Venth's blog http://metaot.com/blog/19/atom/feed 2007-07-22T19:07:48+01:00 Reiki to facilitate spiritual emergence: a personal journey. http://metaot.com/blog/reiki-facilitate-spiritual-emergence-personal-journey 2008-06-28T18:43:38+01:00 2008-07-03T19:56:58+01:00 Venth 0. Abstract:
Reiki is a healing energy technique of uncertain origin. It may not be applicable to occupational therapy, but the process of learning reiki may be of use to occupational therapists for facilitating spiritual emergence and personal development. This blog entry describes my personal journey as a physiotherapist learning reiki, and how the experience led me to re-train as an occupational therapist. The benefits I experienced included increased empathy and interpersonal skills, more ethical living, a deeper respect for occupational therapy, improved physical and mental health, a feeling of connection to the universe and restored faith in God.

]]> 0. Abstract:
Reiki is a healing energy technique of uncertain origin. It may not be applicable to occupational therapy, but the process of learning reiki may be of use to occupational therapists for facilitating spiritual emergence and personal development. This blog entry describes my personal journey as a physiotherapist learning reiki, and how the experience led me to re-train as an occupational therapist. The benefits I experienced included increased empathy and interpersonal skills, more ethical living, a deeper respect for occupational therapy, improved physical and mental health, a feeling of connection to the universe and restored faith in God.

1. What is reiki?
Reiki is a technique for channelling energy from the universe into a person, object or event through placement of the hands. Some believe it was developed in the early 1900s[1]. Others believe that it was revealed from meditation on ancient Sanskrit sutras[2]. A woman named Hawayo Takata is credited with introducing reiki to the West[2]. According to her, reiki was invented by a Christian boys’ school headmaster named Usui Mikao[3], but according to cynics this story may have been contrived to facilitate the marketing of reiki to Christian people in the West[2]. Others believe that Usui was a Tendai Mikkyo Buddhist, influenced by Shintoism and Shugendo[4]. Unfortunately until recent times reiki teachings were conveyed only by word of mouth. It is therefore likely that the techniques and story have been modified several times by people to suit their own needs and religious or political interests. It may therefore not be possible to determine where reiki actually came from.

2. Before I experienced reiki:
As a junior physiotherapist I was scientifically minded to the point of being sceptical about many physiotherapy modalities. I had seen enough inequity and injustice to turn me to atheism. I worked weekends for Britain’s nuclear, biological, chemical regiment, to prove my British identity and express aggression in a socially acceptable way. I consumed tubs of ice cream or family-sized cheesecakes on a daily basis and accompanied colleagues to the pub across the road every day after work to relax myself with stout. A couple of male colleagues and myself used to have regular letching competitions during which we would each try to find the most attractive woman to look at. Unbeknown to me, a chance meeting was about to start a chain of events that would change all of this.

3. My initial experience of reiki:
A woman I met socially told me about reiki and offered me a demonstration. She moved her hands over me without touching me, and as she did so I felt waves of energy pulsating through my body. To my amazement, she told me things she intuitively knew about my military injuries. I thought this would be a great skill to have as a physiotherapist, so I asked for her teacher’s contact details and booked myself onto the first available lesson.

4. The first attunement:
The first lesson took just one day. The reiki teacher spoke of angels and how reiki would change our lives. I thought she was away with the fairies. She told the students that reiki was taught through a series of attunements, each of which would be followed by a detoxification period during which we could feel ill as our bodies became accustomed to a higher energy flow. After a brief ritual she blew into my hands. From that moment my palms were tingling and warm for no apparent rational reason. We spent the rest of the day practising reiki on each other and most of the students were able to find each other’s illnesses and injuries by feeling the energy alone.

On returning to work, I wondered whether I had imagined the whole thing, but as soon as I walked onto a ward my palms started tingling. Practising on patients was out of the question, but one of the senior physiotherapists had a migraine and allowed me to try reiki on her. She said it worked, but I found it very difficult to believe. Similar incidents would soon occur with several other clinicians, but I remained unconvinced. Events did not fit with my understanding of science and I wondered if my colleagues were teasing me when they said the reiki worked. At the pub after work my hands felt repelled by an unseen force around a pint of stout and a strong sense of intuition told me not to put chocolate cake in my mouth.

5. The detoxification:
Over the next month I re-experienced childhood knee pains, digestive problems, asthma and had a terrible cold. According to the reiki teacher these things were significant messages about problems with my life. This theory was just another aspect of reiki that I was not prepared to believe. With time however I came to accept that my childhood abdominal problems were due to a lack of power and social status. My asthma and heartburn were due to inhibition of my love, and my perpetual colds were due to poor awareness of my own intuition[5]. I would come to understand this theory as somatic metaphor. It brought me awareness of the huge untapped potential for occupational therapy. I just needed scientific evidence to triangulate the belief. I was still unsure whether reiki was real or just a figment of my imagination.

6. Learning to use reiki:
I learned to use reiki through experience. The results did not cease to amaze me. Feeling people’s energy provided me with indications of what their psychosocial problems were according to the theory of somatic metaphor. Lifestyle change proved to be far more effective for resolving chronic energy problems than the reiki treatment itself.

7. Progressive attunements:
I went to my second attunement with an occupational therapy manager I knew. The attunement was to an energy called seichem. We were taught a psychic surgery technique that involved liaison with celestial beings. I did not believe in such things, but went through the motions and was shocked to feel an unseen being placing unseen objects in my hand. Several experiences during the surgery did not fit with my understanding of science and I thought I was imagining them until the occupational therapy manager described the exact same events in a way that she could not have known that I had experienced them. My rational mind searched for explanations. Had we been drugged or hypnotised? Was this some form of mass hysteria? As I progressed through four other attunements over the next nine months my paranormal experiences became progressively more vivid. After my final attunement I went on to teach several doctors and a student nurse. Conducting attunements myself was an overwhelming experience. I perceived brilliant light radiating out from inside my body and saw angelic beings for the first time.

8. Progressive breakdown of my reality:
I became aware of sensations that other beings were around me at various times during the day. At first I could not see them but could feel their presence. I became sensitive to other people’s feelings to the extent that my emotional state varied to match that of people in my proximity. Over time I would learn to distinguish between other people’s emotions and my own. I remember going to my pigeonhole at work one morning and wondering whether I had developed schizophrenia. I was experiencing what Collins[6] recently described as spiritual emergency. As my training progressed, my psychosocial problems manifested metaphorically as visible and tangible demons. My intuition told me the meaning of each demon, and what I had to change about my life to leave it behind. The natures and significance of each demon were personal and will therefore not be described in this blog. For my masters’ attunements I was taught how to teach reiki and attune other people. During this lesson I discovered that reiki teachers (from the Tera-Mai lineage) do not actually attune their students, but call on celestial beings that do it. I was unable to believe in such beings until I started teaching reiki myself, and experienced direct contact with them. At this point, the logic I had based my atheism on no longer seemed valid.

9. Ethical problems:
A senior occupational therapist once told me that Jesus is the only source of spiritual healing and therefore reiki must be a trick of Satan. During a lunchtime discussion one day, fellow physiotherapists ridiculed the concept of healing energy and expressed that the idea of occupational choices profoundly influencing health was ludicrous. I was not aware of any published data to support evidence-based practice. The Royal College of Nursing once approved a reiki course for the continuing professional development of nurses, but subsequently withdrew their approval due to their interpretation of a House of Lords report on complimentary therapies[7]. For these reasons, I have never been able to use reiki with National Health Service patients. Some time later, I was presented with two subjects that seemed to have serious energy problems. One had an energy imbalance down one entire side of his body and the other seemed completely deplete of energy. Neither had any awareness of having health problems. I therefore said that there was no evidence that what I was feeling meant anything and it should not be a cause for alarm. After this event I stopped practising reiki because I thought it could worry people unnecessarily. Within a year I was shocked to find that the first subject had a hemiplegic stroke and the second had died of cancer. Diagnosis had been made too late for life-saving treatment. I had a few sleepless nights after receiving this news, before deciding not to start practising reiki again, except for with spiritual aspirants that requested it specifically to facilitate spiritual emergence. I believe that great care should be taken when selecting reiki students, to ensure that they have the emotional resilience to endure spiritual emergencies without developing mental health problems.

10. How reiki changed me:
Reiki inspired several changes in my life. Much to the bemusement of my friends, I gave up alcohol and letching at women. Specific decision-making is often informed by reiki. A memorable example of this was an attractive woman flirting with me and kissing me after a formal army dinner. I felt a very strong force pushing me away from her as though an invisible person had put his palm on the side of my head and was extending his arm. At the time I thought her guardian angel was protecting her from my amorous intentions. I therefore concluded my behaviour was immoral and I left her alone. Later that night I noticed her tendency for attention-seeking and somebody that knew her well told me she was pregnant. Perhaps I was the one that was being protected. On a wider scale, I was unsure of the ethics of the invasion of Afghanistan, but previously ignored this because I enjoyed soldiering so much. As a manifest demon, this dilemma was impossible to ignore, so I transferred to the Medical Corps to ensure that I would never be ordered to kill. My new sensitivity also convinced me to leave unethical jobs in Council Housing and National Health Service management. My experiential knowledge of somatic metaphor convinced me of the importance of occupational therapy[8]. If demons could be real I reasoned that God could too. This inspired me to read the Bible, Koran and various other religious texts that have restored my faith in God and helped me built rapports with patients of each book’s respective faith. The fact that lifestyle change is more effective for restoring energy balance than reiki itself is an indication to me that occupational therapy has the potential to make reiki obsolete. Reiki inspired me to analyse evidence of occupational influences on health[9, 10] and ultimately re-train to be an occupational therapist.

11. Possible implications:
The paranormal experiences resulting from reiki led me to wonder about the functions of hallucinations and whether or not these are always pathological. Perhaps people should only be considered ill if their hallucinations adversely affect their happiness or social functioning. Shamanism is common to several cultures, and though Western science currently tells us to disregard it, there may be a hidden science underlying it. Some occupational therapists have argued that “there is still a need to understand better the impact that spirituality has on health and wellbeing”[11]. Perhaps reiki training is a suitable method for occupational therapists to gain experiential knowledge of this. In some cases, responding to or interacting with hallucinations might change an individual’s life for the better, while ignoring them or medically suppressing them could prove detrimental. An example of this has been documented in the British Medical Journal. A woman was alerted to her brain tumour by a voice telling her a) that she had one, and b) which hospital in her locality had a suitable magnetic resonance imaging (MRI) unit. Responding to the voice she managed to convince her general practitioner that she needed a MRI scan, and was therefore successfully diagnosed and treated[12]. If medical treatment had been focused on suppressing this lady’s auditory hallucinations, the brain tumour would not have been diagnosed as early.

12. Summary:
Modern reiki is a healing energy technique of uncertain origin. I do not believe it is a suitable modality for occupational therapy. It has however been offered by non-occupational therapy staff in National Health Service Hospitals[13] and could be a great personal development tool for occupational therapists that wish to accelerate their own spiritual emergence, or would like to experience a different perspective on how occupation can influence health. The evidence for this is intra-personal. This blog entry only briefly touches on my experiences of reiki, and I only trained with one of many reiki lineages. Further reading is therefore recommended. As scientists I expect graduate occupational therapists to have a healthy cynicism about reiki. I suggest that anybody that doubts reiki or the existence of a spiritual plane should take the six reiki and seichem attunements up to masters’ level to inform their judgment before making up their minds.

13. Recommended reading:
Brown F. (1992) Living Reiki: Takata’s teachings. Mendocino: Liferhythm
Paul N.L. (2005) Reiki for Dummies. Hoboken: Wiley
Stiene B., Stiene F. (2005) The Japanese Art of Reiki. Ropley: O Books

14. References:
1. Stevenson M. (2003) Brief introduction to Reiki. British Journal of Therapy and Rehabilitation 10(1):34
2. Shealy C.N. (1999) The Complete Illustrated Encyclopedia of Alternative Healing Therapies. Shaftesbury: Element Books
3. Brown F. (1992) Living Reiki: Takata’s teachings. Mendocino: Liferhythm
4. Stiene B., Stiene F. (2005) The Japanese Art of Reiki. Ropley: O Books
5. Mailoo V., Wickham J., Bannigan K. (2006) OT and the tantric frame of reference. Therapy Weekly 33(3): 8-10
6. Collins M. (2007) Spiritual emergency and occupational identity: a transpersonal perspective. British Journal of Occupational Therapy, 70(12):504-512
7. Manson C. (2003) A brief introduction to Reiki. British Journal of Therapy and Rehabilitation 9(9):368
8. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. Available at: http://www.metaot.com/blogs/%5Buser%5D-6 Accessed on 24.3.2008
9. Mailoo V.J., Williams C.J. (2004) Psychoneuroimmunology: a theoretical basis for occupational therapy in oncology? International Journal of Therapy & Rehabilitation 11(1):7-12.
10. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11):503-510
11. College of Occupational Therapists Ethics Committee (2001) Addressing spiritual needs. British Journal of Occupational Therapy 64(2):107
12. Azuonye I.O. (1997) A difficult case: diagnosis made by hallucinatory voices. British Medical Journal, 315:1685-86
13. Mehrfar M. (2006) Patient Healing comments. Available at: http://www.cancertherapies.org.uk/patient.php?PHPSESSID=ca4dc83f058d6a7f... Accessed on 28.6.2008

]]> What is in a name? – Why non-holistic interventions should not be termed ‘occupational therapy’. http://metaot.com/blog/what-a-name-%E2%80%93-why-non-holistic-interventions-should-not-be-termed-%E2%80%98occupational-therapy%E2%80%99 2008-04-10T11:37:18+01:00 2008-06-24T10:57:21+01:00 Venth 1. Introduction: Have you ever seen a Ferrari Panda or Fiat Testarossa? What about a Lexus Yaris or Toyota Soarer? What about a Nicole Farhi FCUK T-shirt? If you do, please send me a photograph because I never have. This phenomenon has also occurred with Ralph Lauren and Chaps. Companies are using different names to market products in distinct quality brackets. There is a very good reason for this. What do you think a Fiat Panda would do for the image of Ferrari if it was branded ‘Ferrari’? Ferrari would lose out to other super-car producers that were more sensible with maintenance of their brand images. The occupational therapy profession could learn this valuable lesson from industry. This blog entry is a very brief reflection on that thought.

]]> 1. Introduction: Have you ever seen a Ferrari Panda or Fiat Testarossa? What about a Lexus Yaris or Toyota Soarer? What about a Nicole Farhi FCUK T-shirt? If you do, please send me a photograph because I never have. This phenomenon has also occurred with Ralph Lauren and Chaps. Companies are using different names to market products in distinct quality brackets. There is a very good reason for this. What do you think a Fiat Panda would do for the image of Ferrari if it was branded ‘Ferrari’? Ferrari would lose out to other super-car producers that were more sensible with maintenance of their brand images. The occupational therapy profession could learn this valuable lesson from industry. This blog entry is a very brief reflection on that thought.

2. Relevance to occupational therapy: Here are a couple of examples of non-holistic service being delivered in the guise of ‘occupational therapy’:

“I work in acute orthopaedics. I have been told due to budgetary constraints my role is only to ensure safe discharge from hospital. I have previously been criticised for improper use of resources when I dealt with quality of life issues.” [1]

“….one of their team leaders told me community occupational therapists only work on equipment and adaptations and cannot provide rehabilitation.” [2]

How do you think this kind of practice is affecting the professional and public images of the occupational therapy profession?

3. The consequences: I recently heard that in one acute setting, physiotherapy has been funded for cardiac rehabilitation but occupational therapy has not. Could this be because the funding authorities have no idea what occupational therapy is, due to the various confusing images we have collectively portrayed while working in reductionist ways? [3] Here is another example of where our profession seems to have lost out due to failure to project a clear image of its remit and potential:

“The Primary Care Mental Health Team told me that they no longer have any occupational therapists on their staff. The woman I spoke to said that even when they did have occupational therapists, they did not provide an occupational therapy service, but worked generically. She actually said "we provide mental health-care; not occupational therapy". I asked her how it was possible to provide mental health-care without occupational therapy, but this question just went over her head.” [2]

Our profession is losing out to other competing professions due to failure to maintain a strong professional image.

4. Conclusion: Perhaps we should change our job titles when not practising holistically. This would prevent non-holistic practice (due to constraints set by public service management) from tainting the image of our profession. Discharge facilitators should simply be called 'discharge facilitators' and the social services team leader who thinks “community occupational therapists only work on equipment and adaptations and cannot provide rehabilitation” [2] should consider re-naming her team ‘the ergonomic adaptation team’ or something similar without the words ‘occupational therapy’ included.

V

5. References:
1. Basic grade (2008) Somebody please help me. http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2289
2. Venth (2008) reality check. http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2237&postdays=0&pos...
3. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. http://www.metaot.com/blogs/%5Buser%5D-6

]]> Strategically-minded fighters required http://metaot.com/blogs/%5Buser%5D-8 2008-03-06T16:43:52+00:00 2008-03-08T12:06:13+00:00 Venth 1. Introduction: This blog entry is my reflection on how we as occupational therapists undermine our own profession by failing to reflect deeply on and analyse the global repercussions of some of the mundane decisions we make. The example used for this reflection is conflict with social workers, but it could just as easily have been any one of several other situations that occur routinely during my working day. One of my seniors expressed to me on several occasions that she did not feel able to deal with global issues, and those are the responsibilities of managers and the College of Occupational Therapists. This argument could only stand if we were actually applying the standards set by the College of Occupational Therapists to our work. Some of us would like to think we are, but are we really? When was the last time you studied them with a view to scrutinising your own work? If we do not apply the standards set by the College of Occupational Therapists, how can we expect the British Association to protect us?

]]> 1. Introduction: This blog entry is my reflection on how we as occupational therapists undermine our own profession by failing to reflect deeply on and analyse the global repercussions of some of the mundane decisions we make. The example used for this reflection is conflict with social workers, but it could just as easily have been any one of several other situations that occur routinely during my working day. One of my seniors expressed to me on several occasions that she did not feel able to deal with global issues, and those are the responsibilities of managers and the College of Occupational Therapists. This argument could only stand if we were actually applying the standards set by the College of Occupational Therapists to our work. Some of us would like to think we are, but are we really? When was the last time you studied them with a view to scrutinising your own work? If we do not apply the standards set by the College of Occupational Therapists, how can we expect the British Association to protect us?

2. Context: Conflict between occupational therapists and social workers is a recurring theme I have seen in three hospitals throughout my short career. A common focal point has been social workers’ dependency on us and their ability or lack thereof to act autonomously as professionals. I have worked with social workers who did not believe they could assess patients without first having occupational therapy reports, or even worse, could not set up care packages unless the occupational therapy reports specifically stated how many times a day care was needed. In one post I found myself being asked why a patient had no shopping when she was discharged home, to which I replied: “Why are you asking me? I am an occupational therapist; not a social worker.” On the other end of the spectrum I have worked with social workers that resented being told how many times a day occupational therapists thought service-users would need care, as telling them so showed a lack of respect for their professional autonomy.

3. Specifics: In one particular meeting of occupational therapy staff, we were told that social work managers from one borough were demanding care package specifications on occupational therapy reports before they would authorise care, whereas social workers from another borough specifically demanded that occupational therapists should not specify care package requirements. The team then discussed methods to deal with this situation. Superficially it seems that a simple practical solution to this would be to ‘suggest’ care package requirements without actually ‘specifying’ what we felt was needed. Looking at the wider picture, is this really a good idea though? I argued that we are a self-defining autonomous profession and should not alter the way we work to suit the whims of social work managers if by doing so we would encourage their inappropriate dependency on us, thus generating more non-occupational therapy work demands on ourselves in the future. Care packages are not our responsibility after all; we cannot negotiate directly with care agencies and authorise funding can we? Unfortunately I was the most junior occupational therapist present, and none of the seniors displayed any wish to deeply consider my thoughts. I was told this was an ongoing issue that could not be resolved by us, and this was a case of choosing which battles to fight.

4. The wider repercussions: These events remind me of several themes I believe are currently undermining the occupational therapy profession in England:

4.1. Role blurring leading to an ambiguous professional image and dilution of the occupational therapy ethos: In my opinion, care packages are on the social workers’ remit, not ours. By bending to social work managers’ demands we are re-enforcing the false image of occupational therapy as the profession of hospital discharge management, or a profession that mops up the jobs that others cannot manage or would like to disregard. The same applies to arranging for shopping (social work), tissue viability management such as pressure cushions (except for on wheelchairs) and mattresses (nursing) or splinting of limbs that will never be used occupationally (orthotics or physiotherapy) and incontinence management (nursing and physiotherapy). Why do people expect us to deal with these things? I suspect it is because the occupational therapists who laid the ground for us in the past took on these roles without reflecting on whether they were actually occupational therapy or not, and we have become so busy with these non-occupational therapy tasks that we no longer have the time or resources to practise holistic occupational therapy.

The problem with loss of professional definition is it reduces our ability to market ourselves effectively and other professions will start eating into our role. The other day I faxed referrals to social services occupational therapy and a primary care mental health team requesting community occupational therapy. A social services occupational therapy team leader phoned me and told me that community occupational therapists only provide equipment and adaptations, and a senior nurse from the primary care mental health team told me that the primary care service no longer had any occupational therapists, and even when they used to, they did not supply occupational therapy, but worked generically. She actually said “we provide mental health-care; not occupational therapy”. I wonder if she has any idea what occupational therapy actually is. Meanwhile, physiotherapists are using cognitive behavioural therapy, lifestyle and activity advice, psychosocial interventions and even techniques such mindfulness! The usefulness of life coaches was recently mentioned on television news in England. I doubt these people realise they are actually practising occupational therapy, because most of them have no idea what occupational therapy is. That is simply because we are not projecting a clear professional image. These developments are threats to our profession (and are probably putting occupational therapists out of jobs), but we can choose to ignore them (at our peril).

Some may argue that even though individual services are not providing holistic occupational therapy, over all we are doing so as a team. Acute occupational therapists may simply facilitate hospital discharge and refer on to community services for rehabilitation for example. How do you think this line of thinking would apply to other professions? If a long line of doctors approached a patient, the first cleaned the skin, the second made an incision, the third cut down to the bone, the forth did a bit of drilling, the fifth put in metal work, and so on, do you think any of these people could really call themselves orthopaedic surgeons? Could any of them as individuals not be replaced by technicians? Imagine if there were waiting lists between metal work and skin closure. What would this do for the quality of care and the professional image of orthopaedic surgery? This is metaphorically how the occupational therapy profession appears to be working in England.

4.2. Lacking professional pride or passion: Several of my recently qualified friends expressed dissatisfaction to me because they feel they are not practising occupational therapy though ‘occupational therapist’ is their job title. Ironically, the only newly qualified occupational therapist I know that has expressed job satisfaction is working for a private company as an employment adviser. None of my friends that expressed dissatisfaction had time to read or apply occupational therapy literature (everybody has time, what they choose to do with it is a matter of priority) to their work. None of them thought the College of Occupational Therapists’ Professional Standards for Occupational Therapy Practice [1] are realistic or worth fighting for, and none of them were motivated to do anything about their job dissatisfaction. They have accepted this as the lot of the profession and they are not alone in their apathy.

Perhaps this apathy is due to occupational therapists’ lack of respect for their own profession. An anonymous member of the British Association of Occupational Therapists once wrote “OT is based on a pretty basic idea that any half good mother (have thought about putting father in here but haven't convinced myself to put it in) could invent; but applied well, when it works”[2]. If this is our estimation of the value of our own profession, is it any wonder we are not prepared to fight for it?

4.3. Self-defeating attitude (low personal causation, low professional causation): Several experienced occupational therapists have expressed the belief that our professional ideals are not realistically achievable in public sector employment, in various threads of the British Association of Occupational Therapists’ internet discussion forum: http://www.cot.org.uk/members/phpBB2/ In a previous entry to this blog [3] I mentioned how senior staff I worked with had been directly discouraging about professional standards. Section 3 of this blog entry describes senior occupational therapists believing we are unable to mark our own professional boundaries with respect to a very specific part of our role and inter-professional communication. It is my personal belief that people in positions of leadership undermine our profession by making these pessimistic expressions when they are not accurate. One would be naive to believe that in a competitive environment any battle can be fought, won and then forgotten about. Boundaries will continually be tested and therefore must be continually fought for. This is not an indication for giving up; it is an indication for persistent assertiveness.

4.4. Lack of attention to detail: Section 3 of this blog entry describes senior occupational therapists choosing to simply solve a working problem instead of dealing with the professional role and image issues underlying it. I was told this was a case of choosing ‘which battles to fight’. Most wars are won or lost by the summation of results from numerous battles. The strategic value of ground is often very different to its superficial value due to tactical or symbolic significance. Many occupational therapists in my opinion, have overlooked this when making mundane decisions about the way they work within the multidisciplinary team. They are therefore choosing not to fight battles that are in fact key to the empowerment of our profession, and then not realising that they (through their actions or lack thereof) are responsible for the de-valuing of occupational therapy. The way we communicate with social workers, and generic working in mental health (as mentioned in section 4.1.) are just two examples I have reflected on. A previous example I have used was the timing of home or access visits [4], but there are many others.

4.5. Disparate, non-cohesive efforts: In one of my jobs the clinical lead for occupational therapy told me that she had told all of the occupational therapists not to fax their assessments to the hospital social workers because the social workers should come to the wards to assess the patients themselves (as autonomous professionals), and they can look at the occupational therapy reports while they are there. Superficially this idea may look like bad team working, but reflecting on it more deeply I thought it was a great idea for the following reasons:

a) What do you think would happen if occupational therapists started asking for medical and nursing notes to be faxed down to the occupational therapy office so that we could do our subjective assessments without visiting the ward? Do you think this request would be taken seriously? Why should there be one standard of convenience for social workers and another for occupational therapists?

b) Before the clinical lead had instructed me on this issue I had been faxing my reports to the social workers. The problem was, even when I had done so, they often denied having them and used this as an excuse for delayed discharge. This was despite the fact I had been phoning to confirm receipt of the faxes and had documented the names of the people who confirmed receipt in the medical notes. In other words, there was not much point faxing my reports, because the social work department was losing them anyway and then saying I had not faxed them as an excuse for delayed discharge.

c) Faxing our reports to the social work department just reinforced the over-dependency of the social workers on the occupational therapists and reinforced our false image as discharge facilitators. This kind of behaviour was more likely to encourage them to ask us questions like “how many times a day does X need care” than to come to the ward and do their own professional assessments.

The problem with the clinical lead’s idea was some of the occupational therapists were not following it. She told me she could only tell them so many times, and there was nothing more she could do to get them to follow her lead.

Once the clinical lead had spoken to me I stopped faxing my reports to the social workers. When they asked me for reports I told them they were in the medical notes and could be accessed there when the social workers were on the ward doing their assessments. I also told this to the nursing staff when they told me social workers had told them they were waiting for occupational therapy assessments. Then, one day I was on a ward and a nurse asked me to fax a Section-2 form to the social worker. Section-2 forms were normally filled out and sent by nursing staff and had nothing to do with the occupational therapists. I asked her why she wanted me to send it instead of faxing it herself and she told me I could just fax it of along with my occupational therapy report when I faxed that. I then told her that I was not faxing occupational therapy reports to social workers because they could look at them when they came to the wards to assess the patients themselves. She then told me my senior (band 7) had sent off a section-2 for her, so she thought I would do it too! Later, I asked my band 7 why she did this, and she told me it was to save time. When I told her what the clinical lead told me, my band 7 told me she was an autonomous professional just like me, and that while I sometimes do things differently to how she does, she just lets me get on with it. This to her, was just an example of how different occupational therapists work differently.

When it comes to protecting the profession there are wider repercussions from individual occupational therapists working differently from each other. The above occurrence is a good example of how taking on non-occupational therapy tasks alters people’s expectations of us and therefore alters the image of our profession. Just one occupational therapist’s act of sending a section-2 led to the expectation that we would all do it. It may be through a gradual process of sequential slippages such as this that in-patient occupational therapists devolved into discharge facilitators. Before I was an occupational therapist I tried the reserve forces All Arms Commando Course. During recruit training I could not help but notice that I was robbed of my individuality. Everything about me had to be the same as my colleagues, down to my toothbrush and three-piece razor being blacked out with tape and the way my kit was marked with my identity. At first, in my immaturity, I resented this, but soon I realised that this was what it meant to be part of something much larger than myself, and that sameness was a source of great strength. The same applies to an occupational therapy department. If all of the occupational therapists sing off exactly the same song sheet they can draw strength from and shield each other. It only takes one occupational therapist to drop his or her shield for the whole defensive line to fall though. Can a team that is under threat afford to be divided within itself? In a competitive environment with decreasing financial resources what chance does a team plagued by the above attributes stand of survival? It was no surprise to me that the department described in section 3 above had been downsized yet still had a recruitment and retention problem and was failing to survive. Most of the occupational therapists I spoke to individually knew it, but they all had somebody else to blame.

The same applies to British occupational therapists as a whole. If every single one of us stuck rigidly to our core standards we would be in a much stronger position than we are in now. It seems though, that there are too many people in the profession who believe our ideals are impossible to achieve. Individuals and individual teams are picking which core standards they would like to follow and which they would like to ignore. So many shields have been dropped, it seems there is little hope of our profession achieving its potential without a profound change of attitude.

5. Solutions?
5.1. Recruitment and training: The heterogeneous nature of occupational therapists gives strength to our profession, but I frequently wonder whether we have enough deep thinkers and assertive personalities to compete in today’s statutory healthcare environment. As a physiotherapist I found myself surrounded by type-A personalities. I once saw a physiotherapist walk up to a patient sitting in a wheelchair being adjusted by an occupational therapy assistant, ignore the occupational therapy assistant entirely and walk away with the patient in the half-adjusted wheelchair leaving the occupational therapy assistant kneeling with a spanner on the floor. There is even a Facebook group called ‘Why do physio's think they are god's gift (applies to vast majority)’[5]. I have worked with some great physiotherapists, and therefore do not feel that the generalisations made in this group are accurate. Physiotherapy courses are notably hard to get onto and through though. Perhaps this is where their professional pride comes from. In contrast, while I was at University I met two occupational therapy students who could not write a sentence in English. Another managed to graduate despite getting stoned at night and sleeping during the day while her friends signed the lecture registers for her. What about my friends who do not even care about occupational therapy enough to pick up our journal and read it? How did these people get onto the occupational therapy course in the first place?

The toughest thing I had to deal with during my undergraduate training was boredom. During my third year of undergraduate training I surveyed my colleagues for an assignment and found that only three out of thirty students (10%) could remember Ann Wilcock’s description of occupational risk factors (which she had lectured us on)! When asked how psychosocial factors can damage physical health, two students (7%) said they did not know and one (3%) was unable to think of anything other than hypochondria. Only fourteen out of thirty (47%) third year students believed in psychosomatic disease mechanisms. Of these fourteen, ten (33% of the sample) said they could offer no physiological explanations for psychosomatic disease. How can occupational therapists defend our profession with such limited knowledge of the scientific theories and evidence that can underpin it? I suspect the messenger is going to get shot, but the fact there are 162 members in the Bored of Fluffy Occupational Therapy Facebook group suggests to me that I am not the only person with this opinion. I think we need more rigorous training proceedures to ensure that all student occupational therapists are knowledgable, assertive, deep, critical thinkers by the time they graduate. A tougher course might also inspire greater pride in our profession; enough to make us want to stand up and fight for it.

5.2. Continuing education: Knowing the potential of occupational therapy, and how well it could fill so many of the demands of various national service frameworks and government policies [6] how can occupational therapists stand by and watch the essential corners of their work being cut away while life coaches, reverse therapists and even physiotherapists take over, without becoming enraged by the demise of our profession? Why are we content to busy ourselves only with care-package selection, raised toilet seats and architectural adaptations, while other professions practise the components of occupational therapy that we need to be truly holistic? Is it possible that the students I trained with are representative of how many of my seniors were when they were students? Perhaps regular training to remind qualified occupational therapists of our potential, and inspire professional pride is necessary to remind us that our profession is currently nowhere near achieving all that it realistically could, even in the competitive public-sector healthcare environment. Self-belief and dissatisfaction are the precursors of revolution. I have seen plenty of evidence of dissatisfaction. Perhaps we collectively just need training to increase our professional self-belief.

6. Before you shoot the messenger: This blog entry is far from politically correct, and I expect to take a lot of heat for suggesting profound weaknesses within our profession. I make no apologies for this, as I believe that anybody that thinks the occupational therapy profession is thriving in England has his or her head buried in the sand like an ostridge. When occupational therapy is held in the same esteem as medicine or pharmacy it will be thriving. At least if it was held in the same esteem as physiotherapy I would consider that we were getting by. I see no evidence of this when I am at work though.

My use of the word ‘fighters’ is open to misinterpretation. Fighting to maintain our professional identity in no way implies fighting against other members of the multidisciplinary team; it simply means fighting against a lack of resources and falling standards. I have used the word the same way I would to describe a patient fighting for survival in intensive care. This has nothing to do with conflict or aggression.

7. Conclusion: Perhaps occupational therapists are by nature caring, helpful and flexible workers. This can make us great healthcare providers and team members. If left completely unchecked these qualities could prove the undoing of our profession; occupational therapy is in danger of devolving into the multidisciplinary doormat. Good teamwork does not depend on individuals doing other people’s jobs (generic working); it depends on congruency of the efforts and purposes of each of the team members working within their own specialities (what they are best at). Before we make mundane decisions about changing the ways we work, perhaps we should reflect deeply on how these changes may affect the image and future prospects of our profession.

8. References:
1. College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice London: British Association of Occupational Therapists
2. Guest666 (2007) occupational apartheid http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1848&postdays=0&pos...
3. Venth (2007) Application of the Ayurvedic Model of Human Occupation – A case study.http://metaot.com/blogs/%5Buser%5D-3
4. Venth (2007) Early access visit v later home visit? http://www.metaot.com/blogs/%5Buser%5D-4
5. Rogers L. (undated) Why do physio's think they are god's gift (applies to vast majority) http://www.facebook.com/group.php?gid=2246701539
6. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. http://www.metaot.com/blogs/%5Buser%5D-6

]]> Occupational Therapy First - It is time for our profession to lead; not follow. http://metaot.com/blogs/%5Buser%5D-6 2007-11-18T18:17:37+00:00 2008-03-09T08:18:49+00:00 Venth 1. Introduction:
During my short career in health and social care, I have seen people rushed into hospital by ambulance, treated with major surgery and kept alive against great odds in intensive care. I have seen people rehabilitated by physiotherapists and speech and language therapists and cared for by nursing staff. I have seen social workers speaking to patients to ensure their care needs are met in the community. What is it all for? Why do we work so hard to keep people alive? The answer to this question must lie in the meaning of life. What is the meaning of life? This blog entry briefly explores the meaning of life and extrapolates from it reasons why occupational therapy is an essential component of quality care. It reflects on evidence that occupational therapy is currently undervalued and suggests a radically different professional image for the future.

]]> 1. Introduction:
During my short career in health and social care, I have seen people rushed into hospital by ambulance, treated with major surgery and kept alive against great odds in intensive care. I have seen people rehabilitated by physiotherapists and speech and language therapists and cared for by nursing staff. I have seen social workers speaking to patients to ensure their care needs are met in the community. What is it all for? Why do we work so hard to keep people alive? The answer to this question must lie in the meaning of life. What is the meaning of life? This blog entry briefly explores the meaning of life and extrapolates from it reasons why occupational therapy is an essential component of quality care. It reflects on evidence that occupational therapy is currently undervalued and suggests a radically different professional image for the future.

2. The meaning of life lies within occupation:
To help answer the above question, it may help to study people who have had all meaning taken away from them. It would be unethical to create this situation experimentally, but the United States government has done it for us[1] in their ‘war on terror’. What is the weapon of choice for psychologically destroying a captured enemy? It is occupational deprivation. If you had absolutely no occupational freedom (not even being able to think) would you still wish to live? Would your body effectively be a prison, and your life a sentence? There are accounts of prisoners of war losing the will to live and leaving their bodies. I was a prisoner once, and after just a few of hours I realised I would rather fight to the death than ever let it happen to me again. Reflecting on this, is it safe to say the meaning of life lies within the domain of occupation?

What about non-life-saving healthcare interventions? What is their purpose? The World Health Organisation defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”[2]. Try to imagine a state of well-being with no occupational freedom. Can such a state exist in the material Universe? In contrast, is it possible to experience a sense of well-being without good physical or mental health? Ask a person that is high on heroin. Ask a soldier who has just self-actualised by making the ultimate sacrifice with a heroic act. If a sense of well-being is:

a) possible without good physical or mental health but not possible in the absence of occupational freedom, and
b) a defining characteristic of health

is it logical to assume that the ultimate aim of every healthcare intervention should be the preservation of occupational freedom? In most cases I believe this to be true, and in cases where it is not true, perhaps questions should be asked as to why the interventions are happening at all. If these assumptions are true, would it not be sensible to assume that occupational therapy should be at the core of health and social care delivery?

3. Not seeing the wood for the trees:
The medical model currently dominates statutory healthcare in the United Kingdom. This is a reductionist approach fundamentally flawed in my opinion by the treatment of disease components without regular reflection on why we treat disease at all. When I was a physiotherapist I used to work to increase people’s mobility or sitting balance. In cases where this was not possible I worked to maintain their lung function or passive range of movement. I worked on the assumption that these were good things to do, and was too rushed to think about why. Some of my patients did not agree with the assumption and told me they just wanted to die. Nothing in my professional training equipped me to deal with the meaning of life (or its absence). Medicine similarly seems to focus on life without reflecting on its meaning. My father died with disseminated intra-vascular coagulation and organ failure secondary to an unknown cause. The medical team did everything they could to keep him alive, but nobody thought to discuss how he might have liked to die with us. If he had survived, I wonder what the micro-emboli would have done to his brain. It is doubtful he would have been the same person. What level of occupational freedom would he have had? What would his life have meant to him?

It is often assumed that wanting to die is a sign of mental illness. While this is arguably often true, many of my older patients have said they just wanted to die, but seemed content about it. Similarly, leaving one’s body is the ultimate aim of advanced yoga[3]. Try telling and advanced yogi in the state of Turiya that he or she is ill. The obsession with preservation of life without attention to its meaning or occupational freedom has denied people in the United Kingdom the right to die in the manor of their own choosing[4] and they have had to go abroad to do it. Perhaps our view of healthcare occasionally actually restricts occupational freedom.

4. The full power of occupational therapy:
Occupation may be the greatest determinant of well-being. Can you think of a greater determinant? If not, perhaps sensible use of occupational freedom should be the main explicit aim of all healthcare intervention. Several national service frameworks have addressed occupational factors:

“Many important lifestyle risk factors for CHD are well studied and understood. These
include smoking, a poor quality diet (including consequential serum cholesterol level),
lack of physical activity, and the role of habitual excessive alcohol consumption. There are other risk factors which are likely also to be important, such as particulate air pollution job control and a general sense of security but to date these are less well understood. It is thought that about half of the decline in CHD mortality is due to lifestyle changes and half due to better treatment and care. The steepening of social class gradient in CHD mortality is also reflected in worsening social class gradients in people’s exposure to important risks. For example, among 16 to 44 year olds, smoking rates among the more affluent three quarters of the population have declined sharply since the mid-1970s, but the proportion of smokers among the poorest sections of the population remains unchanged at about 50% and 60% among lone parents. Similarly, men and women in social classes IV and V are more likely to have high blood pressure, and to eat smaller amounts of fruit and vegetables than men and women in social classes I and II. They are also more likely to have experienced poverty during childhood, to live in poor quality housing, to be unemployed or in low-paid occupations. People’s exposure to risk reflects the choices they make about how to live their lives. But these are heavily patterned by the circumstances in which they live: the physical and emotional environment, their access to education, to employment, to an affordable healthy diet, to decent housing and to supportive communities.”[5, p.4]

“2.2 Smoking is the cause of a third of all cancers. Since the widespread availability of cigarettes there has been a huge increase in deaths from lung cancer, which was previously a rare disease. From the 1950s, evidence of the serious health effects and the fatal diseases caused by cigarette smoking has been accumulating. Smoking not only causes most cases of lung cancer but is the major cause of cancers of the mouth, nasal passages, larynx, bladder and pancreas. It also plays a part in causing cancers of the oesophagus, stomach, kidney and in leukaemia.
2.3 Smoking kills people. In total smoking kills around 120,000 people in the UK
per year and over half a million in the European Union……

….._ Obesity may contribute to the risk of post menopausal breast cancer and endometrial cancer. A low fat and low energy diet with plenty of fruit and vegetables can lower the risk of these cancers. The National Service Framework on Coronary Heart Disease required health authorities to have in place local schemes to reduce obesity by 2001.
_ Regular physical activity can reduce the risk of certain cancers, particularly colon cancer. From 2001 health authorities will have physical activity promotion schemes and the Department of Health will issue guidance on supervised programmes of exercise for people whose health may benefit. In addition, the Department of Health is working with other government departments on work to encourage and enable more walking and cycling, particularly in deprived areas.
_ Alcohol misuse is thought to be a major cause in about 3% of all cancers, and can increase the risk of cancers of the mouth and throat. Liver cancer is associated with heavy drinking and there may also be an association between alcohol and breast cancer. The Department of Health will consult on an alcohol misuse strategy.”[6, pp.23-29]

“Mental health problems can result from the range of adverse factors associated with social exclusion and can also be a cause of social exclusion. For example:
• unemployed people are twice as likely to have depression as people in work
• children in the poorest households are three times more likely to have mental health
problems than children in well off households…….
……..•there is a high rate of mental disorder in the prison population
• people with drug and alcohol problems have higher rates of other mental health problems
• people with physical illnesses have higher rates of mental health problems.”[7, p.14]

“As part of their work on promoting independence, many local authorities are developing programmes to encourage health and active ageing. These are often council-wide strategies, involving transport, leisure and education services, as well as social services.” [8]

“It is the activities that enable people to deal with the impact of a long term condition on their daily lives, dealing with the emotional changes, adherence to treatment regimes, and maintaining those things that are important to them – work, socialising, family.”[9]

The national service frameworks have only touched upon the tip of the occupational therapy iceberg. Some things seem to have been overlooked. One of those things is psychoneuroimmunology (PNI)[10].

If occupational freedom is a major determinant of well-being would if be sensible to assume it is a buffer to distress and unhappiness? Did you know that stress has been implicated as a contributing factor to several disease processes ranging from gum disease to cancer? It may even have a role to play in schizophrenia[10]. Distress pre-disposes us to cancers for example, by impairing DNA repair, programmed cell death, immune function, and the inhibitory effect of somatostatin on growth hormone release from the pituitary gland[11]. It may also pre-dispose us to pathological inflammation due to increased release of the pro-inflammatory cytokine substance-p[12].

Stress may also delay healing due to reduced concentrations of interleukin-1, matrix metalloproteinase-9 and tumour necrosis factor in wounds, and increase the risk of infection through the actions of corticosteroids on immune cells[13]. Can you think of anything that would make you happy in the total absence of occupational freedom? Does your happiness come from occupational freedom? Considering the how unhappiness affects mental and physical health, based upon the emerging PNI evidence perhaps occupational therapy has a (if not the) major role in national health improvement.

As the department of health has identified the need for life-style change and occupational justice to improve the health of the nation, why is the government not using occupational therapy to meet the identified needs? Why are there so many unemployed newly qualified occupational therapists and why are services being cut[14]? Is it because so few people know what we are capable of[15]? Is it because the government does not know that we are the profession to meet its needs? Perhaps the fault is our own.

5. Why do people not know what we can do?
Occupational therapy can be metaphorically compared to transport design. Imagine occupational therapy was a car design company and the Department of Health was our customer. There are various things we could do to make our cars more attractive. An example is in-car entertainment (ICE). After a few years we may become experts in ICE production. If we got carried away with it we might even start to think that car production was all about ICE. After a while, our customers would think we were all about ICE, and they would be right. Our developments in ICE technology would far exceed those in car design. What would happen if we forgot about car production altogether and thought ICE was our job? Is there any evidence that this is happening?

“I worked as an OT/Care-Manager for two years. I quit because care management simply isn't OT. OTs make good care managers, but it isn't part of our role and it stops us from doing proper OT.”[16]

“Looking at my acute work, I spend most of my time assessing care needs. Helping social workers determine appropriate care packages rarely increases the occupational freedoms of my patients in any notable or significant way, other than of course enabling them to stay in their own homes. (Some of my patients have chosen to go home and stay in one chair all day waiting for carers, rather than go to a more interactive environment that would enable them to be more active. That is of course their choice.) In my opinion, it is questionable whether this is really occupational therapy at all. In cases of progressed dementia for example, I doubt the patients notice any change in well-being as a result of my intervention. While I document their needs for continuing occupational engagement using the reverse developmental approach I honestly doubt my recommendations will be followed in continuing care. In contrast, enabling a 21-year old male to stick to his normal self-care routine (showering as opposed to strip washing) by issuing a shower-board is highly likely to be therapeutic. There is no doubt in my mind this is occupational therapy.”[17]

I was once told by a senior occupational therapist “the role of OT in the acute setting is to discharge patients home safely”. Is that occupational therapy? Perhaps that is the impression we have given the public and the Department of Health. If we cut any more corners off acute occupational therapy it will be acu e occu a ona era. An example of how the cost-cutting frame of reference has reduced quality of care by overpowering our reference to occupational freedom recently appeared on the British Association of Occupational Therapists’ Internet Discussion Forum:

“The technical instructor asked me why I issued a perching stool and I told her it was for strip washing as the patient could not manage bath transfers. The tech’ then asked me why the patient could not wash standing up. I told her a high degree of balance is required to bend over and wash your lower limbs while standing and the patient did not have this. The tech then told me that older people tend to soak their feet in a bowl and therefore do not need to bend over to wash them and asked me why the patient could not just wash in her own chairs like she did on the ward. I told her ward chairs are waterproof and few people have chairs like that at home. In my opinion it would not be good for a person to sit in a wet chair during the day. This argument did not even take into account that the patient had a fractured wrist and would probably have to carry a bowl of water to get to her chair. The tech’ then told me that older people do not wash their feet every day anyway. She said that generation only had a bath once a week. Another tech’ then said that it was common for people who could not undress their lower limbs and needed TED stockings to go home and wear the same stockings all week, having the Red Cross come around once a week to change them! I asked my band 7 for her opinion, hoping for some back up because I was in a state of disbelief. She explained that I should be client-centered and respect that the older generation has a different culture to us and they are not so bothered about washing their feet. At this point the National Service Framework for Older People and routing out age discrimination sprung to mind. I had previously been told that I was issuing more equipment than the other therapists (issuing three bed-levers in three weeks was given as an example) and due to budgetary constraints if this continued I was likely to be put under scrutiny. I could not believe pseudo-client centered practice and generalizations about a particular age group were being used as an excuse to be stingy with equipment. What is the profession coming to?”[18]

Looking back at the metaphorical example, to who will people who want transport go? To the ICE experts or to other business better suited to meet their needs? Is it any wonder that life coaches, health promoters and reverse therapists are springing up to fill the gaps left by the occupational therapy profession?

6. Cutting out dead wood:
Perhaps we need to disregard the medical model along with some old assumptions to enable occupational therapy to reach its potential. Looking at many settings for example, occupational therapists are second to last to see patients, closely followed by social workers. Other members of the multi-disciplinary team tell us when a patient is ready for discharge and see discharge facilitation as our role. If maintenance of occupational freedom is the basis for healthcare intervention why are occupational therapists the last people to see patients? Can we lead from the end? Reflecting on psychoneuroimmunologic evidence, perhaps occupational therapy should be a preventative modality deployed predominantly in primary care. Some occupational therapists seem unable to envisage this due to the context of the current British health service environment[19]. Perhaps we should disregard this context and blaze our own trail. An erroneous assumption is that efforts to increase a person’s independence are by default occupational therapy. According to physics, there is no such thing as independence in the material Universe. Occupational freedom and independence are not always the same, and even occupational freedom may or may not be therapeutic depending on what an individual chooses to do with it. If independence was all that is required affluent people would not get depression, life coaching would be pointless and Reverse Therapy would not work. Perhaps occupational therapy is not only about ensuring people have occupational freedom, but also about ensuring they have the knowledge and coping resources to use that freedom therapeutically. Looking at the above example of a perching stool, a therapist believing “the role of OT in the acute setting is to discharge patients home safely” would discharge the patient without a perching stool loan, and perhaps advise her to wash her feet with a bowl sitting in her living room. This does not account for the therapeutic effect of enabling a person to stick as closely as possible to his or her normal daily routine, by washing in his or her bathroom with minimal inconvenience. Is it an example of selling ICE without a car?

Some assumptions about healthcare are hidden beneath policy and procedure. In some boroughs for example, service-users have to buy their own self-care equipment. It is worth noting that they do not have to pay for their own surgery or walking aids. Why is this? Is it due to an assumption that self-care ability is less important than the physical state of a person’s body and his or her ability to mobilise? Why are acute occupational therapists being encouraged to scrimp and save on equipment that could improve the quality of patients’ lives? Why should an older person be denied a perching stool in a country that can afford to invade Iraq and Afghanistan simultaneously? The sub-text is that occupational therapy is less important than surgery, physiotherapy or the invasion of foreign countries. Is this actually true? This is one of the disadvantages of following the medical model. By working to the medical model we may actually be reinforcing the subconscious belief that occupational freedom is not as important as measurable physical parameters of health, and by doing so, we may be undermining the occupational therapy profession. Would you rather be able to walk but need somebody else to feed you and wipe your bum, or would you rather be able to feed yourself and wipe your own bum but need help to mobilise?

7. Unleashing occupational therapy:
7.1. Marketing: Marketing occupational therapy would be easier if we projected a clear image of what occupational therapy is. That may mean refusing to take on work that is not occupational therapy and producing evidence that we are the best people to meet occupational therapy-related needs specified in the national service frameworks. As most people who have contact with occupational therapy services are currently likely to do so in the acute sector, it is very important that we practice holistically there so as not to create a false impression of what occupational therapy is. Ultimately government policy is influenced by politicians’ thirst for power. The voters grant that power. Marketing to the public is therefore more important than marketing to the government.

7.2. Maintaining Standards: The government will always put pressure on public service managers to cut costs. That pressure will invariably be transferred onto us. As clinicians we have the responsibility of exerting upwards pressure to let the management know when we have reached the minimal acceptable standards of care provision. If we do not do this, the management, and therefore the government will never know if cost-cutting has been unreasonable, and standards will keep dropping. The standard of care we provide generates our public image. Do we want that to be one of a profession that rushes patients out of hospital as quickly as possible or one of a profession that helps people live happy and healthy lives? If we spread thinly to conserve funding, and provide a poor quality service, few people will recognize the true value of occupational therapy. If we set service-level agreements and minimum standards of care that we will not drop below, and treat people well until our funding has run out, people are more likely to identify how valuable occupational therapy is and demand more funding for it.

Red tape may be put in place as funding is cut to discourage us from supplying better, but more expensive standards of care. An example of this is occupational therapy equipment being taken off standard equipment lists and being put on special equipment lists or not being listed at all. This means more paperwork and senior authorization is then required for the equipment. If we really care about standards of care, and believe occupational freedom is important, we should keep issuing reasonable equipment that will significantly but cost-effectively improve quality of life, filling out all of the documentation and going through the procedures necessary, even though as a result we will be working slower.

7.3. Early assessment and goal setting in in-patient settings: If the purpose of healthcare interventions is to maintain people’s occupational freedom, perhaps occupational therapists should be involved in assessment and multidisciplinary goal setting early, instead of just getting involved at the end of a patient journey to facilitate discharge from hospital. This could help to ensure more holistic, client-centred service delivery[20].

7.4. Moving into the private sector: Public sector management may make it very difficult to practice holistically, but we are an autonomous profession, and we need not rely on the public sector. One of the reasons I use www.MetaOT.com for example, is because it is in the public domain and searchable by Google. It can be used to market occupational therapy directly to the public worldwide. I have previously been contracted to Deutsche Bank as a physiotherapist. I did not notice any occupational therapists there. Why not? Occupational therapy is not tied to the public sector, and it has plenty of room for growth.

7.5. Primary care and health promotion: Psychoneuroimmunologic evidence suggests that occupational therapy may be more effective in a preventative rather than curative role. It therefore arguably makes sense to push occupational therapy out into primary care, starting with occupational health education in schools, continuing through to adulthood. To some, it seems inconceivable that at some point in the future, everybody could have the option to register with an occupational therapist just as they do now with a general practitioner (GP)[19]. Why? Is this because we are unable to think outside the medical model? When I see people with inflammatory bowel disease having abdominal surgery I am filled with sadness. I wonder what percentage of these patients was exposed to holistic occupational therapy early in their disease process. None I guess. The same applies to heart disease, obesity, liver surgery due to substance misuse and to a lesser extent cancer. The health service is currently like a revolving door. The same patients just keep going out and coming back in because they have not been given adequate occupational therapy to avoid psycho-socially mediated health problems. Occupational therapy is the future of pro-active and preventative healthcare delivery. One day occupational therapy will be competing on equal terms with medical care and pharmacology. All we need do is realise this. Believe it, and it will happen.

V

8. References:
1. BBC (undated) Inside Camp X-Ray http://news.bbc.co.uk/hi/english/static/in_depth/americas/2002/inside_ca... accessed 18/11/2007
2. WHO (1948) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. The definition has not been amended since 1948.
3. True World Order, (2000). Sivananda Yoga Teachers’ Training Manual. Val Morin: True World Order
4. BBC (2002) British woman denied right to die http://news.bbc.co.uk/1/hi/health/1957396.stm accessed 18/11/2007
5. Department of Health (2000) Reducing heart disease in the population. Chapter one of: The National Service Framework for Coronary Heart Disease. http://www.dh.gov.uk/
6. Department of Health (2000) The NHS cancer Plan. http://www.dh.gov.uk/
7. Department of Health (1999) The National Service Framework for Mental Health http://www.dh.gov.uk/
8. Department of Health (2007) NSF for older people Standard Eight - The promotion of health and active life in older age http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Olde... accessed 18/11/2007
9. Cayton H. (2007) Self care. http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Long... accessed 18/11/2007
10. Mackenzie S. (undated) Psychoneuroimmunology http://www.sallymackenzie.com/sitev1/infoon.asp?infoid=19 accessed 18/11/2007
11. Mailoo V.J., Williams C.J. Psychoneuroimmunology: a theoretical basis for occupational therapy in oncology?. International Journal of Therapy & Rehabilitation 2004 Jan; 11(1):7-12
12. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11): 503-510
13. Alford L. (2006) Psychoneuroimmunology for physiotherapists. Physiotherapy 92: 187-191
14. Guest (Fri Nov 02, 2007 1:17 pm) What is happening to OT services? http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2237 accessed 18/11/2007
15. Guest (Tue May 08, 2007 1:15 pm) Does it matter that people don't know what we do? http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1785 accessed 18/11/2007
16. Griffin (Wed Nov 07, 2007 1:27 pm) No subject http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2245 accessed 18/11/2007
17. Venth (Thu Nov 08, 2007 6:31 am) Survival http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2237&postdays=0&pos... accessed 18/11/2007
18. Defeated (Fri Oct 26, 2007 9:36 pm) Banging my head against a brick wall http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2134 accessed 18/11/2007
19. Various (2007) occupational apartheid http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1848&postdays=0&pos... accessed 18/11/2007
20. Venth (2007) Early access visit v later home visit? http://www.metaot.com/blogs/%5Buser%5D-4 accessed 18/11/2007

The diagrams in this blog entry have been reproduced from references 11 and 12 with the kind permission of MA Healthcare http://www.ijtr.co.uk/

]]> Application of the Ayurvedic Model of Human Occupation – A case study. http://metaot.com/blogs/%5Buser%5D-3 2007-10-28T19:11:46+00:00 2008-02-21T19:28:00+00:00 Venth 1. Introduction: As a member of the British Association of Occupational Therapists I refer to the Code of Ethics and Professional Conduct [1] and Core Standards [2] specified by the College of Occupational Therapists. I also refer to National Service Frameworks[3] produced by the Department of Health and guidelines produced by the National Institute for Health and Clinical Excellence[4]. Working within the National Health Service I rarely feel empowered to follow these standards or guidelines. This mismatch between professional ideals and working reality seems to be a never-ending source of conflict and emotional turmoil. To manage this conflict I refer to Hindu/Buddhist scriptures on the practice of yoga. Some essence of these has been summarised in a journal article titled ‘The Ayurvedic Model of Human Occupation’[5] in the Asian Journal of Occupational Therapy. This blog entry describes how I apply these scriptures to my working life, to manage my own well-being (that is threatened five days a week). It may make little sense to anybody that does not practise yoga. I would therefore encourage anybody that is interested to refer to the journal article.

]]> 1. Introduction: As a member of the British Association of Occupational Therapists I refer to the Code of Ethics and Professional Conduct [1] and Core Standards [2] specified by the College of Occupational Therapists. I also refer to National Service Frameworks[3] produced by the Department of Health and guidelines produced by the National Institute for Health and Clinical Excellence[4]. Working within the National Health Service I rarely feel empowered to follow these standards or guidelines. This mismatch between professional ideals and working reality seems to be a never-ending source of conflict and emotional turmoil. To manage this conflict I refer to Hindu/Buddhist scriptures on the practice of yoga. Some essence of these has been summarised in a journal article titled ‘The Ayurvedic Model of Human Occupation’[5] in the Asian Journal of Occupational Therapy. This blog entry describes how I apply these scriptures to my working life, to manage my own well-being (that is threatened five days a week). It may make little sense to anybody that does not practise yoga. I would therefore encourage anybody that is interested to refer to the journal article.

The National Health Service is a chronically diseased organisation characterised by employee dissatisfaction and apathy[6]. Standards of care are compromised because employees do not believe they are achievable and therefore make insignificant efforts to meet them. This defeatist culture permeates every stratum of the National Health Service from clinical to managerial levels. From previous experience of National Health Service management I know that (at least in some hospitals) managers expend more effort on keeping up (false) appearances than actual service improvement[7], because they do not believe government-set targets are actually achievable. The result of this failed management culture is that experienced clinical staff are jaded and do not believe things will ever change for the better[8, 9]. Examples of this I have recently encountered are client-centred practice (or lack thereof) and documentation standards. My experience of documentation standards is that nobody even tries to follow them. I was even told by a senior physiotherapist that these standards cannot realistically be achieved and are just something to aspire to (but not actually meet). A senior occupational therapist said to me “you have to realise this is an acute setting”.

How can a basic grade occupational therapist survive in this environment? Thinking purely in material terms it would be sensible to tow-the line to advance my own career. Compromising standards in health care is like using performance-enhancing drugs in athletics; because everybody else is doing it, you have to cheat just to stay in the game. If I do not compromise my standards I will put my career at risk because on paper (statistically) it will appear that I am not working as efficiently as everybody else, as quality is time-consuming. It can take 10 minutes for example, just to make head or tail of a messy set of medical notes, to enable me to number the pages I write on. If I do disregard professional standards I will be more likely to fit seamlessly into the teams I work with. As I further my career I might conveniently forget the standards altogether and become a yet another diseased cell of the health service. Should I do this?

2. Dharma: My actions are based upon what I feel (not think) to be the right and noble path for me as an individual. This is termed Dharma. Each person’s Dharma is dynamic and unique. At this particular moment in time it is my Dharma to write this blog. I know this, because as I type, I am in a state of flow. How does this apply to the paradox I face at work? Do I believe the professional standards are right, or the professionals that choose to disregard them as unrealistic? For me, this is a simple decision. The attitude of the professionals that surround me is responsible for the current state of the National Health Service; it is a vital component of the disease. Once on a ward for example, I saw the abbreviation ‘NSTEMI’ in a patient’s notes. It was not written in full anywhere in the notes. Nobody on the ward at the time (including the charge nurse) could tell me what it meant. Why had nobody questioned this before? I suspect it is because people have come to accept not being able to read doctors’ handwriting or understand medical notes as a norm. When I worked in a pseudo-rehabilitation hospital the notes we received from acute hospitals were never in chronological (if any) order. It would rarely take less than half an hour to forty minutes for a therapist sifting through the notes to be able to figure out exactly what had happened to a patient. Does this type of miscommunication increase clinical risk? Of course it does. What would happen if, at the same time, on the same day, everybody chose to stick to their professional standards and stuck fearlessly and relentlessly to their guns? I suspect through-put would slow down, but standards of care would remarkably improve, and as everybody would be singing off the same song sheet the government would have to put more money into the health service if it wanted more output (sacking everybody would not be a feasible option).

3. Threats: It is easy to find people moaning about the health service, but as a junior member of staff, if I choose to fight for quality will there be anybody on my flanks as I run onto the battlefield? Unlikely; it is far more likely the complainers will be digging holes to cower in and avoid the fall-out. There are sources of help, but I am largely on my own and it seems that no good outcome is possible. This bleak picture was metaphorically described in the Bhagavad-gita.

Arjuna said: "I feel the limbs of my body quivering and my mouth drying up. My whole body is trembling, my hair is standing on end, my bow Gandiva is slipping from my hand, and my skin is burning. I am now unable to stand here any longer. I am forgetting myself, and my mind is reeling. I see only causes of misfortune.....Now I am confused about my duty and have lost all composure because of miserly weakness. In this condition I am asking you to tell me for certain what is best for me. Now I am your disciple, and a soul surrendered unto you. Please instruct me. I can find no means to drive away this grief which is drying up my senses. I will not be able to dispel it even if I win a prosperous, unrivaled kingdom on earth with sovereignty like the demigods in heaven." Bhagavad Gita (1:29-2:8)

3.1. Sources of fear: There are many reasons to cower and tow the line. One may feel unable to speak ones mind for fear of alienating himself or herself from his or her team, or due to a low position of power in the management hierarchy. One may fear for ones job security and as a result fear ones survivability in the material world. Applying the Tantric frame of reference[10] we can see that such fears can cause imbalances of bodily, egotistical and compassionate consciousness and discourage one from acting altruistically out of universal consciousness, or authentically by following intuition. These fears can metaphorically be termed demons.

4. Repercussions of deviating from Dharma: Superficially avoiding ones demons and towing the line may seem like a good idea. The problem with this is that while hidden from the conscious mind, demons do not go away; they become internalised. During a lifetime motivated by fear one is likely to internalise masses of demons. Hidden inside, they reap havoc with ones health on a cellular level. As well has causing deep-seated psychological problems, there is ample evidence that suppressed intra-personal conflicts predispose humans to a plethora of diseases from gum disease[11] and other inflammatory conditions[12], to cancer[13]. The deterioration in health for most people is so gradual, that it is attributed to the aging process. Have you ever wondered why some people age so much better than others[14]? There is a huge occupational influence on the aging process. Stress for example, is known to impair the DNA repair[13]. Towing the line against ones better judgement is therefore spiritual suicide!

5. Coping methods: Having ruled out humouring my demons, only one choice remains; Dharma. My intuition is telling me to struggle for what I believe is right. As I am facing what seem to be impossible odds I am at serious risk of burn out. How can I manage this?

5.1. Balancing the three humours (vata, pitta, kapha): The three humours are subtle energies that permeate my body[15]. I must keep them in balance to maintain good mental and physical health. I can estimate their level of balance from observing my moods, taking my pulse and paying attention to some of my other physical characteristics[16]. My occupational balance, environment and the flavours of the food I eat influence the three humours. At the moment I know I need more rest and would benefit from working part-time instead of full-time. As a rotational basic grade this is impractical, so I am compensating for my lack of rest with meditation and breathing exercises. I am also choosing very carefully which battles I fight, as if I tried to fight them all I would be overwhelmed in a matter of days (if not hours).

5.2. Balancing the three natures (gunas): "All men are forced to act helplessly according to the impulses born of the modes of material nature; therefore no one can refrain from doing something, not even for a moment" (Bhagavad Gita 3:5). I am a very passionate person. This trait has driven improbable success in my past, but poses a serious risk to my health. My excessive passion previously drove my career, but now motivates me to take on excessive altruistic work. The traditional term for this type of work is karma yoga. Too much of it is a sure path to burn out. To survive I need to balance my passion with wisdom (essence) and inertia. Management of these three natures depends on occupational balance and diet. To reduce my passion I need to avoid excessive emotive stimulation. In health care environments this factor is probably beyond my control. I can also influence this balance with the flavours of the foods I eat. To reduce my passion I need to avoid stimulant foods such as meat, garlic and spices.

5.3. Detachment: "Never consider yourself the cause of the result of your actions, and never be attached to not doing your duty" (Bhagavad Gita 2:47). When fighting improbable odds it is important to not care about the results of my actions. This does not translate into not caring about my work. To maintain my own well-being according to the Tantric frame of reference[10] I must develop compassion for all beings and therefore be passionate about following Dharma. This basically means I believe in following professional standards and acting in my patients’ best interests with no regard for my career or job security. I can do this because I am not attached to my career or wealth. I am not particularly bothered about whether the National Health Service improves or not either, as long as I am doing my bit to the best of my ability. If I did care about whether my actions would causally lead to service improvements, it is likely I would rapidly become de-motivated and give up, as to be honest, my actions seem mostly fruitless. My well-being depends on good actions, but not on their results.

6. Coping resources: Detachment is fine in theory but can be extremely difficult to practise. Dharma can be very difficult to see in times of trouble, or when intuition is weak. Yoga provides the coping resources to deal with these problems.

6.1. Raja yoga: Raja yoga is a system of practices to increase intuition. Components of Raja yoga I use include postures, breathing exercises[17] and meditation. All three of these are good for exorcising past demons. The intuition they afford me helps me to feel what my Dharma is at any time. During a four-week intensive yoga teachers’ training course I attended in Canada problems I had buried deep in my subconscious mind emerged to haunt me during the second and third weeks. I was forced to deal with them, and this was the basis of a psychological detoxification that enabled me to detach from my material ambitions and career. I was previously as physiotherapist with a successful military career. Attachment to these things would have prevented me from becoming an occupational therapist (my Dharma) and may have compelled me to act in unethical ways. I currently practice breathing exercises and meditation every day, and postures once or twice a week. It is Raja yoga that empowers me to be fearless about ethical issues at work.

The relaxation facilitated by these techniques makes them great tools for occupational balance management. I occasionally practise advanced meditations that facilitate my awareness of bliss. Regular exposure to this bliss enables me to view the world as a beautiful (rather than hostile) place and alters my consciousness. In this altered state of consciousness, I find it difficult not to love people (even my most difficult patients and colleagues). The beauty of the world is a coping resource, whenever I take the time to look at it.

6.2. Karma yoga: "Perform your prescribed duty, for action is better than inaction. A man cannot even maintain his physical body without work"(Bhagavad Gita 3:8). My clinical work and the academic work I undertake to improve health service delivery are my karma yoga. These altruistic undertakings give my life meaning, and that meaning is a great coping resource in the face of adversity.

6.3. Bhakti yoga: I have a close personal relationship with God. One may argue that there is no scientific evidence for God, but the effects of faith are more relevant therapeutically than its actual validity[18]. My faith in God assures me that I will be looked after as long as I follow Dharma. This is a huge coping resource.

6.4. Jnana yoga: When all else fails it is worth remembering that nothing I perceive in the material world is permanent. If I am having a bad day, all I need do is weather the storm. Soon it will be over.

6.5. Balancing the humors: If a time ever arises when the yoga is not quite cutting it, I could always just visit the Bento Café. Yes, life is good :0)

7. Conclusion: This case study shows how I use yoga to regulate my own occupations for the maintenance of well-being. Pre-reading or previous experience of yoga is necessary for full understanding of this case-study, as terms have not been explained in detail. If you would like to try this model for yourself, please consider formal training in yoga. To network with other therapists interested in yoga you may like to visit this link: http://www.facebook.com/group.php?gid=2352527880

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8. References:
1. College of Occupational Therapists (2005) College of Occupational Therapists Code of Ethics and Professional Conduct, London: College of Occupational Therapists
2. College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice, London, College of Occupational Therapists
3. Department of Health (Various) http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/DH_4...
4. National Institute for Health and Clinical Excellence (various) http://www.nice.org.uk/
5. Mailoo V.J. (2007) The Ayurvedic Model of Human Occupation. Asian Journal of Occupational Therapy 6(1): 1-13 http://www.jstage.jst.go.jp/article/asiajot/6/1/1/_pdf
6. Canty M. (undated) The NHS Is Sucking My Soul Dry http://www.facebook.com/group.php?gid=2217865751
7. Revill J. (2003). Hospitals faking cuts in casualty wait times. The Observer Sunday 11th May 2003: Front page http://www.observer.co.uk/nhs/story/0,1480,953395,00.html
8. Thornbury Nursing Services.(2002) Public service workers feel stressed and under valued. Monday 14 October 16:36 Available from URL: http://www.thornbury-nursing-services.com/news.asp?page=4
9. Demetriou D. (2003) Professor claims St. Georges Tooting bent rules to hide op cancellations. Hospital accused of fiddling waiting lists. The Evening Standard Wednesday 30 April p 6
10. Mailoo V., Wickham J., Bannigan K. (2006) OT and the tantric frame of reference. Therapy Weekly 33(3):8-10
11. Lundy F.T., Linden G.J. (2004) Neuropeptides and neurogenic mechanisms in oral and periodontal inflammation Crit Rev Oral Biol Med 15(2):82-98
12. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11): 503-510
13. Mailoo V.J., Williams C.J. Psychoneuroimmunology: a theoretical basis for occupational therapy in oncology? International Journal of Therapy & Rehabilitation 2004 Jan; 11(1):7-12
14. Rowe J.W., Kahn R.L. (1987) Human aging: usual and successful, Science, 237(4811): 143-149
15. Mailoo V.J. (2005) Yoga: an ancient occupational therapy? British Journal of Occupational Therapy, 68(12): 574-577
16. Lad V. (1984). Ayurveda: The science of self-healing. A Practical Guide. Wilmot: Lotus Press
17. Mailoo V.J. (2006) Pranayama: potential tools to enhance occupational performance. Asian Journal of Occupational Therapy 5:1-10 http://www.jstage.jst.go.jp/article/asiajot/5/1/1/_pdf
18. Yates W.R. (2004) The Link Between Religion and Health: Psychoneuroimmunology and the Faith Factor (book review) Am J Psychiatry 161(3): 586

]]> Gain with no pain; just a little strain – physical conditioning for people with cardio-pulmonary impairments. http://metaot.com/blogs/%5Buser%5D-1 2007-10-27T14:38:47+01:00 2007-11-19T15:11:36+00:00 Venth 1. Introduction:
As a basic grade occupational therapist, I frequently encounter people for whom exercise tolerance is the limiting factor of occupational performance. Usually, this is due to physical de-conditioning secondary to inactivity, but occasionally it is due to pathology. This can often be obvious in people with pulmonary or cardiovascular impairments, but less obvious for those with neurological or renal pathology. Reflecting on my undergraduate occupational therapy training, it has not informed me of how best to manage these people as patients. If I knew no better, I might be hesitant to stress people with cardio-pulmonary pathology for fear of straining their already compromised organs. I might just issue loads of equipment and re-organise tasks to reduce occupational stress. Luckily, from previous experience I know that peripheral physiological adaptations contribute grately to increased performance capacity, and can therefore reduce the overall daily load placed on a compromised heart or lungs. When cleaning out my hard-drive this weekend I found a piece of work I did 9 years ago that has influenced my own physical training and the way I have viewed people with reduced exercise tolerance since. I thought I might as well share it here before deleting it along with the rest of my junk.

]]> 1. Introduction:
As a basic grade occupational therapist, I frequently encounter people for whom exercise tolerance is the limiting factor of occupational performance. Usually, this is due to physical de-conditioning secondary to inactivity, but occasionally it is due to pathology. This can often be obvious in people with pulmonary or cardiovascular impairments, but less obvious for those with neurological or renal pathology. Reflecting on my undergraduate occupational therapy training, it has not informed me of how best to manage these people as patients. If I knew no better, I might be hesitant to stress people with cardio-pulmonary pathology for fear of straining their already compromised organs. I might just issue loads of equipment and re-organise tasks to reduce occupational stress. Luckily, from previous experience I know that peripheral physiological adaptations contribute grately to increased performance capacity, and can therefore reduce the overall daily load placed on a compromised heart or lungs. When cleaning out my hard-drive this weekend I found a piece of work I did 9 years ago that has influenced my own physical training and the way I have viewed people with reduced exercise tolerance since. I thought I might as well share it here before deleting it along with the rest of my junk.

2. What limits physiological (not psychological) exercise tolerance?
Aerobic performance (exercise with oxygen) depends on the ability to utilise oxygen relative to demand (l·min-1kg-1). Thus VO2max (maximal oxygen uptake) is a performance indicator. In twelve year old males, Counil et al[1] found that asthmatics achieve only 79% of normal VO2max. At first this appears to suggest respiratory function is the limiting factor, but asthmatics also have decreased cardiac stroke volume[1] and lung function is known not to limit VO2max in healthy subjects. Lung perfusion (circulation of blood through the lungs), red blood cell count and haemoglobin concentration[2] are determinants of oxygen uptake.

Cardiac output affects systolic blood pressure and rate of oxygen carriage between the lungs and muscles. Stroke volume is therefore a determinant of VO2max[3]. Forceful skeletal muscle contractions occlude blood flow[4], so perfusion (circulation of blood through the mucles) is dependant on blood pressure[5] sufficient to overcome this resistance. Local vasodilation occurs in response to muscle activity, but if a large mass of muscle is working, the sympathetic nervous system overrides this reflex to prevent hypotension (low blood pressure)[5]. Thus blood pressure and circulating volume affect performance.

Muscle mitochondria (the site of aerobic respiration) are the last factor of VO2max[6, 3], and some think, the limiting factor[5]. Skeletal muscle characteristics may also influence blood pressure control during exercise[7]. Type I (slow twitch) fibres have greater vascularity and therefore, offer less peripheral resistance than type II (fast twitch) fibres[7], contributing to higher VO2max[5].

The validity of VO2max in performance prediction is questionable. Lactic acid accumulation (which causes muscle pain when you exercise too hard) occurs at activity levels below VO2max, and correlates more closely with ventilatory threshold[8]. Ventilatory threshold is the point at which ventilations increase disproportionately to oxygen uptake, and is also a performance indicator[8]. Ventilatory threshold and point of onset of blood lactate accumulation have been used as indicators of anaerobic threshold[8] - the point of oxygen debt. It is unclear whether there is a causal link between ventilatory threshold and onset of blood lactate accumulation, and whether onset of blood lactate accumulation lactate concentration is fixed, or varies between individuals[8].

The belief that aerobic fatigue results from neuro-transmitter depletion has been disproved[9]. Fatigue can result from fuel depletion[10], so endurance below onset of blood lactate accumulation depends on glycogen and fat storage. Patients are unlikely to experience this unless they are malnourished or have poorly managed diabetes. Anaerobic capacity (the ability to exercise without oxygen) correlates with lean body mass[11], and is limited by the ability to buffer the pH[12, 4] of lactic acid accumulation[10].

3. Physical conditioning to remedy poor exercise tolerance:
Effects of training on the respiratory and cardiovascular systems can be determined by two methods; comparison of physiological measurements in trained and untrained subjects, or comparison of physiological measurements in subjects before and after a training program. The former approach confirms nothing, as it fails to account for genetics, but it provides insight for further research.

3.1. Cardiovascular response to training:
3.1.1. Cardiac output: Gregoire et al[13] compared aerobically trained and untrained young and middle-aged subjects, and noticed reduced sympathetic- and increased parasympathetic- nervous activity, at rest and during exercise in the trained groups, which could be due to changes in central integration of muscle afferent information[14]. Trained middle aged individuals had greater resting heart rate variability than matched untrained subjects[13], but there was no significant heart rate variability difference in the young[13]. Endurance training increased heart rate variability in nine out of eleven young males tested by Al-Ani et al.[15], whose methodology was more valid.

Aerobic training increases maximal cardiac output[16], reduces resting pulse rate[17, 3] and heart rate during sub-maximal exercise[18, 19]. Sprinters respond to isometric exercise with a larger heart rate increase than distance runners[7]. Differences are thought to be due to increased vagal tone[18], and/or decreased sympathetic tone[3], though some have proposed changes of intrinsic heart rate[18].

Di Bello et al.[3] compared male endurance athletes to sedentary males matched by age, height, weight and relative body surface. The athletes had larger resting stroke volumes, resting- and exercise- left ventricular end diastolic volumes. Athletes' ejection fractions increased during exercise as did stroke volume, significantly more than sedentary subjects'[3]. Non-invasive measures of heart volume were used, so reliability of this data is questionable, but ejection fraction increase is supported by the findings of Kavanagh et al.[17] with chronic heart failure patients.

Di Bello et al.[3], found athletes have greater end diastolic volumes than sedentary subjects during recovery from exercise. This depends on venous return and heart rate. Heart rate returns to resting values quicker in trained subjects, so there is more time for filling between each stroke.

3.1.2. Blood Pressure: Endurance athletes have larger blood volumes than matched sedentary subjects[3], but comparable resting blood pressure. Isometric[14] and endurance[20, 21] training lower resting blood pressure. Muscle capillary beds enlarge in response to training[5], but resistance (muscle) training has been shown to have no effect on blood pressure in subjects over seventy years old[20]. This may indicate that muscle plasticity decreases with age and physical conditioning may be less effective for older patients. Torok et al.[7] found sprinters respond to isometric exercise, with greater increases in blood pressure than distance runners. No significant difference was found in dynamic exercise blood pressures, though distance runners exhibited greater vasodilation[7].

Endurance athletes have a greater increase in mean arterial blood pressure than matched sedentary subjects during maximal exercise[3], but the maximum pressures are comparable. Regular exercise may cause baroreceptor resetting[22, 14], decreased sympathetic nervous system activity[13], and reduced catecholamine release[23], thereby decreasing peripheral resistance. McArdle et al.[24] proposed that exercise may facilitate sodium elimination from kidneys, but cited no evidence.

3.1.3. Structural adaptations: Structural cardiac adaptations and physiological changes, are specific to posture[25] and activity. Weight lifters have thickened cardiac muscle, with minimal increase in ventricular volume[24], whereas endurance athletes have increased internal atrial[5] and ventricular[24] volumes.

Athletes' hearts have thicker septums, and higher left ventricular mass indexes than sedentary subjects'[3]. Resting end diastolic left ventricular diameter is increased in endurance athletes[3]. This accounts for the increased ejection fraction and stroke volume, in accordance with the Frank Starling mechanism[3] - increased mechanical efficiency due to altered relative positions of actin- and myosin-filaments (resulting in more forceful muscle contraction). Trained skeletal muscles facilitate venous return better than untrained[3].

3.2. Pulmonary response to training:
According to McArdle et al[24], ventilatory muscles develop increased endurance in response to aerobic training, thereby allowing a higher maximal respiratory rate and larger exercise tidal volume and, athletes have higher maximum ventilation rates (l·min-1) than untrained subjects, but evidence of pulmonary changes is lacking. Three months of aerobic training improved lung function, as assessed by forced vital capacity, forced expiratory volume in one second and peak expiratory flow rate, of a subject with acid maltase deficiency, in a single case study by Leutholtz and Ripoll[21]. The subject was treated with Depo-Testosterone[21], which may have enhanced beneficial training effects[26] while preventing detrimental effects of training and pathology[27]. Validity of generalisations may be poor due to the unique pathology, and the specific nature of the study[28]. Clark et al.[29] concluded there is no relationship between ventilatory variables and exercise capacity in healthy individuals, having measured the effects of 19 weeks of aerobic training on ventilatory performance in 27 subjects.

Some advocate specific training when respiratory muscle function is a limiting factor of performance[30, 31], but Berry et al[32] found that inspiratory muscle training with a general exercise program, was no more beneficial than a general exercise program alone. Various studies indicate respiratory muscle training may be of benefit in chronic obstructive pulmonary disease[33]. Performance in chronic obstructive pulmonary disease is ventilatory limited[34], not cardiovascular limited as is the norm, so findings may have no bearing on people with normal respiratory function.

Torok et al[7] found no difference in maximum oxygen uptake (VO2max l·min-1) between sprinters and long distance runners, but when adjusted for body mass (ml·kg-1min-1) distance runners had greater relative VO2max. For previously mentioned reasons, extrapolations from this data, on the effects of training may not be valid, but other research has confirmed endurance training increases VO2max[6]. Ventilatiory equivalent for oxygen (the ratio of the volume of air passing through the lungs to the volume of oxygen uptake) decreases with endurance training[24]. If anything, this shows that adaptations take place outside the respiratory system.

In people with chronic obstructive pulmonary disease, endurance training reduces VO2(volume of oxygen consumed l min-1) at standardised sub-maximal power outputs[30]. Training improves efficiency, and economy of oxygen consumption and ventilation (reduces ventilatiory equivalent). Trained subjects expire relatively less oxygen than untrained[24], but training only reduces ventilatiory equivalent for exercise of the trained muscles[5]. This is because adaptations (increased aerobic enzyme concentrations and number of mitochondria) take place in muscles, rather than the respiratory system[30].

4. Conclusion:
The validity to rehabilitation of much of the research looked at here[3, 13, 25, 7] is questionable, as differences between athletes and sedentary people may not all be due to training. Also, findings in disease[32, 24, 17] may have no bearing on people without those specific diseases. All things considered, evidence suggests that cardio-respiratory adaptations to training are; left ventricular physiological hypertrophy[35], increased: stroke volume, blood volume, sympathetic nervous system modulation[3], vascularity[36] and ventilatory muscle endurance[37].

We can extrapolate from adaptations to training, that ,VO2max[18], heart size and shape[5], blood volume[3], lean body mass[11] and muscle fibre type ratio[6], contribute to performance. No one variable has proved more critical than the rest[5]. While people with compromised cardio-pulmonary systems may not be able to produce cardio-pulonary adaptations there is adequate evidence that adaptations of skeletal muscle and peripheral circulation in response to training can contribute to increased exercise tolerance and reduced resting loads on the heart and lungs. Occupational therapists should therefore consider rehabilitation for these people instead of just compensatory interventions. Obviously, any conditioning programs should be graduated sufficiently to avoid dangerous physiological stress.

This work is now nearly ten years out of date and I got a bad mark for it at the time, so feel free to recycle it with newer information. Modern guildines such as Chapter 7 of the Cornary Heart Disease National Service Framework[38] are available from: http://www.cardiacrehabilitation.org.uk/ It is also worth noting that this document only focuses on the cardiovascular and pulmonary systems though studies of the effects of exercise on other systems relevant to occupational therapy have been conducted[39].

V

5. References:
1. Counil F-P, Varray A., Karila C., Hayot M., Voisin M, Pr‚faut C. (1997) Wingate test performance in children with asthma: aerobic or anaerobic limitation? Medicine and Science in Sports and Exercise Vol.29, No.4 pp.430-435
2. Scott W.C. (1990) The Abuse of Erythropoietin to Enhance Athletic Performance. Journal of the American Medical Association Vol.264, No.13, p.1660
3. Di Bello V., Santoro G., Talarico L., Di Muro C, Caputo M.T., Giorgi D., Bertini A, Bianchi M., Giusti C. (1996) Left ventricular function during exercise in athletes and in sedentary men. Medicine and Science in Sports and Exercise Vol.28, No.4, pp.406-413
4. Robergs R.A., Roberts S.O. (1997) Exercise Physiology Exercise, Performance and Clinical Applications Mosby St.Louis
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