Holding Hands With Client-Centered Practice

"Will you hold my hand?"

That’s actually all she wanted. With my careful assistance, she had just moved from the edge of her bed to the commode. She was in the midst of explosive diarrhea, yet delightfully demented.

Resting on her new throne, she sat totally contented and stumbled for her final wording of the question that (in an OT-kind-of-way) made my day, “Will you, will you, will you...hold my hand?”

Without hesitation, our hands just rested together. So there i stood, holding her hand while she sat on the commode. (Can't say that I'd predict this scenario would make my day.)

Sometimes being client-centered leads us far from expected engagements in our typical day, yet it always feels so good to reach out to the challenge.

Just for today: How can I be more present to my client’s needs?

Occupational Profiles: Long term & Residential Pediatric Care Facility

I am very happy to introduce a new series, Occupational Profiles, with a guest post from Meredith Daly. The hope of the series is to expose readers to different occupational therapy settings, perhaps to spark interest in pursing a specific speciality or perhaps to find commonalities between seemingly very different practice ares. Afterall, as Meredith writes below, we are all working to give clients as much control over their lives as possible.

Q&A with Meredith  

What is your current practice setting?

I work at the Massachusetts Hospital School in Canton, MA, which is a long term & residential pediatric care facility. It’s a really unique model in that a majority of the patients live on campus for a traditional school week; they go home to their families on Friday afternoon and return on Sunday evenings.  I work on the hospital side of the facility (vs the school side) and so get to focus on pediatric physical disabilities without being bound by IEP goals. It’s the best of both worlds!  

Who is your typical clientele? 

MHS services children aged 8-22 years old with multiple physical & cognitive disabilities. There are 5 OTRs on site and we each have our own unit.  We have 2 COTA/Ls that share responsibilities across units as well! My unit is home to 19 patients aged 14-21 who have severe cerebral palsy, spina bifida, seizure disorders, mitochondrial disorders, various chromosomal abnormalities and/or genetic conditions. All but two are non-verbal and five are AAC device users!  

How did you land in this practice area? 

I have always loved working with kids. For a long time I thought I’d be a teacher, but I always had an interest in physical disabilities & rehabilitation. I ended up volunteering at MHS as a high school student in the therapeutic recreation department.  Once I was in, I never left (even while in NYC for grad school!).

How are you specifically poised, as an OT, to help clients in your practice area? 

Really what these kids want to do is have as much control over their lives as possible… luckily that is something that we, as occupational therapists, specialize in (not to mention get joy & satisfaction out of)! Simple things like choosing which book to read next, participating in turning the page, and choosing nail polish colors are a HUGE deal! The training that we got at NYU with focus on client-centered practice, activity analysis, & assistive devices/tech has prepared me with the foundation & confidence I need to help these little guys out.

OT is such a great profession because it allows you to collaborate with your patient to find areas that are motivating & special to each individual.  Since these kids really just want to do “typical things” my goal is to create opportunities for them to make choices & direct their care as often as possible. Obviously as an OT in a hospital setting, many interventions are centered around ADLs & grooming. One of my favorite activities with one of my favorite little chickies is having her use her Dynavox to direct a grooming task. Without doubt she always chooses “paint my nails” or “pick out clothing”. These tasks allow her to work on finger & wrist extension without the use of her very stylish black & hot pink Beniks splints, so while she feels great & proud of herself, she is simultaneously (and secretly!) refining communication skills, directing care, establishing a sense of self/personal style, AND working on upper extremity coordination goals.

What advice would you give to someone interested in your practice area?

Become familiar with wheelchair seating, assistive tech, and AAC devices! When working with kids with severe physical disabilities, it’s important to be educated on current assistive technology approaches! Become as comfortable and familiar as you can with these devices, and then remember that the kids are just kids!  

What areas of growth would like to see in the profession, with regards to your practice area? 

Many standardized assessments are motor based & difficult to administer to students who are wheelchair users, particularly those with all limb involvement. Some of the motor free assessments are difficult due to the communication skills require. I would also love to see more advanced course training for assistive technology as it relates to access & participation in daily life especially at group homes or day programs! Tools for transition preparation & assessment!

Photo of Meredith and a client by the Massachusetts Hospital School

Magic Therapy

I used to be a little embarrassed of the juggling balls that my husband keeps on his desk, but apparently I need to be taking magic a little more seriously. I just read an article on "Magic Therapy" which has been used a treatment modality in mental health and physical rehab.  There is even a magic as healing program that is approved by the AOTA. 

I might need add juggling to my own OT bag of tricks! 

Featured PT Post: UE tests for CSM

This may be old news to those of your specializing in neuro, but the neuro test for CSM described below was new to me and seemed like something good to keep tucked away in the memory banks. Thanks to Harrison Vaughn at In Touch Physical Therapy Blog for letting me repost this article! To see some YouTube videos of positive and negative tests, please check out his original post. 

HOFFMAN’S TEST AND INVERTED SUPINATOR SIGN

February 21, 2013 · by Harrison Vaughan 

One of our jobs as physical therapist’s include identifying red flags and ruling out more serious disorders that warrant referring out.

Considering I treat a great deal of spinal patients (especially ones of increasing age), one disorder that comes to mind is identifying cervical spine myelopathy (CSM).  The main concern with this condition is the compression placed on the actual spinal cord, not nerve roots.  If neurological status is worsening, this would mean immediate referral.  There are many sites to read about the pathophysiology further, but here is one you can go to.

In 2010, Cook et al published a paper entitled, “Clustered Clinical Findings for Diagnosis of Cervical Spine Myelopathy”.  The findings provided a clinical decision making tool that had high sensitivity (to rule-out CSM) and even high specificity (to rule-in CSM).  The picture below shows these values:

Out of the five tests, the two that students have the most trouble with (and never see a positive sign) are the Hoffman’s Test and Inverted Supinator Sign.  I find both of these to have high specificity values in my practice (which means if the test is positive, a high probability of an upper motor neuron disorder is present).  So, here they are:

Hoffmans’ Test:

How to perform: Grasp the patient’s middle phalanx of 3rd digit at distal end with your 2nd and 3rd distal phalanges.  Flick the patient’s distal phalanx into flexion using your thumb.

Positive test: Adduction of thumb and/or flexion of fingers

Inverted Supinator Sign

How to perform: Using reflex hammer, strike the brachioradialis tendon near radial styloid process at distal end of radius (C6 DTR).

Positive test: Finger flexion

Here is a gem of social participation, unscripted and at its best! 

Ugly Medical Records

Anyone who has worked with EMRs (electronic medical records) knows that they neither represent cutting-edge design nor user-friendliness.  As you might have guessed, research is showing that they are not saving time and money as hoped (for more info please read In Second Look, Few Savings From Digital Health Records.)

I found a source for optimism, however, though in an article published last month in The Atlantic, The Future of Medical Records, which highlights a challenge to re-imagine the health record. The entries are inspiring and give me hope that someday I will work in a setting that boasts such user friendly design.  

I was also inspired by the reminder that one of the goals of EMRs is to make records more accessible to patients. While this is not happening in a widespread manner yet, I think the industry is slowly heading this way. I look forward to clients becoming even more involved in the occupational therapy process and to the upcoming challenge of crafting notes that are empowering to patients. 

Above is a sample of the 2nd place best overall design by William Brian Smith and Leigh Salem from Studio TACK- see the complete record here.

Good PT Blogs

I can't tell whether I'm more excited for Sunday Feb. 24th so I can know who is going home with an Oscar OR so I can know who is going home with the 2013 PT Blog Awards! This is a big week people. 

If you are looking for some quality blogs to follow, let me recommend checking out some from our therapy world co-workers. Therapydia has the best PT blogs all nicely categorized for you. I have been greatly inspired by perusing some of them tonight! 

Hiearchy in Health Care

Have you found yourself afraid to speak up for good patient care at work, owing to the fact that you feel low on the totem pole? A recent New York Times article, Afraid to Speak Up to Medical Power, addresses hierarchies among doctors and you can bet your bottom dollar that similar power dynamics are pervasive across the healthcare field. 

While professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

OT Practice: Interdisciplinary Research

Do you get tired of constantly working to define lines and defend your area of practice with PT and SLP?  If a desire of yours is to truly be interdisciplinary, maybe research is a path to consider pursuing. 

The Q&A with Kenneth Ottenbacher in the January OT Practice (pg. 33) highlights the National Center for Medical Rehabilitation Research, where there is a growing push for rehabilitation science as an interdisciplinary research field. Ottenbacher states that the rehab professions are much smaller, less coordinated and much less homogenous then, say, nursing.  It seems that a key to progressing in science and research for our field is to give up our battle lines and collectively work to study rehab. 

In a fragmented field, I was pleased to find this little gem that seems to espouse the development of best practice over defending our individual practice areas. For further reading check out "Looking Back and Thinking Forward: 20 Years of Disability and Rehabilitation Research."

At a clinical practice level there has always been a need for autonomy, which is mostly justifiable. You need to have some separation, because rehab professions are different. They provide different services. They have different standards of practice, different licensure laws, so they need to be autonomous at the level of practice. But when you talk about the development of science the reasons are not as convincing.  -- Kenneth Ottenbacher, PhD, OTR

Cost of OT: Transparency

Can you imagine walking into a hospital patient's room, giving your standard OT spiel (My name is Sarah. I am from Occupational Therapy. Are you familiar with Occupational therapy?.......) and concluding with "would you like to pay $238 for an OT evaluation?" 

The New York Times just ran an article entitled "Cost for a New Hip? Hospitals are Stumped." The premise is that a student made phone calls to 100+ hospitals asking how much it would cost for her 62 y/o, uninsured but able to pay out of pocket, grandmother to receive a total hip replacement. Most hospitals were perplexed by the question and the resulting quotes ranged from $11,100 to $125,798.

Despite the current push for reigning in health care costs, the article illustrates how difficult it can be for consumers seeking competitive prices when healthcare pricing is so difficult to understand, as hospitals have seemingly had little pressure to be transparent about the cost of different services. 

It will be interesting to see how these hospitals respond to the mounting pressure for transparency and competitive pricing. For OT specifically, the evidence is pointing towards the need to get better at justifying the $238 for our service.