT geeks, and then the Slagle lecture was terrific. Tomorrow is very up in the air... I have 3 sessions that are interesting in the morning and 3 in the afternoon that all overlap. I don't have a 3 sided coin. and we are planning on going to the AOTPAC night which judging by last year's pictures should be a lot of fun.

I've got a lot of notes from the various sessions and I'm really glad that I took off Monday to process everything.

Looking at the conference program, I realize I saw several of the "pixel people" at sessions today... I've also been able to match up the color photos with the grayscale on the cover... totally dweeby of me.

The updates on twitter under #AOTA11 have been interesting to follow, but I'm only getting them sporadically given the spotty wifi and cheap cell phone coverage. It's exciting to see so many people posting. I hope that people will also go back and use OTConnections more post-conference to make some dynamic SIS-type interactions.

Sorry this is so random, but that's the way of things during this time of sensory overload and OT-awesomeness. There's a lot of excitement tomorrow and I need my beauty sleep! More updates to come after I get home for sure.


An Introduction

Hello OT Practice Readers!
Thanks for reading Molly's article on Social Media. (You're already ahead of me, since I haven't read the previous issue yet). If you haven't been to my blog before, welcome, and please feel free to see the About Me pages or the manifesto I wrote when starting this blog 3 years ago.

Things you may want to know... I am a real OT, though I don't necessarily know what I want to be "when I grow up" so to speak. I write and rewrite material a lot (and do try to have a social life) so postings can be infrequent. I don't intend to come off as an expert about most OT-related things, I am still learning and plan to keep learning. That being said, I work hard at staying involved in OT on multiple levels. I read a lot of research articles and texts during my commute. I care about our profession and want it to grow, and me to grow with it. This blog helps me share that goal with the OT world at large.

If you're wondering what I'm doing in the upcoming months when I'm not doing something OT-related, it would include going to several concerts and shows, repotting my violets, getting outdoors, playing with my first smart phone, or reading (most current books: Thirteen Days, The Girl with the Dragon Tattoo, and The Count of Monte Cristo).

Please feel free to comment or email me with your input, questions, encouragement, or suggestions for future posts. You can also find me on Twitter (otnotes) and OTConnections. If you're interested in other things I have written recently outside of the blog, check out the AOTA State Affairs newsletter, the MOTA newsletter, or the legislative section of the MOTA website (not up yet, but forthcoming). I will be at the upcoming AOTA Conference in Philadelphia and would be THRILLED to meet and talk with anyone who will admit to having read any portion of this blog.

Intended upcoming entries: OT-relevant smart phone applications; kitchen reorganization for energy conservation; caregiving tales; and a special shoutout to my twitter followers.

Again, thanks for reading!


New roles & responsibilities

I have taken on some additional OT tasks this year, and it's getting to be an interesting balancing act.

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.


Who gets to go home? 3 short case studies

One of my biggest responsibilities from a hospital standpoint is providing discharge recommendations. Hospital stays are notoriously short and it is a priority of the case management staff and doctors to determine discharge location, for which they recruit OTs and PTs to assist. But determining discharge readiness and placement is more of an art than a science, no flow chart can be easily developed to guide a novice through the process. So here are 3 case examples of similar patients and situations, whom I saw on the same day, and my rationale for their discharge locations.

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.


OT Web Gems- Nationwide Statistics and AD edition

Welcome to another edition of OT Web Gems, AKA "Cheryl has too many tabs open of cool articles, so let's update." Some of these are pretty hefty reading, but it can be worth it depending on your field. Several related to Alzheimer's Disease as well.

Food Environment Map- it's easy to talk about making the right nutritional choices, but understanding the reasons why these aren't followed through is very important. For clients living within a "food desert" where there is little access to fresh produce, groceries, or low-cost healthy foods, this can be especially difficult. Map allows you to break down multiple statistics on a county level. Could be very useful if you are considering implementing a program for childhood wellness.

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.

Alzheimer's Association "Baby Boomer" report- Lastly, some statistics regarding the past decade or so regarding demographics of AD in association with research money and other costs. Some scary stats on their main page, the full report requires you to sign up with email, I haven't read the original report. Again, this would be helpful if you're looking for support in a program designed to assist those with AD or their caregivers.

Financial Skills Decline in those w/ AD- another Alzheimer's Reading Room post regarding the quick financial decline in those with even mild AD. This is an important ADL to test- it may be helpful diagnostically. Moreso if done within an established testing protocol such as EFPT or KELS. (Sidenote- I looked up the AMPS tasks and they do not have a money-management task. However this is also widely called for in my workplace when trying to assess cognitive decline. If you're AMPS certified, there are a lot of good resources on their website to make things faster or form a research project)

Tips to Prevent Wandering- A Geriatric Care Manager wrote some nice tips on strategies to decrease wandering in those with AD. I thought of some other environmental and behavioral modifications that we use as OTs. If you frequently work with adults with dementia in the home setting, I highly recommend Occupational Therapy and Dementia Care: the Home Environmental Skill-Building Program, which I found to be a very helpful text and has many useful home modification ideas. (Link is to amazon.com since AOTA site is down this weekend but I believe there is a reduced price on AOTA.com for members.)

Lifehacker Top 10 brain-training tricks- on a more upbeat note, here is a quick list of brain-training activities. Nothing here is groundbreaking, should be familiar to most but might be a good jumping off place for cognitive rehab.

Concussion/mTBI Detector- such a cool idea. Tests a blood sample for biomarkers indicative of brain injury. This could be revolutionary in the diagnostics (and thus treatment of) mTBI, which is a very big deal for OTs in cognitive rehab.

Procedural Change- make sure you get your feedback to your RA member on the proposed changes to the organization. There is a video, written documents, and a message board on OT Connections to review.
General Elections- review candidates and cast your vote- closes at 11:59 pm EST on Sunday, February 27
Philly Convention Center- if you're planning on attending the AOTA conference (which you totally should!) then there are some good resources at the convention center website. Maybe I'll be able to not wander around empty halls looking for the group unlike last year (I have such poor spatial skills, lol).


An Open Letter to Nintendo

Dear Nintendo Wii,

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.

Cheryl OT


Adventures in Serial Casting Part II: Review of the Evidence

The term "serial casting" refers to the use of plaster casts applied over time to gradually increase PROM, decrease abnormal tone, and hopefully therefore increase functioning. Typical population for this intervention is either for children with cerebral palsy or adults post stroke or TBI. This (really long) entry aims to examine the evidence behind the intervention by answering multiple questions regarding the intervention.

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.

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.

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.

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.

*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.

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.

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.