Monday, February 27, 2012

Let's Talk About Sex

So while I typed the title, you know I was humming the song, 'Let's talk about sex, baby; Let's talk about you and me.......' :)

I've worked at a variety of places where people are at different stages of the medical process. Right after heart or knee surgery, days, weeks or months after a stroke, etc.  I feel like we cover a lot as Occupational Therapists: strength, coordination, dressing & bathing, vision, assistive technology, cognition, range of motion, adaptive equipment, ergonomics, hand therapy, play, handwriting, social skills, and the list goes on and on! One thing that we have education on but often stay quiet about is sex/sexuality.

I never completely avoided the topic, but I didn't eagerly bring it up either. If it came up, I would at least let them know that as an OT we can cover the topic and give them education if they are seeking it ::: appropriate positions after a joint replacement or stroke. If they wanted information, I'd give them a handout and go through it with them, but that was pretty much it.

At my current job it is encouraged to be brought up at evaluations or during the treatment process if it is appropriate/applicable. Usually it's on our IADL (Instrumental Activities of Daily Living) list of questions to go through: Transportation, Money management, sexual activity, household management, medication management, etc. It's a lot easier to bring it up if it's along side other topics. Some clients are more than grateful that the question is asked and I am sometimes surprised at their response, while other times people like to keep that information to themselves and don't feel it should be addressed in therapy.

Looking for information that we can give? I'd check your textbooks from school, conferences, or check the internet (just be careful as there may be some crazy results). What can OTs assist with? Sometimes it's discussing positioning and giving handouts, 'adaptive equipment' options and resources for purchasing, pictures or other options to assist with aphasia, and education of the disease/injury process and how it can affect sexuality. I've often had people discuss problems with Erectile Dysfunction after a surgery or injury, and then I'll refer them to their physician as well, as I obviously am not prescribing any meds.

Other times I've had clients that act sexually inappropriate in public either with words or actions. This could be grabbing themselves or others inappropriately (I've seen this more often with people with developmental disabilities in pubescent kids into adulthood) or saying sexual or offensive comments to others (I've seen this more often with brain injuries or long-term drug abuse...which is also injuring your brain). In those situations it's more about finding the root of those behaviors and then finding solutions to them. Maybe they need a journal to write those thoughts down instead of saying them, maybe they needs some time each day to themselves to act on those feelings in their alone time instead of doing them in public.

There are a lot of options, and I'm no pro, but I'm working on making it more common in my practice as an OT. If you're thinking about doing this too, I'd suggest going back to your books again, digging into some research, as well as asking other therapists around you. You'd be surprised at what great suggestions you may get! One of the therapists I work with actually made a binder with a ton of information she has collected from conferences, books, and other resources, and it's so nice to have a lot of things together in one spot to use as a great resource. Sometimes it feels that it's a taboo topic in our culture, but we have to do justice to it and not forget to address it. Let me know if you have any more information that has helped you in this area!

Friday, February 24, 2012

Pediatric Assessments I Use the Most

Just thought I'd go through a list of assessments I use for different ages and diagnoses of peds clients. Obviously it's different from location to location, but this is what I use the most often. I remember my first travel assignment not really knowing what assessment to use for what types of clients. Now I work a lot more often and consistently with pediatric clients, so it's gotten a lot easier. I still have a long way to go, but here's a start at least!

:::Pediatric Outpatients:::
-With all of our pediatric clients, the PEDI (Pediatric Evaluation of Disability Inventory) is completed. It gives us (OT, PT, and some with ST) a pretty good idea of where we are at functionally at time of the evaluation, and we also use it as an outcome tool to see how they progress in these areas during treatment. It's also really nice for functional goal writing as well. It goes over things like fasteners, opening snacks, jumping on one foot, etc.
-If they're younger (birth-5) or will have difficulty completing higher level tasks, I'll usually complete the Peabody (Developmental Motor Scales). I think that the Peabody is a bit hard to follow as it jumps around a bit, but it gets easier as you get more experience. If they are older than 5 but can't do something like the BOT, I will sometimes do Peabody tasks to at least get an age equivalence for insurance companies. The Peabody includes everything from reflexes in babies to holding a marker and lacing beads.
-For school aged kids (4-21), I usually complete the BOT-2 (Bruininks-Oseretsky Test of Motor Proficiency, Second Edition). I really like this assessment and it's fairly easy to administer. Everything comes in one bag and it's easy to keep it all together. Scoring isn't bad either. I also complete the Beery VMI (test of Visual Motor Integration) often with kids that are able to use a pencil. It's for ages 2-100, includes 3 parts, and is easy to administer. Hard for kids that have a hard time with sustained attention though.
-If they have sensory needs, I will go over one or two of the following with the parents: the Sensory Profile (short or caregiver), TABS (Temperament and Atypical Behavior Scale for kids 11-71 months), or the BRIEF (Behavior Rating Inventory of Executive Function, 5-18 years).

We usually do multiple assessments in an evaluation which is typically and hour. The PEDI is always completed, and we'll pair together the BOT-2 and the VMI or the Peabody and TABS. Often, if there are sensory based concerns, we also complete additional sensory based assessments that were listed as well. It's nice to get a broad view of who the client is -- both their strengths and weaknesses. Time constraints are the worst in evals, so we always encourage them to come early to get some of the admission paperwork finished before the appointment. I like to at least have some small talk with them before I drag out all of my tests, but will do things like offer them a piece of gum (much better concentration in many kids), or have some quick fun breaks between tests to jump, play on a ball, etc. Afterward, I like to give them a tour so they can be excited to hang out in the super fun gym the next time they come instead of sit in a room and do 'homework'. :)

Most insurance companies require 1-2 assessments, and usually require that children are a certain number of standard deviations (SD) from the mean in at least 2 areas to give approval for therapy. Some insurance companies require them to be 1 SD away, but many require 2 SD away from the mean. Ha, I wasn't sure I'd ever reuse my stats knowledge after I graduated, so I guess I got Punk'd!! If they're long-term kids, insurance companies require that you complete the assessments every 3-6 months to see how they are progressing.

Anyway, that's enough for now as I'm sure I'm totally boring you. :) I'll have to do another one with adult assessments. Hopefully this was helpful!

Monday, February 20, 2012

Apps for Brain Injuries

People with brain injuries make up a very large population of clients that we see daily. We work on things like cooking, dressing, cognition, balance, strength, transfers, functional use of affected extremities if that is an issue, memory, attention, path finding, money management, etc.

One thing I like to do is to provide them or their families/caregivers with dependable outside sources that they can also get information from. Sometimes as therapists who see them consistently, we may be some of the only ones that get one on one time where they are free to ask questions and have time to discuss issues they may be having in their daily lives. is a great website with fantastic information for those affected by brain injuries. One of the bummers is that our facility isn't listed on theirs as a resource in MN. Anyway, they have put together a list of 24 Life-Changing iPhone and iPad Apps for People with Brain Injuries and 18 Life-Changing Android Apps for People with Brain Injuries!!!  I actually just print a copy of these and give them to clients if applicable.

I haven't had access to them all but here are some that I have used with clients or use myself:

iPad : They are becoming more and more common for some clients to have so it is so great to have so many fantastic options available.
   - Dragon Dictation : Love this one. Dragon Naturally Speaking is also one we recommend a lot to many types of clients. Great for clients that have difficulty with organization, pain, or want things to work more efficiently if they have hemiparesis that slows them down. Downside is if clients have difficulty with cognition or aphasia, as well as certain accents/dialects.
    - Proloquo2go : I haven't used this one as much but I know our speech therapists use it often. We see it more often with kids who have speech delays but it is also incredible for those with aphasia, especially expressive aphasia alone.
    - My Emergency Info : Great to have all of your medical history in one spot in case of emergencies or to bring to appointments. It's super helpful! However, I'd maybe think about putting a lock code on it to keep it safe if I ever misplaced it.
    - Pill Time : Apps like these are a lifesaver for those who have to keep track of multiple meds or times.
    - Locate Me Now : Great! Need wireless capabilities on a network with an iPad.
    - Lumosity : GREAT website. Specifically designed for those with brain injuries. You can choose what you'd like to work on specifically and they will form a plan that fits your needs. Our facility has a membership to it so I have used it in sessions and have my own account as well. Downside, you have to pay a monthly fee.
    - There are also apps to help with calenders, grocery lists, password keepers, banking, etc.

Android :
   - Smart Hearing Aid: Have not used this one, but now I totally want to. How cool is that!
   - Evernote: I use this one often. Keep to do lists, take notes, store pictures, etc.
   - Where Am I? : also good for people with dementia
   - PTSD coach and support for veterans. There are great resources out there for those who have risked their lives for our country and our freedom. The more links we can have the better!

Do you have any others that you have used or want to use that aren't on these lists??

Sunday, February 19, 2012

Assistive Technology

Because I am the system wide float for the facility I work for, I get the opportunity to be trained in many different areas. Sometimes it's difficult for me to always be switching from one focus or facility to another, but the training I am receiving is well worth it!

This week I did some training with a Dynavox rep, as I will be working with clients who have ALS and need to know a lot more about assistive technology. It's so incredible to see what technology can do to help others access their environment. I will be getting more training from a Tobii rep in a couple weeks, but know that the devices have similar features.

For those of you who know people struggling with ALS, I would recommend checking in with their state's ALS chapter as they will usually have a lot of resources available. The one here is incredible and they make it very helpful for those diagnosed to have access to things more easily with less financial restraints.

I was able to train with the EyeMax and calibrate the machine to my eyes in order to control my choices. You can access text messaging, the internet, turn your TV channels, communicate with others, etc. By using your eyes, you can either choose a blink setting or a dwell setting. It's actually pretty tiring but your eyes need some 'training time' to get used to it. You can also access it via switch or by the touch screen if you have that capability.  It's a device that's access option can be changed as the disease progresses. Start by using the touch screen, and then advance to switch or eye gaze. There are so many incredible options with these items that are so helpful for many people.

Not only does the program use devices like the one above, but there are a lot of low tech options available to make things more accessible too. Things like different remote controls, special speakerphones, speech to text software (mostly Dragon Naturally Speaking), visual aides for staff or friends to help make sure daily routines are more consistent or to explain the nature of the illness, voice banking phrases so the client will be able to use their voice to communicate rather than the device, switches to allow visitors into secure entries, etc. Total independence isn't usually an option eventually, but it's so nice to empower people with as much control of their surroundings that they can manage.

Here is a video of Augie Nieto using the device to communicate. Check it out, and enjoy the rest of your Sunday!

Sunday, February 12, 2012

Fieldwork Advice

Lately I've had a few conversations with co-workers and friends about students: OT, PT, ST, etc. There a lot of students where I work and they have always seemed very prepared and ready to take on the demands of being a student. However, I've known some people who have had a lot of problems with students. I'll give you a couple examples of the kinds of students we get nervous about as well as a GREAT link written by students and others for tips for OT fieldwork. A lot of it would also apply to other areas of work as well.

I personally have never had a student for the whole 12 or 8 weeks because of the nature of my past employment and most likely won't in my current position since I will often be floating from position to position. I have had experience supervising students however in both OT and COTA roles, mostly for shorter periods of time.

I think having a student is great but I wouldn't be able to do it all year long. It's a lot of extra work for the therapist, mostly in the beginning, because of the prep work and maintaining your caseload while helping the student become comfortable with everything. As time goes on and the student becomes more independent and confident with clients it's great! For me it's a great learning experience and keeps me on my toes sometimes making me a better therapist. There are good clinical educators and not so good. I hope you only end up with the good. :) There are also good students and not so good students. Your fieldwork will help shape you into the therapist you will become, so take it seriously and have fun!

Some problems that are more common are students that aren't professional: dress, talk, and actions.
Dress:  I've seen students and other co-workers who have worn clothes that are either way too tight or low where skin shows that is super unecessary. Be sensitive to the cultures you work with. Some may be very offended. If you wear scrubs, wear something underneath. When you're bending over to help them with socks, shoes, or whatever, the client can often see everything. If you don't wear scrubs, watch how low your shirts are. Also, make sure they cover your back is covered when you bend over from behind. Your clients do NOT need to see your back tattoos, butt, or what kind of underwear you're wearing.
Talk: Be compassionate. Try to make conversation if client's want to talk, but make sure it's appropriate. Often religion, politics and sometimes death are stay away topics. If it comes up, don't be one sided. A friend of mine just told me that they had a student tell a client that they didn't like a certain denomination of Christianity because they weren't 'real' or 'authentic'. Turned out that the client practiced that denomination. I can't imagine how angry I would be with that student. I've worked with others who talked often of their fear of death in front of client's that were trying to defeat it. Also, talk at their level. If they are kids, don't talk to them like they are infants and know some of them have real hard problems in life and reasons for their behaviors. If they are elderly, don't assume that they are hard of hearing and remember that they have led an important life worth learning about. Don't assume anything.
Action: I often bring water into my sessions, and offer it to my clients as well. However this is not appropriate in all settings. Always let client's know what you are going to do before you do it. We would never want to be treated in that way in our own personal appointments. Be kind. If someone is asking for directions and you don't have time, find someone to help them. Smile. You are representing that company for the time you are there, make your representation positive.

Here is the link with some great advice. It was last updated in 2003, but is from AOTA and was put together by ASD (Assembly of Student Delegates) Steering Commitee. I'll put a bit of their information here. It talks about finding housing, how to get by without much money, what will prepare you the most, advice from others, skills to brush up on, time and stress management, tips, sample code of ethics for students, and common fears about fieldwork. It's definitely worth checking out! Here is the sample code of eithics and common fears::::I'll add my comments in a different color.

Sample Fieldwork "Code of Ethics" for Students
• Respect and adhere to the philosophy, policies, and procedures of the fieldwork center.
• Respect the opinions and decisions of the supervisor. Disagreements with stated policies, procedures, or directions should be discussed with the student’s immediate supervisor. If there are problems, also discuss this with your Fieldwork Director at your school.
• Respect, protect, and conserve the resources available to the student for learning and therapeutic purposes; prevent misuse, abuse, or destruction of materials, equipment, and resources. If you want to take copies with you when you leave, ask how you can use them in the future::(Will they care if you make copies and give them to future clients?)
• Maintain the clinic environment in a safe, organized manner and contribute to the maintenance of adequate supplies and equipment.
• Respect the rights and assure the integrity of clients/patients, which includes assuring confidentiality of treatment information regardless of the source as well as maintaining a goal-directed relationship.
• Complete all documentation related to the fieldwork experience in a timely manner and in accordance with fieldwork facility guidelines.
• Adhere to the contractual agreement for fieldwork education between their fieldwork center and academic program.
• Retain proof or current malpractice, professional liability, and health insurance. Your school usually helps to take care of the malpractice and liability insurance.
• Respect, cooperate, and collaborate with other members of the health team.
• Serve as an advocate for clients, their families, the fieldwork center, and occupational therapy.
• Contact the fieldwork coordinator when resolution of fieldwork problems with the supervisor is not successful or when concerns about continuance of the fieldwork arise.
• Abide by the uniform requirements of the fieldwork facility and assure a professional appearance that does not hinder the treatment environment.
• Commit to continual learning throughout the fieldwork program by using unscheduled time to observe therapies, engage in educational interaction with other team members, review resource materials, or engage in other professionally relevant educational opportunities. Take advantage of this, it's well worth it!!
• Be accountable for actions at all times during the fieldwork experience by recognizing that the facility is first and foremost a treatment environment and secondly an educational environment.
-Treatment has priority over education, and it is the student’s responsibility to assure this process while also maintaining his/her educational needs.
• Self-direct their learning as much as possible, carefully assess the need for supervision during difficult situations, and seek appropriate supervision before proceeding. Go home and research things you may have questions on, then seek further advice after. Go back to your books, search journals, and do a Google/Bing/Yahoo search!
• Seek information regarding principles, standards, and policies of fieldwork setting, fieldwork education, and the profession.
• Support quality assurance and research related to the fieldwork setting practices
• Do not act with improperly or engage in illegal conduct while on the fieldwork or act in a way that would question one’s integrity as a professional.
Crist, P. A., & Slach (1986). Fieldwork Philosophy. Contemporary Issues in Clinical Education, 7, 67-68.

Common Fears About Level IIs
• Don’t be afraid to express your thoughts and ideas. It might seem overwhelming at first, but you will feel comfortable and very competent by the end I usually did this after sessions with my supervisor, depending on the situation. They may have already attempted that with the client or maybe not at all. Sometimes it's more appropriate to bring ideas up after or prior to a session.
• Be enthusiastic—give ideas—everyone appreciates a new or different perspective - Same as above
• Relax and remain confident
• Groups and treatment sessions will fail—it’s okay, learn from it. We still sometimes feel this way at times, it's ok.
• Don’t be afraid to be wrong, try your ideas
• Keep a positive attitude, and speak up if there is a problem
• You won’t remember everything, that’s what books are for. Use them! Agree!!! :)
• Expect the worse and hope for the best - I'd say to expect anything, always be overly prepared.
• Don’t be afraid to contribute in team meetings
• Twelve (eight) weeks go by quickly, good experience or bad - Super true
• Go in with an open mind, you may see some pretty strange things - Yup!
• Your supervisor is there to help/teach, use his/her resources
• You will not be a perfect OT/OTA, not now, not even when you have 10 years experience :)
• Don’t be afraid to try new things. Don’t be afraid to ask questions. Don’t be afraid of your patients—treat them with love and respect. Learn from your patients, they have much to teach as well
• Keep a variety of resources, including your textbooks handy for reference. Use libraries and reference materials available at the site
• Clearly communicate your learning style with your supervisor in order to prevent yourself from becoming confused or overwhelmed during your fieldwork experience
• Relax and observe other professionals
• Be prepared to spend time on documentation techniques and language
• Learn to set limits with patients
• Ask for feedback if you feel you need it
• Keep a journal or patient log, writing down specific diagnoses and how you treated each patient (i.e. treatment plan, activities, what was good, what was bad, what you would have done differently, etc).

Alzoni, D., Link, S., & Trone, J. submitted as part of course requirement for OT 410: Administration, Management, and Supervision at Elizabethtown College, Elizabethtown, PA

So there you go! There is a ton of other advice out there, but here are at least a few good niblets of info to start with. Sorry it was so long, hopefully it was helpful!!!