It is a truth universally acknowledged that occupational
therapy is an evidence-based practice. Or is it? As an OT student, I’m aware of
all the thought and research put into every activity I do, but I am well aware
that most people don’t really understand what we do. I’ve been compared to a
nurse, a teacher and a doctor (I didn’t actually mind this one), because our
role as OT overlaps with so many other professions and still remains completely
unique. There is logic, evidence and research behind OT and these are used to guide our
treatment, protect our clients from harm and substantiate all our actions. Nope,
I’m not a doctor, nurse, teacher, scientist or physiotherapist. I’m an OT.
Well. Almost. Okay, I’m a student OT whose therapy is well thought out and can
be justified using scientific evidence. I like the sound of that.
This week has been a good one for me, which is a welcome change
from stress and anxiety! I’ve conducted some successful sessions which always
gives that extra bit of confidence and swing in your step that comes with achieving
your aims. Treatment sessions are not conjured out of thin air, there’s an extensive
thought process that leads to the eventual activity selected. We’re taught in
our 3rd year how to develop a treatment subprogram which is the
first step to identifying what areas we will focus treatment on. The
subprograms I develop have to include all the physical or psychological issues impacting
my client’s life, the way treatment sessions will be conducted to address these
issues, and lastly, what scientific evidence and theories I’ll be basing my
treatment on. Our approach to treatment and the practical application of theory
into assessments and intervention, is done using an applied frame of reference
(AFR), which is chosen based on the client’s diagnosis and context. Each AFR has
its own theoretical basis and individual approaches, an individual body of
thinking that guides what you will treat and how you will treat it[1].
My clients, Client A and Client B, have different diagnosis,
impacting their health and function differently. Client A has a traumatic brain
injury (TBI) and Client B has cervical meningitis, impacting her spinal cord. When formulating a subprogram for Client A, I referred
to the Neurodevelopmental Therapy Applied Frame of Reference because this
centres around injuries to the brain and the approaches to treatment will be
specific to complications resulting from brain injuries. Within the
Neurodevelopmental Therapy AFR I’ll be using the Bobath approach which is a way
of facilitating normal movement patterns by treating problems of motor coordination,
neuromotor and postural control abnormalities [2]. The practical application of this involves using
therapeutic handling at Key Points of Control (such as holding the pelvis or shoulders),
grading physical cues, and encouraging symmetry; therefore, these are the
principles I’ll be sure to include in all of my sessions. The Neurodevelopmental
Treatment AFR is a new concept for me and my supervisor recommended that I research
it extensively so that I fully understand why it will benefit my client and exactly
how to implement the approaches practically. At first, I understood how to
practically perform the exercises and use the techniques in my sessions but knew
nothing about why these work on my client’s physical issues. By researching the
AFR, I now understand how and why it is used to activate muscles and influence
tone. My goal for Client A is to normalize his movement so that it is
coordinated and efficient, and this approach will help me achieve my goal.
With Client B, I must take an alternate to treatment because
her physical problems do not stem from the brain and therefore the
Neurodevelopmental Therapy AFR will not be applicable. Instead, I’ve chosen to use
the Biomechanical AFR, which focuses on improving physical factors that my client
has lost due to her quadriplegia, such as range of motion and muscle strength. The approach I chose within this AFR focuses
on using grading (increasing or decreasing task demands) and compensation[3]
(due to lost function that will not return) in my activities. During treatment,
I’ve included compensation principles by having the client use assistive
devices such as wearing a universal cuff when eating to compensate for her lost
hand functioning. Grading has been incorporated by increasing the duration of
the activity to improve the client’s endurance as more effort must be exerted over
an increased period of time, and have also downgraded to decrease the physical requirements
of the task, such as providing support at the elbow during feeding so that the
client does not require as much strength to move. By using the Biomechanical
AFR with Client B, I’m aiming to improve on her strength and endurance so that
she can return to independently completing tasks such as brushing her teeth,
taking her own medication and feeding herself.
My future sessions will continue to incorporate the principles
stemming from the AFRs I’ve selected with adjustments made to how they are
practically implemented during the session. Sometimes, though I know how to
treat the physical components that need to be addressed, it becomes difficult
to identify what those problem areas are and what is causing them in order to
apply the correct treatment. Client B had me scratching my head in confusion a
few times this week because I wasn’t able to pinpoint what was causing her impaired
ability to balance therefore, I could not apply my compensatory or graded approaches
to the root of the problem. My supervisor helped me narrow down my options and in
my subsequent sessions I’m going to do further assessment and identify exactly
where her functional areas are so that we can work on these. Treatment with Client
A has been very clear cut and I have a good understanding of how I can use NDT
techniques to improve his physical state, particularly around symmetry, as he
has hemiplegia which is resulting in favouring his unaffected side during activities, neglecting his posture and handling of the affected side. Without the theory
behind AFRs and Approaches, therapy would be really difficult because I’d have
no clear direction on how to apply theory to my clients and whether or not that
theory would even be applicable to their contexts. Though it is a headache to research
and gather all the information pertaining to the AFR and approach- the benefits
outweigh the sleepless nights, as it unifies the way we practice OT and ensures
a cohesive approach to treatment.
So yes- now you know-and therefore it is a truth universally acknowledged that
occupational therapy is an evidence-based practice. You don’t just brush your
teeth, there’s a science behind it (Joint range! Hand function!). You don’t just
roll out of bed, there’s a science behind it (Movement patterns! Coordination!).
And, you guessed it, you don’t just put on a t-shirt, there’s a science behind
it (Muscle strength! Joint range!).
Nope, I’m not a scientist, just a fledgling
OT.
Until next week,
Kaylee
Pedretti, L. W., Pendleton, H. M. H., & Schultz-Krohn,
W. (2013). Pedretti's occupational therapy: Practice skills for
physical dysfunction. St. Louis, Mo: Elsevier.
https://gifimage.net/wp-content/uploads/2018/05/science-gif-17.gif
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