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.


Looking forward to 2011

Goodbye 2010. I don't have the energy for a LONG year in review, but...
I will touch on a few ups and downs of the year.

Firstly, let me thank all readers. I really appreciate the comments (that aren't plugging fake universities or spam in other languages) because I like to see that there has been an effect from my efforts. I don't look at the stats often, but glancing today, I see that since I started tracking in 2008, pageloads have increased by 20,000- more than 300%! WOW! And the cross-posts in the sister blog on OT Connections have brought in an extra 50-350 viewers each time, with one anomaly (thank you 1-minute update). It's really exciting to see how this blog has grown and spread, and gets me thinking about some plans for the future (more on that later). So a BIG THANK YOU to each of you, and please always feel free to comment or email me with suggestions.

Most popular pages on this site continue to be Writing Goals and a Case Study With Goals, which is understandable since this is one of the more difficult skills in OT that is not hands-on. I do intend to spend some time getting back to the 'roots' of this blog and posting about decision making, goal writing, and treatment plans. Perplexingly, a rather random What a Week post is the most read on the mirror site, with the exception of my post about Glee that got picked up by 1-minute update. Ironically, some of the posts I spent the MOST time on (e.g. Metacognition and Serial Casting Case Study) don't seem to be as popular, but I don't have tracking to that degree so I can't be positive. I did get several thoughtful comments on my most emotional post (Struggling as an OT for my Family) so I appreciate that deeply.

2010 was the first AOTA Conference I've been to as a practitioner, and even the first I saw after fieldwork. It was great to re-energize and network with other therapists. I think that as you are in the profession longer, you become more aware of others in the field, so I spotted dozens of OT Celebrities this year and got to talk with many, which was awesome.

It was interesting to see all the uproar in AOTA this past year with the potential organizational changes. As we are heading into election season again I see the new blogs and OTC memberships cropping up and it's always notable to see who sticks with it. Props to Bill Wong for continuing to post, and also to Florence Clark for taking up the mantle of the President's Blog.

There were some serious downers last year. We lost my husband's grandmother to Alzheimer's Disease in the summer, which was very difficult for the family. Then over the holidays, we had several additional hospitalizations of our family members, which have yet to completely resolve. Health is so very fragile and some families are like a house of cards... I am learning to take pleasure in contentment and tranquility, because it can all be very fleeting.

I struggled on my final rotation of the year on the cardiopulmonary floor, made extra difficult by the chronic nature of those diseases. It is hard to watch others' independence fade as their bodies fail, and I felt like the efforts I made brought about little change. There were some truly tragic stories in the ICUs that even made attending rounds difficult. I did my best for them, but I am so thankful to be back with a more stable patient base.

As the year ended, I realized that I am no longer really a "new practitioner." Granted, most of my experience is consolidated in one practice area, and I certainly don't know all there is to know about the acute care setting, but I now have a valuable level of skill. I feel like I could go to any adult hospital confidently and be a skilled member of their team. I caught multiple strokes and other medical problems, which makes me feel bad at the time (I hate to see people doing poorly) but it makes me feel that I am a competent professional doing my best to look out for my patients. I progressed with treating pediatrics by taking on outpatients for a few months and doing some feeding interventions for the infants. I was really proud to recognize self-soothing in the baby I evaluated my last day, because even though it's simple, it shows that I am retaining what I've learned though my time to practice is sporadic. I also had my first true fieldwork student, and I don't think I screwed up too badly or she would not have sent beignets. :)

I have a lot to look forward to for 2011. My goal is to spend less time typing notes at home (which is awful!) and more time being able to participate in my "OT extracurriculars"- this blog, OTC, twitter, association stuff. I am now the VP of Advocacy Relations for the Maryland OT Association and things are already in full swing. We are planning for Lobby Night in Annapolis, and would certainly love your company if you're able to attend. I am looking forward to the AOTA Conference in Philly (a mere 2 hours away) and the MOTA Conference (a mere 15 minutes away). I really enjoy how close Baltimore is to fun and excitement, so I know there will be more trips to DC and NY this year too.

Happy, healthy, awesome new year to all.