Blog Title: ABC Therapeutics Occupational Therapy Weblog

Reading recommendations...

I have been absent for a couple weeks - immersed in important tasks that precluded my writing. While 'away' I did quite a bit of reading and so want to share some of my recent perusal.

1. A great blog post was brought to my attention recently. This should be required reading for all OTs... Emily writes in 'A life less ordinary' about "To OT or not to OT." Don't stop at that one entry - keep reading. This blog is so full of excellent writing and parent perspective that it will keep you busy for a very long time.

2. Connor Gifford is a young man who has Down Syndrome and he co-wrote a book entitled "America according to Connor Gifford." This book has a clarity to it that is difficult to find in writing about historical events. Go buy it. Today.

3. Ori and Rom Brafman wrote the book "Sway: The irresistible pull of irrational behavior." This entire book is fascinating, but OTs will be particularly interested in the chapter on 'the bipolar epidemic and the chameleon effect." When you read this chapter you can't avoid the questions that will enter your mind about self-perpetuating circle that drives away science in the diagnostic process. Sensory integration, anyone?

4. Siddhartha by Herman Hesse. I read this once every few years because I enjoy the process of the protagonist's development. Siddhartha achieves his goals and does so by his own unique path. It is an interesting allegory for an occupational therapy process of client-centeredness and self-direction in occupational choice.

There was a lot more - but these were the most interesting.

On the occupation of blog editing

I get dozens of emails daily from readers and I generally enjoy them all. I try to respond to most emails.

Sometimes I get comments directly on the blog but those are more rare. I guess that many people prefer anonymity and that is fine.

Many of the comments are from anonymous people and I am frequently torn about whether or not I want to advance their comments. For example, someone may agree or disagree with something that I have written and they want to advance their own opinion on it - but they don't want to put their name with their comment.

This is easily fixed by disabling anonymous comments but some of the most thought-provoking comments are anonymous. All my life I have been fascinated by anonymous self expression - like carving into picnic tables or graffiti or on publicly posted leaflets or pamphlets. That is a topic for another day.

Many of the comments that never get published here are links to people's proprietary websites that sell products and I never wanted my blog to become a trolling site for potential customers. I get the whole 'long-tail' phenomenon but that is not what this blog is about.

Another category of comments that never get published are drive-by hit jobs on people or ideas or products. I don't mind publishing someone's opinion about people or ideas or products (even if their opinion is about me or the things I write) but if they want to engage in drive-by hit jobs then I figure they can at least let people know who they are.

Anyway, sometimes I wish that the dialogue was a little broader but it is what it is. Of the thousands and thousands of hits this site gets we usually only get a comment or so a week. That makes my blog more about my own rants then about bilateral dialogue but I suppose that can change since this is a dynamic observation of the situation.

So my policy that is in effect today is that I prefer people to take responsibility for their comments. If people take responsibility it is more likely their comments will be published. The exceptions are if something is particularly witty or poignant or if I change my mind.

Auditory interventions - a trip down the rabbit hole

I posted two and a half years ago about problems with a lack of evidence for the Wilbarger intervention methods. In that post I included a link to http://www.sensorydefensiveness.com/ which at the time was allegedly sponsored by Pat Wilbarger. Now that website curiously redirects and links to a mirror page for Valerie Dejean and The Spectrum Center, which is now located in New York. Apparently they used to have a center in Maryland, but according to documents from the Maryland Board of Occupational Therapy Practice, it is a matter of public record that a Valerie Dejean surrendered her license to practice for several reasons including:

• use of the Tomatis Electronic Ear which has been banned by the FDA
• use of unlicensed persons to practice occupational therapy
• fraudulent billing practices

I previously wrote about concerns with the Tomatis program and the FDA ban here.

So in summary this Tomatis progam is not generally accepted but some occupational therapists continue to flirt with these programs. I don't understand why.

I called The Spectrum Center today to get more information and they told me that they do not practice occupational therapy in New York state. They are still using the Tomatis device and they told me that they use a combined approach that includes sensory integration techniques and Tomatis. But it is not OT. On their website they call it "vestibular re integration" and claim "80 percent success in improving if not curing these 4000 autistic children."

This is just conjecture - but based on the current prices they reported to me ($400 for an evaluation and $7440 for the 'therapy') that is a windfall of over $30,000,000.00 dollars. That's not a bad days work, especially for someone who had to surrender their license to practice occupational therapy.

The rabbit hole continues - a Dr. Ron Minson owns Integrated Listening Systems. His work is based largely off of Tomatis as stated on his website - but rather than using the banned FDA device his system relies on music recorded on an IPod. They also have a 'device' that they sell (the iLs 1000) but I don't know if this is related to the banned FDA device.

Interestingly, in a fascinating document available online that references the Dejean case, the FDA is asked to evaluate the Tomatis version of the device. Referenced in the petition is that manipulation of the Freedom of Speech principle would allow filtered music to be streamed online or distributed on compact disc. The CDs or online streamed filtered music would presumably be protected as 'Free Speech.'

There are a plethora of 'filtered music' CDs and programs, like Dr. Minson's, that are being marketed and distributed in an apparent loophole around the FDA ban. So with all this filtered music - where are the devices located that MADE the filtered music?

So why mention Dr. Minson specifically? Well he is directly associated with Dr. Lucy Miller and together they co-founded the Sensory Therapies and Research (STAR) facility. The SPD Foundation (formerly the KID Foundation) is a Colorado public charity sponsored in part by STAR Center. According to this page, iLs makes donations and training discounts for the benefit of The SPD Foundation.

The SPD Foundation, from my perspective, has contributed significantly to the knowledge base of sensory processing disorders. But why be entangled with Tomatis and similar programs that are under such heavy criticism. At a time when people are trying to determine if SPD is eligible for inclusion in the DSM, how can alignment with Tomatis help the cause?

A bottom line issue remains - and I am still waiting for someone to stand up and explain this - but I believe that this auditory intervention is only tenuously related to occupational therapy practice. Occupational therapists don't typically intervene with direct auditory stimulation in any other interventions - so how did some practitioners come to think that this is within the OT scope of practice?

When most people think of auditory evaluations or auditory interventions they obviously think that is within the scope of practice of an audiologist or perhaps a speech pathologist. If you search the American Academy of Audiology website for 'Tomatis' there are no results returned. Anyone out there beside me wonder why? Here is the most recent document on the subject from the American Speech Language and Hearing Association. Do OTs know something that the speech therapy professionals don't?

I think that OT as a profession needs to come to grips with this issue. Here is my attempt to start a conversation.

Public Law 110-374 - The Prenatally and Postnatally Diagnosed Conditions Awareness Act.

Abortion rates of children who have disabilities are high, in excess of 90% of all pregnancies of children who have Down Syndrome (Mansfield, Harper, Marteua, 1999). In consideration of recent conversations here I think that it is critical to highlight the passage of a new law. Public Law No: 110-374 is called the Prenatally and Postnatally Diagnosed Conditions Awareness Act. It is the purpose of this Act to--

(1) increase patient referrals to providers of key support services for women who have received a positive diagnosis for Down syndrome, or other prenatally or postnatally diagnosed conditions, as well as to provide up-to-date information on the range of outcomes for individuals living with the diagnosed condition, including physical, developmental, educational, and psychosocial outcomes;

(2) strengthen existing networks of support through the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and other patient and provider outreach programs; and

(3) ensure that patients receive up-to-date, evidence-based information about the accuracy of the test.

This law, while opposed by some ardent partisans, had strong support from people on both sides of the abortion debate. Much of the impetus behind this legislation can be tracked back to the efforts of people like Dr. Brian Skotko. I strongly recommend you go to his site and read some of his work.

I read rather widely and this new law has barely gotten any attention.This law will strengthen the informed consent process around prenatal testing. Spread the word - this may be one of the most significant disability rights laws that we have seen in a very long time. It doesn't matter what side of the abortion debate you may be on - this law is a major step forward in providing real support for families and children.


References:

Mansfield, C., Hopfer, S., Marteau, T. (1999). Termination rates after prenatal diagnosis of Down syndrome, spina bifida, anencephaly, and Turner and Klinefelter syndromes: a systematic literature review. Prenatal Diagnosis, 19(9): 808–812.

Skotko, B. (2005). Mothers of children with Down syndrome reflect on their postnatal support. Pediatrics, 115: 65-77

Skotko, B. (2005). Prenatally diagnosed Down syndrome: Mothers who continued their pregnancies evaluate their health care providers. American Journal of Obstetrics & Gynecology, 192: 670-77

Sensory processing characteristics of adults who have complex regional pain syndrome

I. Literature Review

Introduction

The purpose of this project was to explore complex regional pain syndrome (CRPS) by using current models of sensory modulation disorder (SMD) and by using narrative interview. Sensory processing theory as grounded in sensory integration theory (Ayres, 1979, p. 5) and later modified by Dunn (1997) provided the background neurophysiological models for this study. Dunn stated that there is a relationship between neurological sensory thresholds and observed behavior (1997). The Sensory Profile was used to provide an assessment of this relationship based on the report of patients who have CRPS. This type of test that measures behavioral responses was used in this study to inform a narrative inquiry to understand the impact that these disorders have on occupation.

Current scholars are integrating sensory integration theory into occupation-based intervention approaches by re-examining ways to broaden Ayres’ original concepts (Parham & Mailloux, 2001, p. 330). Although Ayres may not have explicitly described the impact that disordered sensory systems have on occupations, these concepts can be applied to develop a richer understanding of what it means to have sensory processing difficulties.

Some practice models identify the relationship between the individual, the occupation that is being performed, and the environment. The P-E-O model (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996) states that behavior can’t be separated from its contextual influences. This type of model was helpful in describing the relationships between personal/constitutional factors, chosen occupations, and illness factors for people who had CRPS.

My initial interest in this topic was generated by seeing patients who developed CRPS and learning that the recommended occupational therapy treatment protocols for this condition include sympathetic stress loading (Carlson & Watson, 1988; Phillips, Katz, & Harden, 2000). These protocols for sympathetic stress loading seemed very similar to the recently popularized “sensory diet” protocol (Wilbarger & Wilbarger, 2002, p. 335-338) used for people who had SMD. My familiarity with both patient populations of adult orthopedics and pediatrics provided perspective and interest in the topic. I continued to read extensively on the topic of pain and pain sensation, initially motivated after reading the groundbreaking work of Melzack & Wall (1965). My interest in the subject has never diminished and this has led me to the literature contained herein and the interest in completing this project.

Studies of sympathetically mediated pain provide evidence that hypotheses regarding central processing may be useful in describing the pathological mechanisms involved in CRPS. Still, a larger question that remains unanswered is whether or not there was an increased risk of developing CRPS because of the sympathetic processing differences or if those differences became evident as a function of the CRPS. To date, there have not been any predictive epidemiological studies of CRPS that would address this basic question.

There is potential utility for exploring the relationships between CRPS and sensory processing. First, if there is a population of people who have SMD and are more at risk for developing CRPS it could be helpful to know who they are so that early intervention could be attempted as soon as they incur an injury to a limb. Second, if there is an underlying mechanism of sensory processing dysfunction that predisposes people to CRPS, this would provide a more solid physiological explanation for what occupational therapists currently identify as SMD. The research that has been completed on CRPS may provide important information for helping occupational therapists understand SMD.

Although any implied linkages between these conditions are theoretical at this time, identifying common features of the disorders could assist in understanding them both at a deeper level.


Complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a disorder characterized by chronic pain that is disproportionate to the trauma that caused the pain. It is important for clinicians to be able to understand different types of pain, and there are clear distinctions between acute nociceptive pain and chronic pain. Nociceptive pain is related to the degree of receptor stimulation that is caused by a specific tissue injury, and involves the normal activation of the nociceptive system by noxious stimuli (Kandel & Jessell, 1991, p. 386-7). By contrast, chronic pain may occur by continued irritation of the nociceptors, which can cause neuroactive, biochemical, inflammatory, or vasoactive effects such as histamine release that can activate or increase the sensitivity in the cellular/receptor environment (p. 386). Over time, peripheral to central processing may also modify nociception, (p. 389-92) and behavioral/emotional states may also influence the perception of pain (p. 398). Chronic pain syndromes can often lead to long-term disability and loss of occupational functioning; for this reason they have been studied extensively and are of interest to occupational therapy practitioners.


Classification

Complex regional pain syndrome has been called many different names such as reflex sympathetic dystrophy, causalgia, and Sudeck's atrophy. This disorder commonly occurs in the limbs following an injury. Typical features include dramatic changes in the color and temperature of the skin over the affected limb or body part, intense burning pain, skin sensitivity, sweating, swelling, decreased joint mobility, and changes in nail and hair growth patterns (NINDS, 2003).

The International Association for the Study of Pain developed a classification system that delineates CRPS into two distinct categories (Stanton-Hicks, Janig, Hassenbusch, Haddox, Boas, & Wilson, 1995). In CRPS I the individual may experience regional pain and sensory changes following a trauma. In CRPS II there is also regional pain and sensory changes but a nerve lesion is identifiable. CRPS I is classically associated with the previous entity defined as reflex sympathetic dystrophy; CRPS II is associated with the previously defined condition of causalgia (Baron & Wasner, 2001).


Etiology

There has been considerable debate regarding the etiology and pathophysiology of CRPS. Sympathetically maintained and sympathetically independent pain categories are phenomena that are referenced in the current classification system (Stanton-Hicks, Janig, Hassenbusch, Haddox, Boas, & Wilson, 1995). Sympathetically mediated pain is typically identified by its amelioration after treatment of sympathetic-blocking intervention, while sympathetically independent pain does not (Manning, 2000). However, it is unclear if these two classes are entirely independent of each other or if they can occur at the same time. This distinction may be important in understanding and developing intervention for CRPS.

Several researchers have investigated sympathetic nervous system functioning in patients who have complex regional pain syndromes. Specifically, several studies indicate that the nervous systems of people who have these syndromes are measurably different than normal. For example, normal inhibitory influences on pain during sympathetic arousal are compromised in the majority of patients with CRPS (Drummond, Finch, Skipworth, & Blockey, 2001). Evidence also exists that patients who have sympathetically mediated chronic pain have widely spread prefrontal hyperactivity, increased activity in the anterior cingulate, and decreased contralateral thalamic activity as measured by functional magnetic resonance imaging (Apkarian, Thomas, Krauss, & Szeverenyi (2001).

Another hypothesis is that there is brain reorganization in the primary somatosensory cortex of patients who have CRPS and that the degree of neural reorganization as measured by magnetoencephalography is directly related to the degree of pain (Maihofner, Handwerker, Neundorfer, & Birklein, 2003). Another study identified a change in the central representation of somatosensation, most likely in the thalamus or cortex, and that sensory threshold are higher on the affected side of the body in people who have CRPS (Rommel, Malin, Zenz, & Jänig (2001).

Preliminary studies demonstrate that brain imaging scans are different for people who have CRPS (Juottonen, Gockel, Silen, Hurri, Hari, & Forss, 2002). Other authors (Schwoebel, Friedman, Duda, & Coslett, 2001) found functional neurological changes in patients who have CRPS. Specifically, they state that patients who have CRPS have impaired body schema involving their painful limbs, suggest atypical processing of proprioceptive, somatosensory, and vestibular sensory inputs. These studies provide evidence that hypotheses regarding central processing may be useful in describing the pathological process involved in CRPS.

Differences in neuroendocrine functioning may explain some alterations in central processing of somatosensory inputs. Janig & Baron (2002) state that nociceptor hyperexcitability may be facilitated by sympathetically-released norepinepherine, which in turn may generate a state of central excitability that causes spontaneous and secondary evoked pain. Therefore, the pain and sensory changes seen in CRPS I may be the result of distorted processing of information in the central nervous system involving the somatosensory pathways.

The pattern of progression of symptoms has also been useful in generating hypotheses about the mechanisms underlying these disorders. For example, Maleki, LeBel, Bennett, and Schwartzmann (2000) describe patterns including contiguous spread, independent spread, and mirror spread. Contiguous spread represents localized progression of symptoms close to the initial injury site. Independent spread represents general nervous system susceptibility for CRPS evidenced by symptoms in distal/unrelated parts of the body. Mirror spread represents contralateral processing errors where symptoms are noted on the opposite side of the body to where the injury occurred. These differing patterns all represent different neurological processing of responses to the initial injury.

Some research is beginning to investigate genetic predisposition for developing CRPS. Janig & Baron (2003) and Wasner, Schattschneider, Binder, & Baron (2003) both reviewed studies that identified possible genetic causes. The studies that have been completed are preliminary; controversy remains regarding the role of genetic factors on this disease.

The presence of psychological factors in people who have CRPS has led to ongoing speculation that there may be a psychological basis for these disorders. A biopsychosocial model (Van Houdenhove & Vasquez, 1993) of CRPS suggests that loss of occupational functioning can lead to helplessness, which in turn causes passive coping and stress-related sympathetic overreactivity and higher norepinephrine levels. The authors suggest that these factors contribute to worsening of symptoms. However, although stress responses may exacerbate symptoms it is now generally accepted that there is no common psychological profile of people who have CRPS (Lynch, 1992). Rather, it is believed that CRPS leads to anxiety and depression rather than anxiety and depression leading to CRPS. This is a phenomenon that continues to be the subject of interesting research that has mixed results. For example, Harden et.al. (2003) found that preoperative distress and pain had modest utility in predicting CRPS signs, although there was a high rate of false positive identification. More research is needed to help clarify the relationship between psychological profile, psychogenic predisposition, and CRPS.


Diagnostic tests for CRPS

Diagnostic testing that identifies common parameters of physiologic functioning could be helpful in investigating the possible intersection of CRPS and SMD. However, there is no specific diagnostic test for CRPS. Several medical tests can be used to assist in the diagnosis. Bone scans (Schiepers, 1997) use radiation to identify areas of bone where there may be abnormalities. Infrared thermography (Gulevich, et.al., 1997) measures relative temperature distributions in the limb which may provide information about blood flow and sympathetic activity. Axon reflex testing (Chelimsky, et.al., 1995; Low, Caskey, Tuck, Fealey, & Dyck, 1983), and resting skin temperature/resting sweat output (Chelimsky, et.al., 1995) have also been described in the literature. These are nervous system tests that provide specific information regarding autonomic functioning. Selective tissue conductance (National Pain Foundation, 2003) is a newer diagnostic test that measures galvanic skin responses but it has not been well researched.

In some cases, a sympathetic nerve block can be used to diagnose CRPS in patients with clinical evidence of sympathetically mediated pain; however, not all CRPS is due to sympathetic nerve dysfunction (Rho, Brewer, & Wilson, 2002). Some researchers have tried to identify patients who are at higher risk for CRPS based on other factors including psychological profile, genetics, and sensory processing but none of these are widely accepted and used for diagnostic purposes.

Diagnosis is generally made by the presence of clinical signs and symptoms including dramatic changes in the color and temperature of the skin over the affected limb or body part, intense burning pain, skin sensitivity, sweating, swelling, decreased joint mobility, and changes in nail and hair growth patterns (NINDS, 2003). Additionally, the physician will gather important patient history and rule out any other conditions.


Diagnostic tests for sensory modulation disorders

Pfeiffer & Kinnealey (2003) describe the use of the Adult Sensory Questionnaire (Kinnealey & Oliver, 2002) to determine degree of sensory modulation difficulty but this tool is not widely accessible or commonly used. Kinnealey & Fuiek (1999) also used the Adult Sensory Questionnaire and proposed a model of interrelationship between SMD, anxiety, depression, and pain perception in adults although they noted that more research was needed to clarify these relationships. Preliminary studies (McIntosh, Miller, Shyu, & Hagerman, 1999) support the presence of a physiological basis of SMD, finding that electrodermal responses were larger in children with SMD, excepting those who were non-responders. Additionally, children with atypical electrodermal responses had more parent-reported abnormal behavioral responses to sensation. Miller, et.al. (1999) identified Fragile X syndrome as a clinical condition where baseline hyperarousal may exist because unimodal over-reaction predicted hyperarousal in other sensory modalities. Additionally, Schaaf, Miller, Sewell, & O'Keefe (2003) found that cardiac vagal tone index was significantly decreased for children who had identified sensory processing difficulties. These studies provide preliminary evidence that there is a physiological basis for SMD. All of these studies used the Sensory Challenge Protocol (Miller, et.al., 1999) which is a research tool and is not designed for clinical application. A single case study (Reisman & Gross, 1992) using physiological markers of an adult has also been reported to identify improvements following intervention for SMD.

The Sensory Profile is a standardized assessment used by occupational therapists “to measure a child’s sensory processing abilities and to profile the effect of sensory processing on functional performance in the daily life of a child” (Dunn, 1999, p. 1). Dunn states that there is a relationship between neurological sensory thresholds and observed behavior (1997). The Sensory Profile (Dunn, 1999) provides an assessment of this relationship based on the report of the child’s parent. The Adolescent/Adult Sensory Profile (Brown & Dunn, 2002) provides an assessment of this relationship based on self-report. These measures are the most widely used and widely accepted standards used by occupational therapists for assessing SMD.


Summary of diagnostic tests

Both CRPS and SMD are disorders that are not easily identified and are typically diagnosed through the use of tools that involve clinical observations of presenting symptoms or a report of those symptoms. Researchers often measure neurophysiologic characteristics to determine the presence of each disorder. Many of those neurophysiologic markers are common to both disorders in that they represent altered sympathetic/autonomic functioning; however, most of those tests are not easy to administer in a clinical environment.

The Adolescent/Adult Sensory Profile (AASP) represents a behavioral self-report of sensory processing. The AASP measures four quadrants of sensory processing as identified by Brown and Dunn (2002). The four quadrants include sensation seeking, sensation avoiding, sensory sensitivity and low registration. Preliminary studies suggest that this format of assessment is an accurate predictor of altered neurophysiologic functioning. Specifically, this four quadrant model was validated through expert rating and skin conductance testing (Brown, Tolefson, Cromwell, & Filion, 2001).

The AASP is easy to administer and it is non-invasive. As there seem to be common underlying features of CRPS and SMD relating to altered sympathetic functioning, this assessment may be clinically useful for predicting sympathetic hyperarousal that may potentially lead to CRPS. Additionally, if the assessment is sensitive enough to identify the relationship between CRPS and SMD it may provide evidence of a common underlying neurological deficit between the two conditions.


Face validity for the use of the AASP for predicting CRPS

The Adolescent/Adult Sensory Profile is a sixty item self report questionnaire designed as a “trait measure” (Brown & Dunn, 2002, p.1) of sensory processing, meaning that the individual is supposed to answer regarding how they generally respond to sensory stimulation. It does not measure specific response patterns to specific sensory stimulation. The AASP measures responsivity across categories of taste/smell processing, movement processing, visual processing, touch processing, activity level, and auditory processing (p.2). From these scores the assessment provides a profile of sensory processing across four quadrants: low registration, sensation seeking, sensory sensitivity, and sensation avoiding (p.1.). Dunn’s Model of Sensory Processing (1997) is used to explain the relationship between altered neurological thresholds and the impact that this has on daily life functioning.

Based on previously identified evidence of altered sensory thresholds leading to pain and hyperarousal in people who have CRPS, it seems reasonable to apply Dunn’s model to this population. Although the exaggerated state of sympathetic arousal in people who have CRPS is not clinically identical to hyperarousal in people who have SMD, these two conditions may constitute a continuum of pathology that is reflective of sympathetic nervous system dysfunction.

Literature review does not provide information regarding any possible connections between these disorders, although the presence of parallel studies that examine neurophysiologic/sympathetic markers is intriguing. Occupational therapists who understand these two conditions may assist in elucidating common features that will assist in understanding both CRPS and SMD. The significance of this inquiry is considerable. The ability to identify the population of people who are ‘at-risk’ for developing CRPS would be invaluable for clinical purposes of intervention planning. The significance of this is even greater if this can be determined through the use of a non-invasive self-report questionnaire like the AASP. Additionally, there is only beginning physiologic rationale and understanding of SMD. If a link is present between these disorders CRPS may provide an interesting presentation of sensory-affective hyperarousal that can help occupational therapists better understand SMD and how it impacts occupation.


Summary

Complex regional pain syndrome and sensory modulation disorder are clinically distinct entities that are often treated by different populations of occupational therapists. As a result, there has not been any literature describing or exploring any intersection of these disorders. There has not been any documentation of discussion regarding the intervention strategies that overlap and address similar underlying components of both disorders.

Both disorders are poorly understood, but hyperarousal and excessive sympathetic nervous system outflow are suspected as being significant contributors to both of these disorders. Sympathetic stress loading techniques are commonly used as intervention for both conditions.

Occupational therapy researchers are conducting studies regarding neurophysiologic parameters that would help to quantify sympathetic nervous system hyperarousal. Similar testing techniques have already been used in researching complex regional pain disorders.

Because of multiple points of commonality, assessment strategies useful for sensory modulation disorders may provide useful clinical information regarding complex regional pain syndrome. In turn, these points of commonality could provide a stronger basis of neurophysiologic rationale behind the explanation of sensory modulation disorders.

This paper describes an initial attempt at investigating the intersection of these two disorders. Researching the similarities between these two conditions provides useful clinical information that can lead to better understanding of the disorders and improved intervention strategies and patient outcomes.


II. Methodology

Sample size and composition:

Five subjects were identified for participation in the study. The subjects were all over eighteen years of age. Subject criteria stated that they could be either male or female, but had to be English speaking and residents of the Counties of Erie or Niagara in New York State. All subjects had to have a current diagnosis or recent history of complex regional pain syndrome secondary to orthopedic injuries including fractures, ligament or tendon injuries, or peripheral nerve damage.

The principal investigator provided eligibility criteria to the lead therapist at the ABC Therapeutics facility in Lockport, NY. Based on the criteria, the lead therapist used purposive sampling to develop a subject eligibility list. Subjects were then given an invitation to participate in the study. After subjects expressed interest to participate in the study, all personal and confidential information was de-identified and presented to the principal investigator. Patient charts were never viewed by the principal investigator.

Purposive sampling was used with specific selection criteria as follows: all subjects had to have current or historical clinical signs of complex regional pain syndrome; they had to be over 18 years of age at the time of their initial injury, and they were drawn from the patient pool at a private occupational therapy practice in Lockport, New York. None of the subjects will be patients of the principal investigator. Maximum variation sampling was used regarding subject gender, underlying orthopedic condition, educational attainment, and job title.


Informed consent:

Subjects who expressed an interest in participating were contacted for an appointment to discuss the study with the principal investigator and to sign the informed consent paperwork. During this appointment the principal investigator provided informed consent information to the subject to read. The principal investigator answered all questions relating to the study and the informed consent forms and followed the format as listed on the signature sheets. Once the informed consent process was completed, the subjects were invited to stay to complete the two assessments. Additional appointment times to accommodate the subject’s schedules were provided, as necessary.


Methods and Procedures

Following selection and informed consent processes, the principal investigator provided subjects with the Adolescent/Adult Sensory Profile (AASP) (Brown & Dunn, 2002) to complete. The AASP is a standardized assessment used by occupational therapists to measure sensory processing abilities and to profile the effect of sensory processing on functional performance in daily life. Dunn states that there is a relationship between neurological sensory thresholds and observed behavior (1997). The AASP (Brown & Dunn, 2002) provides an assessment of this relationship based on self-report. This measure is the most widely used and widely accepted standard used by occupational therapists for assessing SMD in adults.

Following completion of the AASP, the principal investigator administered the Canadian Occupational Performance Measure (COPM) to the subject. The COPM (Law, et. al., 1990) is an individualized, client-centered measure designed for use by occupational therapists. The COPM measures self-care, productivity and leisure outcomes. Clients rate themselves on performance and satisfaction with performance.

It is primarily designed to be used as a clinical outcome measure and is cited extensively in the occupational therapy literature. The COPM showed good evidence of concurrent criterion validity and sensitivity to change when used to measure performance after client participation in a pain management program (Carpenter, Baker, & Tyldesley, 2001).

The authors of the COPM identify that it can also be used as a measure of occupational performance in research (Law, et. al., 1990). Specifically, the authors suggest that the COPM is useful for studies aimed at understanding the determinants of occupational performance problems as well as for explanatory studies that try to show relationship between occupation and other variables. For purposes of this study, the COPM was administered once to obtain data on the subject’s perception regarding occupational performance difficulties. It was chosen for this study specifically because it elicited information regarding quality of life and satisfaction with current occupational participation (Liddle & McKenna, 2000).

Although purposive and maximum variation sampling strategies were used, the subject pool had some common characteristics. In summary, they were all within the range of 45-65 years of age. All of the subjects had a diagnosis of complex regional pain syndrome secondary to an injury. Their job titles were significantly variable and although three of the five subjects had distal upper extremity fractures, not all of them were caused by work injuries. Only one subject had education beyond high school. Three women and two men agreed to participate in the study.



The following table outlines demographic characteristics of the subject pool.













Using descriptive methods, information obtained from the AASP was graphically tabulated and analyzed to report frequencies and distributions of scores. Information from the COPM was analyzed with identical methods to report frequencies and distributions of self-reported occupational performance difficulties. Information from the COPM provided additional narrative information that assisted in descriptive analysis.


III. Results

The subjects were given the Adolescent/Adult Sensory Profile to complete. The AASP classifies responses into categories of Low Registration, Sensation Seeking, Sensory Sensitivity, and Sensation Avoiding. Scores are classified as being much less than most people, less than most people, similar to most people, more than most people, and much more than most people.

Low registration refers to a pattern of sensory processing that is characterized by high sensory thresholds and a passive self regulation strategy (Dunn, 1997). Three of the five subjects scored differently than the normative group. Two had a greater degree of low registration and one had a lower degree of low registration.

Sensation seeking refers to a pattern of sensory processing that is characterized by high sensory thresholds and an active self regulation strategy (Dunn, 1997). Two of the five subjects had lower sensation seeking scores than the normative group.

Sensory sensitivity refers to a pattern of sensory processing that is characterized by low sensory thresholds and a passive self regulation strategy (Dunn, 1997). Two of the five subjects scored differently than the normative group: one had a greater degree of sensory sensitivity and one had a lower degree.

Sensation Avoiding refers to a pattern of sensory processing that is characterized by low sensory thresholds and an active self regulation strategy (Dunn, 1997). One subject scored lower than the normative group and one scored much lower than the normative group. Another subject scored much higher than the normative group.

The following table summarizes score performance of the subject pool.













Finally, the subjects were given the Canadian Occupational Performance Measure to complete. Using the COPM scoring card the client was asked to rate the importance of each chosen activity on a scale of 1-10, (1 as not important at all and 10 as extremely important). After reviewing the ratings with the client, the top five highest scored, self- perceived problems were scored for performance and satisfaction. These were also rated on a scale of 1-10. Each score was then divided by 5 (the number of problems identified by the client).


The following table summarizes reported scores of the subject pool.
















As indicated in the chart below, the most common problems highlighted by the subjects were inability to complete various aspects of dressing occupations (8 prioritized problems) and inability to work at all (5 prioritized problems). In the leisure category, two subjects specifically identified inability to participate in grandparenting occupations as a prioritized problem. The remaining prioritized problems scattered around individual tasks within the three occupational domains.






IV. Discussion

In this small sample there was evidence that all of the subjects had areas of atypical sensory processing as measured by the AASP. However, there was absolutely no consistency whatsoever in the pattern and distribution of scores on this test. The AASP measures sensory processing differences in a bidirectional manner – meaning that scores can either be higher or lower than the normative range and are considered atypical in either direction away from the mean. However, the nature of that atypicality is dependent on the directionality of difference of the scores.

As identified in the literature review there is some evidence of altered sensory thresholds leading to pain and hyperarousal in people who have CRPS. However, there was not a significant pattern of sensory sensitivity that was seen in the AASP test scores of the subjects. There are several factors that could explain why this relationship was not observed.

First, there may in fact be no relationship to CRPS hyperarousal and pre-existing sensory sensitivity as measured by the AASP. The literature provides strong face validity to the hypothesis that sensory sensitivity and the associated active sensory avoiding behaviors might be associated with the sensory processing of people who have CRPS. However, the patients in this study may have been at different stages with their CRPS and in part that could account for differences in their AASP responses. Very acute CRPS could potentially bias sensory sensitivity responses, where chronic CRPS may not.

Additionally, although the tactile hypersensitivity factors account for a degree of overall hypersensitivity scores, there are other sensory channels that are considered on the AASP. So simple tactile hypersensitivity is only a component of overall sensory sensitivity and may not be enough to trigger identification as in the sensory sensitivity quadrant on the AASP.

Second, the sample size may be too small to identify a reliable measure of sensory processing tendencies of the group. So although it is interesting that the scores of the subjects all were atypical, it is not possible to draw conclusions on this finding at this time.

It may be possible that people who have CRPS are more likely to have sensory processing disturbances that manifest atypically in directions of both hyper and hypo-arousal and responsivity. The AASP measures both behavioral responses and actual sensory perceptions. Depending on an individual’s passive or active coping strategy the nature of the difficulty may be more complex than a simple univariate model that is explained by sensitivity associated with heightened avoidance strategies. Additional research is warranted to elucidate the scoring patterns observed in this initial probe.

More directly, the subject’s prioritization and ranking of perceived occupational performance problems was clear. The subjects report significant problems with loss of ability to participate in preferred occupations, with self care being the greatest area of concern. Work and leisure concerns were also reported, but not at the same frequency. Not all disability or disease processes have a direct relationship to decreases in functional performance. In this case, whether or not there is any underlying relationship between sensory processing factors between CRPS and SMD, it is very clear that people who have these diagnoses experience significant occupational dysfunction. Self care skills and performance in daily activities are domains of concern for occupational therapists. The low COPM scores in perceived performance and satisfaction validates that people who have CRPS with SMD are good candidates for occupational therapy evaluation and intervention.


V. Summary

Complex regional pain syndrome and sensory modulation disorder are clinically distinct entities that are often treated by different populations of occupational therapists. As a result, there has not been any literature describing or exploring any intersection of these disorders. There has not been any documentation of discussion regarding the intervention strategies that overlap and address similar underlying components of both disorders.

Both disorders are poorly understood, but the literature indicates that hyperarousal and excessive sympathetic nervous system outflow are suspected as being significant contributors to both conditions. Sympathetic stress loading techniques are commonly used as intervention for both conditions. Occupational therapy researchers are conducting studies regarding neurophysiologic parameters that would help to quantify sympathetic nervous system hyperarousal. Similar testing techniques have already been used in researching complex regional pain disorders.

Because of these multiple points of commonality between the conditions, assessment strategies useful for sensory modulation disorders were used in this study to obtain additional clinical information regarding complex regional pain syndrome. Although there was no single pattern of sensory processing disorder for people who had CRPS, it was clear that they all had some degree of atypical sensory processing as measured by the AASP. Additionally, all of the subjects who had CRPS had significant occupational dysfunction as measured on the COPM.


VI. Conclusion


The research that has been completed on CRPS provides useful information for occupational therapists to consider when investigating sensory modulation disorders. This literature review and exploratory study demonstrates that there is justification for continuing to study the possible relationship between disorders that share common sensory processing factors as they have a significant impact on people’s occupational function.


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Acknowledgement

Many thanks to Dr. Carol Reed and Dr. Sandee Dunbar who both provided neverending encouragement, review, and editing for this project.

"I'll see you always."

(second in a recent series of self indulgent reflections on parenting)

On the intersection of being a parent and being an occupational therapist

I spend so much of my professional time discussing parenting with parents - it only seems fair that I share some of my own parenting experiences.

Guest entry and debate on what constitutes occupational therapy practice

I received an email from Michele Karnes who wrote the following in the interest of advancing the debate on recent postings and comments regarding interventions that I consider quackery. Michele writes:

This offers a different view in response to your continuing competency column, OT's should be made aware of treatments that are offered to clients/patients, whether it is traditional or non-traditional, a long existing treatment or new one. This enables our OT profession and professionals to better educate the people they treat and interact with.

Instead of taking anyone's word that a particular treatment is 'mysticism' (as you put it) or the best thing since sliced bread, the OT who attends a 2-3 hour session can be introduced to the history and theory, what the treatment or program consists of, indications/contraindications, etc.

In response to Quantum Touch, it is based on the chi concept much like Tai Chi but focuses on therapeutic touch, a long standing principle used in OT. From the Quantum Touch website: “In principal the Quantum-Touch practitioner learns to focus and amplify life-force energy ("Chi" or "Prana") by combining various breathing and body awareness exercises” (I fail to see the problem with this). Additionally, “Over the past eight years, …have taught QT to well over 4000 people. Without exception, professional practitioners of the various modalities have told me that this work can be seamlessly combined with what they know, and in most cases it has transformed their practice. This list includes chiropractors, osteopaths, physical therapists, acupuncturists, cranial sacral therapists, chi gung instructors, and reiki masters, to name but a few”.

Notice the absence of OT, whether we buy into it or not is our own personal preference, however when talking to another health professional, it seems you would rather OT be clueless about what it is, who does it and what the theories behind it are. Tai chi has only become more evidence based recently and early practitioners were pooh-poohed!

Your comment "Undoubtedly, continuing education organizers and providers reap reasonable financial dividends through their offerings" couldn't be further from the truth, if fact one of the reasons this company was formed was to provide accessible, affordable, quality continuing education to our local health providers. The fees are low, food is often provided as well as current information offered by quality speakers who have vast experience in the content area. While Evidence Based Practice is on all of our minds, and ultimately the best to utilize with our patients, if we only used treatments for all of these years we would have missed out on the many treatments that OT’s have historically (and still) use.

Additionally, IACET is the gold standard of continuing education, AOTA CEUs have fewer standards and the standards they have are in line with IACET. IACET enables OT/PT/ST/Athletic trainers and others to learn in an interdisciplinary manner which is highly encouraged by the Institute of Medicine in “Crossing the Quality Chasm: A New Health System for the 21st Century”.

I would also like to urge those that question a practice or program to at least attend an event and look for yourself, much like the therapists who have found this to be a valuable resource!

Thanks for having an open mind!

Michele Karnes

Erie County Executive Collins: Right and wrong at the same time

The issues are just too fast and furious lately - but this one had me falling out of my chair. Check out Collins comments on the burden of unfunded mandates from the State in this Buffalo News article.

Collins statement as it relates to preschool services is excruciatingly correct - although I am not sure if his solution really solves the problem. The article states:

"Besides Medicaid — the local costs for which eat up all the $200 million in revenues raised by property taxes in Erie County— Collins cited as among the unfair mandates a program that provides special services for children younger than 5 who need help to get ready for going to school.

He said the county pays the costs of the program — $23 million a year — but has no authority in running a program administered by local school districts. When children turn 5 and schools have to then pick up the costs, Collins said, pupils are “miraculously cured” and no longer offered the services."

This is oh so true, but the preschool/UPK advocates will correctly point to numerous studies that demonstrate the benefit of providing this kind of programming and how it provides long term educational benefits.

But there is something more interesting to watch - see how politicians duck their heads and hope no one sees why all the preschoolers who had problems are suddenly declassified once the responsibility for payment slides back onto local school tax rolls.

I guess it is easier to spread the pain, point fingers, and have a broadly distributed and partially state subsidized tax pay for these programs. No one wants that pain when it starts to exclusively and specifically impact the local property tax rate.

In the end it boils down to a moral issue: do we want to provide these programs for children and do we think that we get enough benefit for the money spent? If we believe in the positive outcomes then the investment is worth the cost - no matter what politician's budget it lands in.

Or do we allow the politicians to tell us that it is not worth the cost - not based on any measured outcome but rather because they are afraid that the cost of the program on their budgets will jeopardize their chances of re-election?

And to think that people have the mistaken idea that these decisions on who gets how much service has anything to do with the welfare of children or the creation of a functional educational system!

NYSOTA response re: continuing competency regulations

I received an excellent response from Jeff Tomlinson about the recent continuing competency issues. I didn't want his response to get lost in comments, so I am posting it as an entry. There is a lot of good information here. I would really like to hear more about the direct access issue and problems in securing scripts for school aged children - sounds like something that could benefit from roundtable conversation.

Anyway, here is Jeff's response:

I have also been encouraged by another occupational therapist to check out this discussion.
We were certainly surprised by the speed with which the physical therapists were able to pass their mandatory continuing education bill. It was quite an accomplishment in a legislative session that passed very few bills that regulated the professions. I will be talking to the lobbyist and the leadership at NYPTA about how they got this done.

At the same time, it should also be noted that the PTs continuing education law is not like the NYSOTA's continuing competency bill. NYSOTA's proposal is much more consistent with the NBCOT continuing competency program and all the research that has been done over the last fifteen years on promoting professional competency. So in my own view, I'm concerned that a mandatory continuing education program will not be the best thing for the profession of physical therapy.

NYSOTA considers both the practice act amendments bill and the continuing competency bill a priority. We have asked legislators to combine the bills into one, and that request has been denied. We have been told that the practice act must be amended first so that the regulatory authority over the ota is straightened out first. Then the continuing competency bill will follow. We are certainly hoping that the continuing competency bill might move as quickly as the PT bill did, once the practice act amendment bill is passed.

Regarding splitting off the OTA section of the practice act amendments bill and passing that separately. NYSOTA has certainly considered this option since we consider the regulation of OTA practice an urgent public protection issue. However, at the same time we have another issue that may be considered by many to be just as urgent. We have learned over the last year that possibly hundreds of children in lower socio-economic school districts, face lengthy delays or receive no occupational therapy because of the prescription requirements in the practice act. We believe that the amendment allowing for direct access in non-medical conditions may address this issue. The idea that children are going without necessary OT services is very disturbing to me.

The biggest issue that we have had opposition to has been our addition in the definition of our practice of the concept that we address cognition. NYSOTA has fought hard for that cognition amendment and we have negotiated in good faith with our opposition, and we have made progress on the issue.

Finally, it is unfortunate but very common practice to combine less palatable, or less mobile legislation together with legislation that is easier to move. That is a reality in the legislative world. For example, the extension of the exemption process on the Medicare Part B Therapy caps was included in a bill with the physician fee schedule, a much more public and poular issue. The recent mental health parity legislation passed by the US Senate on Tuesday was included in a Tax bill! This is how legislation gets done. Our assessment is that many of the amendments in the OT bill would potentially languish for years if not attached to more urgent issues.

As far as I can recall I never saw the letter to NYSOTA regarding this issue, but, consider the silence broken. And always feel welcome to communicate directly with me at legislation@nysota.org

Jeff Tomlinson
NYSOTA Legislative & Government Relations Coordinator

Time for more name changing?

Juliet:
"What's in a name? That which we call a rose
By any other name would smell as sweet."



There is a history of name changes in describing sensory integration problems. People have probably heard:

1. SI disorder
2. SID (sensory integration dysfunction)
3. DSI (Disorder of sensory integration)
4. SPD (Sensory processing disorder)

Occupational therapy and habit re-training for idiopathic toe walking

I don't know that I have ever seen any occupational therapy literature on idiopathic toe walking.
For an excellent overview and references on this condition please check this article from the Journal of Family Practice.

As the reference states, it is important to avoid 'over medicalizing' the problem especially since there are not many toe-walking adults that are presenting themselves for intervention. It is possible that toe walking is a self limiting problem in many children. However, there is a reasonable concern when toe walking begins to contribute to pes cavus deformities which of course can have longer term implications. In our clinic we see a few children each year with toe walking that is beginning to cause functional foot deformity.

Idiopathic toe walking is a relatively common condition that is often seen by occupational therapists - but not generally as a primary reason for referral. Some professionals view toe walking as a marker of other developmental immaturities. It is critical to make distinctions between true idiopathic toe walking as opposed to toe walking associated with cerebral palsy, autism, muscular dystrophy, or other conditions. Toe walking should always be evaluated by a medical diagnostician first to rule out these other more severe conditions.

Some occupational therapists attribute toe walking to sensory problems but there is no evidence that this is true. Many occupational therapists leave intervention for toe walking to physical therapy colleagues who are often more specialized in nuances of gait analysis and biomechanics of ambulation. However, I have found that traditional physical therapy interventions often fail to address some of the specific problems associated with idiopathic toe walking.

There is a lot of literature that discusses different treatment options including serial casting, range of motion, and strengthening. Medical interventions often include botox injections or muscle lengthening. There is debate over which of these are most effective, or if they are at all effective.

At our clinic we try to complement traditional biomechanical interventions with re-training for self care (dressing) habits. Many of these children do not like to wear shoes and as soon as they come home from school the shoes are off and the children are tiptoeing around the house and yard barefoot. Toe walking without shoes promotes hyperextension of the toes and exacerbates the muscle imbalances that are already occurring in the foot and lower leg. Even when parents know that allowing their children to be barefoot can exacerbate the problem - it is difficult for them to effect behavioral change.

When there is no orthopedic or neurological cause of the toe walking we add a positive reinforcement component to the intervention program. The goal of this is to promote shoe wearing throughout the day and to break the habit of being barefoot. We find that children respond well to a 'puzzle' that has bones of the foot, and they can 'earn' puzzle pieces each day for successfully keeping their shoes on for a specified duration of time. Each day that they wear their shoes they get a new piece to add to the puzzle.

After the children complete the puzzle by earning all of their foot bones they are able to win a specified reward. Children respond well to the visual cue of the puzzle, are easily able to understand their progress toward the goal of wearing shoes every day, and like to learn about the way their feet work. Parents also benefit from use of the bone puzzle because it is easy to implement and is also helpful as an educational aid for teaching them about biomechanics of the foot.

If shoes fit properly and are supportive it is difficult to toewalk. Thankfully, Converse Chuck Taylors are back in style with kids! We find that compliance with regular shoe wearing is improved with use of 'cool' sneakers and the prospect of earning a reward by completing their puzzles.

It is important to have good dialogue with the orthopedic doctor and orthotist. Depending on the degree of functional foot deformity sometimes it is necessary to have even more modification to shoes including SMOs, AFOs, or modified shoes with a high toe box to avoid pressure sores.

We don't see enough children with idiopathic toe walking in our clinic to do a well designed study but still have had good anecdotal success with our combined biomechanical intervention and behavioral program. It would be interesting to see if the behavioral component increases the length of time that children demonstrate more functional gait patterns following intervention.


Reference:

M. Patrice Eiff. "What is the appropriate evaluation and treatment of children who are "toe walkers"?". Journal of Family Practice. . FindArticles.com. 17 Sep. 2008. http://findarticles.com/p/articles/mi_m0689/is_5_55/ai_n26877929

Professional competence: How do you weed the weeds?

We are making strides in promoting continuing competence and ongoing professional development in the occupational therapy profession but there is still work to be done. The current theme running through my head has to do with quacksalvers and quality in continuing education offerings.

As far as I can tell, there are few if any standards for the quality in continuing education courses as it relates to the CONTENT of the offering. I read the IACET standards and was disappointed that Standard 7 didn't really delve deeply into the issue of regulation of the QUALITY and CONTENT of continuing education courses. So if the primary standard-setter of quality in continuing education does not address quality of CONTENT, what should be done?

As an aside, I don't know that I blame IACET - how could they possibly address quality across so many diverse topic areas? Does this leave the professional associations to make statements about quality of content? Or is this left to certification bodies?

Here is what the physical therapy profession did. I especially like standard 5 which states "Each CE offering must be based on referenced scientific evidence, reflect evidence in practice and clearly label personal experience or hypotheses." I am still not sure if it makes much difference though: if we look at myofascial release as a case example I am not sure if many physical therapy course offerings in this area really meet standard 5. Even more frightening, check out what happens when you start to poke the tiger.

I did some cursory searching and couldn't find a similar OT document from AOTA that directly addresses the continuing education quality of content issue. The document may exist - I just couldn't find it. If anyone knows of any such document please let me know so I can include it here.

And if it does exist - does it matter? Any given professional association doesn't really have the resources or even teeth to address the issue. Would someone actually step forward and say that over two decades of continuing education on the Wilbarger DPPT without accompanying progress in researching the technique is ENOUGH ALREADY? Or will these types of little student projects that are done every year in EBP classes remain the hushed secret that all OT students know but are never admitted to by the people who continue to promote the madness?

A good colleague today suggested to me that perhaps all this is best left to the marketplace. I don't know. Maybe I just need to rub some lavender essential oils on my temples or something. I hear it works.

Silence from NYSOTA on OT Continuing Competency

I recently posted on the status of continuing competency requirements for occupational therapists in NY State. In summary, my concern is that the bill for these requirements has been stalled in senate committees but a very similar requirement for physical therapists just passed. I wrote to NYSOTA asking about an update on this issue and have not received any response.

Of course this is an issue that I have all kinds of historical interest in - and it is no secret to anyone that I am a long-term volunteer for the National Board for Certification in Occupational Therapy. This is where my passion over the issues of competence and competency was born and bred.

Still, my feelings on this matter also have a lot to do with the perceived legitimacy of occupational therapy as a profession and broad protection of the public. Regulation is sometimes unnecessary and stifling - I am not a believer in the nanny-state. However, health professions are historically unable to police themselves appropriately - and occupational therapy is absolutely no different than any other health profession. Case in point:

In New York State the therapist treating your grandparent who fractured a hip or your child who has cerebral palsy only needs to pass a certification exam ONCE. There is no requirement that this therapist ever steps foot inside a classroom or continuing education course EVER AGAIN. There is no requirement for them to advance their knowledge and competency in any way. Even if they DO decide to pursue continuing education our current models are accepting any continuing education course from a provider that is IACET approved.

Now consumers might not realize that there are many IACET approved courses that have truly dubious content. A recent local example is a continuing education course for Western New York occupational therapists on Quantum Touch. Undoubtedly, continuing education organizers and providers reap reasonable financial dividends through their offerings; I am just so disappointed to see that occupational therapy professionals in my own community who offer continuing education would advance themselves over the larger well-being of the people we are entrusted to provide services to. Please, someone help me here: in what way is this Quantum Touch quackery consistent with the scope of practice of occupational therapy?

So watch out, Western New York consumers! Even if your therapist does attend continuing education courses - make sure that they aren't attending continuing education that is based on mysticism. The New York State Occupational Therapy Association is silent - only choosing to comment on other bills. When it comes to protection, the public has to look out for itself.

The power of words

There is more opportunity to follow the conversation in the Advance for Occupational Therapy magazine about early intervention service delivery. I read the magazine today and still felt uncomfortable as I kept stumbling over what Dr. Jane Sorenson wrote:

“At the end of the year, all of them were performing at maximum potential… I explained, as I do with all parents whose permanently disabled child is performing at his maximum potential within the reality of the disability, that more treatment won't mean more function right now… I believe it is our responsibility to the children to discharge them from direct service when they have reached realistic goals within the reality of their diagnoses.”

I wanted to do some self-checking to be sure that I wasn’t applying any bias to reading her based on my disappointment over her previous comments. After a lot of consideration, I think I understand the nature of my concern and discomfort.

It is the words.

As an amateur anthropologist I have some passing understanding of the Sapir–Whorf hypothesis. This hypothesis states that there is a power to words and that words frame our perspectives and understandings. This is not a discussion about political correctness which has pejorative connotations because of the way that the concept has been co-opted in American political discourse. This is about the power of words and the language we use.

Language is a medium for expression of a culture – and a culture is a shared set of beliefs and practices. In the simplest form, language transmits the beliefs and practices of people. I would be remiss if I did not also reference Jerome Bruner, who described the construction of reality through narrative. In short, words are powerful. Words reflect our beliefs that frame our narratives and support our culture.

Occupational therapists have a culture. There are variations in the culture but there are some basic beliefs that most occupational therapists hold. Perhaps the most important of those beliefs has to do with human potential.

I am not talking about human potential from some wishy-washy 1960s mind-expansion perspective. I am talking about the basics of humanistic psychology, and people’s needs, and how they experience their lives and how their needs are met. Occupational therapists, perhaps more than any other professionals, understand this dynamic nature of human need, and how needs ‘imperatively demand satisfaction’ – which I believe is an Eric Fromm quote that was recycled by Mary Reilly in her Slagle lecture. People have needs and meeting those needs is often derailed and impeded by life experiences or disability.

So what are we saying when we state that someone is performing at their maximum potential? What exactly does that mean? What is potential and how does one know when it has been maximized? Is there anyone that reads this who has ever believed that their own potential has been maximized?

For your potential to be maximized your needs must be met. To state that someone has maximized their potential is to state that they Need no more.

If you Need no more, you can not have growth. And perhaps you have no meaning. If I say that you Need no more than I have placed you in a box, de-humanized you in every way possible, and stated that your human potential is complete. To take away your Need is to take away your human-ness. You are a defined object and not a self-actualizing subject.

The words are horrifying – I can only imagine the punched-in-the-stomach feeling that a parent would feel to have someone tell them that their child has no Needs and that they are at their maximum potential within the reality of the disability.

Whose reality? The reality of the all-knowing professional who after having completed some assessments in a limited contextual understanding of that child completely and abjectly disregards the parent’s larger hopes and aspirations? Is that reality?

I can’t imagine harsher words. That is where I am getting stuck.

There is no doubt that there are times to discharge a child. There are times to change from direct to indirect interventions. There are times to make all kinds of changes in the recommended intervention program of a child. These are not real issues – everyone knows these things.

But it should never be time to use words that limit the human potential of anyone.

Here is an easy fix – how about saying that “the child has derived the maximal benefit from participating in occupational therapy at this time.” I can accept that.

I can’t accept the statement that they have achieved their maximal potential given the reality of their disability. It is just too cruel and this is not the culture of occupational therapy.

There is a difference of articulation here: is the child done and do the parents need to accept some reality? Or is the therapy done for that particular time and context?

I know they are just words – but let’s hear your opinion – isn’t there a difference?

The effectiveness of the HowdaHUG seat in improving attending behaviors of preschool-aged children during circle time

Christopher J. Alterio, DrOT, OTR
Jennifer Welninski, OTS
Danielle Green, OTS
Lauren Martin, OTS

Christopher J. Alterio, DrOT, OTR is owner of ABC Therapeutics in East Amherst, NY and directed the study. Jennifer Welninski was a student at D’Youville College and assisted in research design and proposal writing. Danielle Green was a student at Quinnipiac College and assisted in data collection. Lauren Martin was a student at D’Youville College and participated in data collection. All students participated in this research project as part of their Level II Fieldwork experience at ABC Therapeutics. The research project was conducted during 2007.

Statement of the Problem

Howda Designz created a seat product for adults and children that is being used by schools and parents nationwide. Anecdotal evidence supports claims regarding the benefits of using the seat. However, higher level clinical evidence is lacking. This company is a small business and they lack sufficient resources to conduct clinical trials. Research into the actual effectiveness of the product is needed.

Statement of the Purpose

The purpose of this pilot study is to determine whether the HowdaHUGs seat increases attending behaviors during circle time for preschool-aged children.

Brief Literature Review

The Product
A company named Howda Designz (2007) created a seat product for children. The HowdaHUGs seat is a wooden flexible seat with no legs that contours around the body. According to Howda Designs (2007), the chair provides back support and feels like a “hug” to a child’s body. The product comes in a variety of sizes and an adjustable model is available (Howda Designz, 2007).

According to the Howda Designz website (2007), children are calmer while using the chair. This claim is justified by the linear movement or rocking motion that the chair provides. Furthermore, it provides a ‘hug-like’ feeling for the child. It is believed that this deep pressure makes children feel more peaceful and calm and assist them in focusing and listening while in circle time (Howda Designz, 2007).

Interestingly, this product has been produced and sold for 20 years (Howda Designz, 2007). Fairly recently, the design has been used for children. As stated in the previous section, this product is associated with anecdotal benefits and effects for children, and even for relief of back pain in adults. The company states that they are a small business, and therefore they are unable to study the effects of the chair on outcomes such as attention and calmness. Anecdotal evidence from parents and school personnel seem to support the claims made by the company (Howda Designz, 2007). Several possibilities can be considered as to why the chair seems to increase attention and promote calmness. The first is the concept of deep pressure.

Deep Pressure

Most deep pressure research has been completed using weighted vests or other devices. The HowdaHUGs chair presumably supplies a similar type of deep pressure.

Deep pressure is discussed as part of sensory integration theory. Sensory integration theory states that the proprioceptive, vestibular, and tactile systems are important for functioning (Honaker & Rossi, 2005). These systems need to be register and process sensory information appropriately. According to Ayres (1979), if there is dysfunction in sensory processing, a behavioral outcome may be observed (as cited in Olson & Moulton, 2004). According to Vandenberg (2001), these behavioral outcomes may include shifting from activity to activity, being distracted by other stimulation in the room that is not relevant to current activity, restlessness or difficulty staying seated, poor quality school work, and frequently talking or touching peers.

Among these sensory systems, proprioception plays an important role in the principles of sensory integration (Honaker & Rossi, 2005). Proprioceptive input is said to influence sensory integration. Proprioception and deep pressure sensory information is carried by the by the dorsal column to the thalamus and the reticular formation. The reticular system plays an important role in arousal, which may explain the effect of deep pressure on arousal level (VandenBerg, 2001).

Furthermore, deep pressure may stimulate and increase in the neurotransmitter Serotonin. Serotonin leads to calming of the central nervous system (VandenBerg, 2001). Proprioceptive, or deep pressure stimulation, may calm other sensitive systems such as the tactile and vestibular, and modulate arousal level (Honaker & Rossi, 2005).