OT A to Z: H is for Habit

Today in our OT alphabet, H is for Habit!! If we all stopped to think about it for moment, we can probably identify several of our habits. Interestingly, we may tend to think of habits in reference to bad ones, or behaviors that are less desirable or supportive. But habits serve an important function in our occupational lives!

OTs consider habits as specific, automatic behaviors that may support - or hinder - occupational performance. The key to habits is that they are automatic so that we don't even really think about these behaviors when we do them. Examples may include the way we brush out teeth, the order in which we get dressed, how we groom our hair, or the way we place our keys in the same place upon arriving home (well - I have hear some people do that!).

What purpose do habits serve? In OT terms, effective habits enable us increase the efficiency of our occupational performance because the behaviors are automatic. For instance, how long would our morning self-care routine be if we actually had to stop and think about performing each step of brushing our teeth, getting dressed, or grooming our hair? It would take us HOURS to get ready - everyday!! But because our habits enable us to do large portions of our daily tasks efficiently, our occupational performance is improved.

But what happens when an injury or illness occurs and we are no longer able to utilize our existing habits? As OTs we work with clients to find new ways to do things, or adapt an activity, but do we use the term "habits" when working together?

Wallenbert and Jonsson (2005) published a fascinating study on the challenges people with stoke encountered in developing new habits to support their occupational performance. They discovered the participants in their study were often reluctant to utilize the adaptive strategies they learned through OT, or develop new habits, as this would be an acknowledgment that they would not continue to progress. It was as if they resisted developing new habits, they could remain in a "waiting" period to see if things improved. For me, reading the words of the study participants, made me think of our OT process in such a different way.

So, do you specifically address habits with your clients?

References

Wallenbert, I., & Jonsson, H. (2005). Waiting to get better: A dilemma regarding habits in daily occupations after stroke. American Journal of Occupational Therapy, 59, 218–224.

OT A to Z: G is for Grading

G proved a little tougher to select a word! Thanks to @kirstyes and @clissa89 for their suggestions of goals, goal attainment scaling, and groups. But I opted to use @clissa89's suggestions of "grading" as the word to represent the OT "G," as grading is a concept that is truly inherent in OT practice regardless of the client population or setting.

What is grading? Grading is the modification of an activity to support the client's performance. Grading of activities occurs in the therapeutic process when a client is working toward a specific goal. Therefore, activities may be modified - or graded - for the purpose of making them easier or more difficult, depending on the goal. Activities can be graded in a variety of ways. A few examples include increasing or decreasing the complexity or difficulty of a task by changing the amount of steps required to complete it, the amount of time given to complete a task may be altered, or the amount of cues or assistance given to the person may be changed. Grading of activities is done for therapeutic purposes and can only be done with consideration of the client's abilities.

However, the precursor to grading of an activity is a process termed activity analysis. Activity analysis is when an OT analyzes all of the complexity inherent in an activity in order to know how and in what ways to grade it. This would include things such as space requirements, the objects that must be used to complete the activity, the social or cultural requirements of the activity, the required actions to complete the activity, and the body structures and functions needed for the activity.

To illustrate this, let's think about the seemingly simple activity of making a peanut butter sandwich. As part of activity analysis we would consider demands or the requirements of the activity. This will include things like:

1. Formulate a plan to make the sandwich
2. Sequence the activity
3. The properties of the objects needed to make the sandwich such as the supplies (bread which is pliable, peanut butter which offers resistance, the knife which requires grasp)
4. Physically gather the supplies
5. Manipulate the objects - open the jar lid, open the bag of bread, hold the knife
6. Position the objects for performance of the task
7. Complete each step of the process including: get the bread out of the bag, open the jar, use the knife to get an appropriate amount of peanut butter out of the jar, put the peanut butter on the bread, spread the peanut butter on the bread without tearing the bread, put the bread together with appropriate pressure, place the sandwich on a plate, close the peanut butter jar, close the bread, wash the knife, clean the work area

First, I think we begin to recognize how even "simple" are actually complex, multi-step tasks which require multiple processes to be working effectively in parallel. After analyzing the requirements to make a peanut butter sandwich, it becomes easy to imagine how any challenge in cognitive skills, visual skills, perceptual skills, coordination, sensation, motor planning can make this activity difficult.

So how would an OT grade this activity? Depending on the goals being addressed, the OT may choose to have the supplies out already or may have the person retrieve everything from the cabinet. The OT may provide minimal or maximum cues for the planning and sequencing of the task. The OT may choose to add more items to the sandwich, or make a deli sandwich with vegetables and spread that will require numerous additional steps to complete.

In other examples of grading, if a person is having difficulty completing their morning self-care routine due to debilitation, the OT may select portions of the activity for the person to complete so they are able to do as much as possible. For instance, rather than having a person retrieve their dressing and grooming items in the room, the OT may "set-up" the activity so his or her available energy may be utilized in performing the dressing and grooming activity. As the person's endurance and safety improve, the OT may choose to grade the activity to make it more challenging, by having the person retrieve the needed items prior to dressing.

Another example of grading may be when a person is working on cognitive skills such as problem solving by developing a budget for a trip to the grocery store. To grade the activity, the number of items may be increased or decreased, the quantities of items may be changed to increase or decrease the complexity of calculations, coupons may be applied, etc.

The possibilities of grading an activity are multi-faceted, but it must be done with regard to the client's goals. OTs, because of their education and experience, have the expertise to assess the ability of the client as well as the requirements of the activity in order to achieve a therapeutic outcome.

OT A to Z: F is for Function!

Today...F is for Function!! Function is a word that is near and dear to the heart of OTs. My intuition would say that OTs probably use the word function even more often than they use the word occupation. But, as I learned in preparing this post, function seems to be one of those concepts that we know what it means but is a bit hard to actually articulate.



I fumbled with a few definitions on my own, then consulted some standard documents and texts. Interestingly, the word function readily appears - function, functional activity, functional performance - but an actual definition was elusive. After retrieving dictionary entries of function, this one seemed the most applicable:

The purpose for which something is designed or exists.

I think this really gets to the heart of how we think as OTs...we - as humans - are designed to do. Our ability to do - or to function in our environment - supports our health and is also affected by our health. So when we address function, we are focusing on ways to support a person's ability to do what they need or want to in the context of their daily lives.

So, how do you define function?

OT A to Z: E is for Evidence

In the A to Z Challenge for the letter E, there were several OT words and concepts that came to mind including environment, evaluation, and education. However, evidence is the "E" of the day because how OTs identify, use and convey evidence about our practice is so vital.

The prominence of using the best evidence to support our OT practice, or evidence-based practice has certainly increased in the past decade in OT. Evidence-based practice is defined as the conscientious use of best evidence to make decisions regarding care of individual clients, and is the integration of clinical expertise, systematic research, and patient goals (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000).

Gutman (2010) has stated that occupational therapy – like other health professions – has not fully answered questions regarding treatment efficacy and efficiency. Consequently, this has placed third-party payers in the decision-making role regarding many aspects of treatments including who receives services, for how long, and even what treatments are denied (Gutman, 2010). In an effort to build the evidence needed to respond to these external challenges, the publication goals of the American Journal of Occupational Therapy (AJOT) were aligned to match the research needs of the profession. The stated publication priorities of AJOT include: high-quality effectiveness studies; efficiency studies including cost and time efficiency, patient satisfaction, safety, and patient compliance; studies addressing the psychometric properties of occupational therapy assessment measures; studies demonstrating the relationship between participation in occupation and health indicators; and analyses of current professional issues (Gutman, 2010).

While research priorities of the profession have been stated, it is important to recognize that challenges exist in the utilization of research. Research on professional practice indicates that many barriers such as lack of time, resources, and training on how to locate and incorporate research into daily practice creates a gap in the utilization of research in clinical practice (Grol & Grimshaw, 2003).

But what about the instances where there is little systematic research or perhaps conflicting findings? Keep in mind that evidence-based practice also considers clinical experience and patient goals. The key is that we are aware of the evidence - or perhaps lack of evidence - related to an intervention and are prepared to discuss that with our clients and families.

Last week, @virtualOT shared an eye-opening blog post (which was brought to her attention by Bronnie Thompson and Claire Hayward) that was written by a parent of a child with autism. Please keep in mind that in no way do I intend for this to be a commentary on the intervention being discussed (of which I know almost nothing), nor do we know of the conversation that occurred between the OT and the parent regarding the OT's clinical experience in using this intervention. But what is clear is that the parent is well-informed and readily obtained information regarding the lack of published evidence related to this intervention. Furthermore, it is clear from the post that this experience has substantially reduced his view of OT.

In thinking about evidence-based OT...

• What is your reaction to the parent's post?


• What are barriers you experience in identifying and utilizing evidence in your practice?


• How do you work to incorporate best evidence into your practice - despite the challenges in doing so?

References

Grol, R. & Grimshaw, J. (2003). From best evidence to best practice: Effective implementation of change in patents’ care. Lancet, 362(9391), 1225–1230.

Gutman, S. (2010). AJOT publication priorities. American Journal of Occupational Therapy, 64(5), 679–681.

Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence based medicine: How to practice and teach EBM (2nd ed.). London: Churchill Livingstone.

OT A to Z: D is for Domain of OT

An exciting part of the OT A to Z Challenge is that I have received a few messages and comments from people who are not OTs! Therefore, it seems important that early in this process, we take the opportunity to address what is it that OTs do. In other words, what is the Domain of OT?

Any OT student or practitioner has undoubtedly had the experience of trying to explain succinctly and clearly what we do. No, we are not "kind of like [insert other profession - nursing, PT, social work]", nor do we just work on the upper body or find people jobs. However our work can vary tremendously depending on the setting and the client population, so explaining our work can be a bit of a challenge. Interestingly, I once read that Eleanor Clark Slagle, one of the founder of OT in the US, did not particularly like the name "occupational therapy" for the profession as she felt it was unclear and would be confusing to others.

So what is the domain of OT? It the broadest sense, it is defined in the Occupational Therapy Framework: Domain and Practice (AOTA 2008) as "supporting health and participation in life through engagement in occupation" (p. 626). While we understand what those words mean, I am not sure it helps explain to others what it is we actually do!

To be a little more specific, our domain is further defined by the areas we uniquely address:

• Activities of daily living - basic activities such as self-care, instrumental activities such as home management and driving, but also work, play leisure, education, and social participation
• Client factors - values and beliefs of our clients, but also body structures and function
• Performance skills - motor and praxis skills, cognitive skills, sensory processing skills, communication and social skills
• Performance patterns - roles, habits, routines, and rituals
• Context (our post from yesterday!) and environment - physical, social, cultural, personal, temporal, and virtual
• Activity demands - objects used, activity requirements, sequencing, timing, body structures and functions required to complete the activity

Of course, when working with a client, these things are not addressed in a linear approach as we recognize that these functions and systems are at work simultaneously and cannot be considered independent of the others. On one hand, this is an exciting delineation as we begin to see the unique contribution of OT and how no other professions addresses these aspects of engagement in participation. However, it is still quite a litany of information to provide to someone who is learning about OT!

When explaining our domain to others, I have found that using the word occupation early in the process really makes a difference. If a client, or family, or person sitting next to me on an airplane begins to understand to what we are referring to when we say "occupation," their understanding is greatly supported. So I usually say something to this effect:

Think of all the things you need and want to do during the day - you get up, get dressed, complete your grooming, prepare your meal and feed yourself, go to work or school, interact with others, socialize with friends and family, participate in a hobby - these are all occupations. If a person has difficulty performing their daily occupations due to an injury, illness, or a developmental condition, he or she greatly benefits from occupational therapy. Occupational therapists - or OTs - address a person's ability to participate as fully as possible in their daily activities. Sometimes this is achieved through the use of activity, or sometimes the underlying cause that is limiting their participation - such as decreased strength, endurance, cognition, or sensory processing abilities - is addressed. But the goal of any OT is to support a person's occupational performance.

So how do you explain the domain of OT to those who are not familiar with our profession? What words do you consistently use in your definition?

If you are not an OT, do these explanations give you a clear picture of what it is OTs do?

OT A to Z: C is for Context

The letter "C" seemed to offer many opportunities to explore, such as the array of topics suggested by @clissa89: cognition, creativity, client-centered, children, culture, and context! Whereas other professions also address many of these areas, I think context is something uniquely considered by OTs. So, today, C is for Context!!

The concepts for environment and context are often considered together and these terms may even be used interchangeably. Context is defined in the Occupational Therapy Practice Framework (AOTA, 2008) as interrelated conditions that surround the client and are within the client. These include cultural, temporal, personal, and virtual. Context is distinguished from environment in that environment refers to the external situations that surround the client to include the physical and social environments. In general, OTs emphasize occupational performance at the intersection of the client, the context and environment, and the activity.


The cultural context is includes the customs, beliefs, activity patterns, and behavioral expectations accepted by the society of which the person is a member. The temporal context is the experience of time as shaped by occupational participation and includes aspects such as time of day, duration of activity, rhythm, tempo, and stage of life. The personal context considers aspects of the individual that are not part of the health condition and includes things such as age, gender, as well as socioeconomic and educational status. Finally, the virtual context is when communication occurs in the absence of physical contact and may be real-time or asynchronous.

The aspect of context that I have spent the most time thinking about recently is that of cultural context. I am fortunate to co-teach a service learning course in Belize for OT students and we spend a lot of time considering the cultural context of the adult and pediatric clients we serve while we there. Immersion in another culture is such a profound way to experience cultural aspects of occupational performance - everything from the value of various occupations to the manner of engaging in occupations. It is a powerful learning experience as we strive to better understand the cultural context and, perhaps most importantly, not relay on or emphasize aspects of our cultural context.


In thinking about context, do you

• tend to specifically address aspects of context in your assessment and intervention, or are they aspects you consider as part for of the whole picture when working with your clients and families?
• emphasize one of the aspects of context more frequently that others?

For you personally, what aspect of your contexts either support or hinder your occupational performance?

References

American Occupational Therapy Association. (2008).Occupational therapy framework: Domain and process(2nd ed.). American Journal of Occupational Therapy, 62,625–683.

OT A to Z: B is for Balance

After consulting my OT colleagues on Twitter (thanks, @kirstyes!), it was decided that B is for Balance...occupational balance that is!

Image by cogdogblog and used under a Creative Commons License.

The concept of balance is certainly one that garners media and public press attention. Usually this is the form of discussions surrounding work-life balance. So I think there is at least a general acceptance of the notion that it is healthy to balance the activity demands and roles in our lives. And while many people may agree with the concept, this is probably one of those areas where knowing and doing may not always coincide.

But how do OTs view balance? OTs readily state that there needs to be a balance in our occupations - often thought of in general terms or self-care, work, and leisure. OTs would also assert that occupational balance and health are interdependent. Changes in health may impact occupational balance - either in the short-term or long-term, but occupational imbalance certainly may impact health.

First, how may health impact occupational balance? Let's think of two clients - perhaps one who underwent a total hip replacement due to osteoarthritis and another who had a spinal cord injury (SCI). The person with the total hip replacement will certainly experience occupational imbalance - he or she will initially have difficulty performing activities of daily living (ADLs) such as dressing, bathing, and toileting and much effort will be focused on completing self-care tasks. However, she or she will also have difficulty performing instrumental ADLs such as driving, meal preparation, and home management and most likely is temporarily not going to participate in work or leisure activities. But with the assistance of an OT, he or she will be able to adapt (our "A" word) some activities and perform them in a different way - such as dressing his or her lower extremities using adaptive equipment. And we can also assume that in a fairly short period of time, his or her ability to perform the range of occupations - from self-care to work and leisure - will be improved with recovery from the surgery and increased strength.

However, if we think of a client with SCI, it is easy to recognize that not only may they have difficulty performing many occupations but the time required to perform them leads to an imbalance. Early in my OT career, I worked with a college student who sustained a cervical SCI. He made terrific progress in his rehabilitation and achieved his goal of returning to school in a matter of months. However, he did not stay away at school for long. In talking to him some time later, he shared with me that while at college he could do everything he needed to do himself, it took him so long to do everything that tending to much beyond his self-care and making it to classes was not realistic. So when friends called to go out, he quickly grew frustrated with the time that it took him to get ready and felt that he missed many social activities because of this. So because his self-care activities took such as large portion of his time, he had difficulty achieving occupational balance.

What are some ways that occupational balance affect health? I think one area where this is truly evident is the occupational imbalance experienced by caregivers. Hunt and Smith (2004) studied the experiences of caregivers of people with stroke and found that many reported changes in their activities, their roles, and their routines. While this is probably not a surprise, it certainly warrants increased attention as reports of studies indicate that caregivers also sustain decreased health status.

Furthermore, this is really an area where OTs have the expertise to contribute to the public discourse on health. It is an interesting prospect to consider how many public health challenges could be improved at least if more attention were focused on occupational balance.

What do you think?

• Do OTs have a role in addressing the occupational balance in a public forum? If so, how might this be accomplished?
• What about in working with clients - do you address the occupational balance of their caregivers?
• How do you strive to achieve occupational balance in your own life?

References

Hunt, D. & Smith, J. (2004) The personal experience of carers of stroke

survivors: an interpretative phenomenological analysis. Disability and Rehabilitation, 26 (16), 1000- 1011.