Activity

This is a somewhat old post that I had been taking my time to finally post it so here goes..it is based around two letters that were submitted to the Telegraph way back about a year ago:

“Tea test

SIR - Office juniors are not the only people who have no idea how to make real tea (Letters, July 15). My mother was assessed last year by an occupational therapist as to whether she was fit to return home after a stroke. The OT considered she was not fully compos mentis. Why? She warmed the teapot with hot water, then poured it away before putting leaf tea in the pot and adding boiling water.

I was not believed when I pointed out that this method was correct and she had not been making the tea twice over.

N. Beale London, SE3”

Telegraph 18 July, 2006

I can’t of course speak on behalf of the OT in question but I know this complaint, if not directly the same, is not unheard of (from both patients and staff). The therapist in question has not been able to reply to these letters but there could of well been a reasonable reason for saying these patients in question were not “compos mentis”. Or of course they never actually said those things but hinted towards it. Whatever the case its simply not on.

So why is it that this sometimes occurs? Well the problem lies with that little thing called activity analysis which OT’s are supposedly fantastic at. The problem in particular is that we all have our preconceived idea of how a person should do something. Tea making is a classic example used by OT’s as a every day activity and as James suggests it is a somewhat subjective measure:

“One of the main criticisms of kitchen assessments in hospital - usually in the hospital OT kitchen, is that it isn’t actually the same as in the person’s own home, where they will probably be returning to. Someone might quite happily manage to do all sorts of things in their own kitchen, but appear to be confused and unable to the OT kitchen”

With much regret to my workmates I regularly provide an example of getting this activity “wrong” and that’s simply because I don’t make tea. Actually scrap that - I don’t drink tea. Infact my friends and family ban me from trying to make tea because I’m so lousy*. Yes, I am a total social outcast! God forbid the day if I have a brain injury and someone asks me to make a cup of tea - I would invariably fail with the above example.

Here’s a little side story which will let you into a little about me. I spoke to an old computer programming friend the other month and completely unprompted (regarding my current role as an OT) he said the following:

“I had to write a program for a job interview to simulate making a cup of tea. do you know it had about 200 steps?! a cup of tea is hard you know! … the worst bit was working out which order to put it all in - I’m a milk before tea man myself but realise its not the common method”

Aye, I certainly do.. there are more coincidences between computer programming and OT but that is for another post. The point is that OT’s sometimes forget the complexity of the task and more importantly the route in which it is taken. There is also another thing to remember we all have cultural differences between the way we do things. George Orwell recognises this issue when he talks about the “Russian style” of tea drinking in his essay “A Nice cup of tea”:

“Lastly, tea—unless one is drinking it in the Russian style—should be drunk without sugar. I know very well that I am in a minority here. But still, how can you call yourself a true tea-lover if you destroy the flavour of your tea by putting sugar in it? It would be equally reasonable to put in pepper or salt”

Unlike George we need to be understanding of these cultural differences, and some would argue this means learning about them. If you aren’t aware, the strange technique of warming the teapot is not unusual and infact it has been declared as the scientifically best way of making tea:

“Yesterday, he said the keys to producing the perfect cup were using soft water, warming the pot before filling and allowing the tea to brew for three minutes. It was also essential to use loose-leaf Assam tea rather than tea bags - “they slow down the infusion”.” From the Guide to the perfect cuppa starts a storm in a teacup

And now for the second letter in this posting.

“World Cup Revision

SIR - I was interested to read Neville Beale’s letter (July 18) about his mother who failed her stroke recovery test because medical staff did not understand the old-fashioned way she made tea. It does not Surprise me.

Eight years ago, during the World Cup, I had a stroke. The nurses were going to write me off because I could not answer their questions on football. They would not believe my wife when she told them I had no interest in the subject. “All men know about football” the said.

It took a visit to the hospital by my boss, to converse with me about nuclear engineering, to convince them I was actually compos mentis.

Since then, the joke every World Cup has been that I have to do my revision in case I have another stroke.

Richard Chester-Browne. Warrington, Cheshire.”

Telegraph 25 July, 2006

So what about the second letter writers experience? What can be the excuse for that? Lets imagine for a moment that the writer meant “OT’s” rather than “nurses” which could well have been the case*. Well, if that’s the case then I have to say there isn’t really any excuse - and even if they were nurses that’s still no excuse. OT’s *should be skilled in being client-centred and at the heart of this, working out what it is that engages & motivates individuals. We realise that no-one individual is the same and we are all different. Or at least we should.

In certain environments mistakes do happen and the reasons are often so numerous and complex that no one person is to blame. The football one is a classic mistake that I have kind of witnessed when you run a group five times a week, every week and your mind goes blank when trying to think of a current affairs topic to discuss and the general group seems to like football - but on a one-to-one basis? The mistake is perhaps borne out of routine and to a certain degree the human trait of stereotyping people. It can be difficult to assess a persons interests if they cannot easily communicate or their friends & relatives are not around. You could argue that if you take the average OT, their understanding of nuclear engineering would be quite limited (or perhaps “we were never taught that at college!” would be the response) - but now I’m stereotyping right?! So if you have been in this situation buck this worrying stereotype; What trouble would it take to google “nuclear engineering” and spend 5 minutes over lunch discovering that the man may be interested in that MRI scan you have recently taken of his brain! (if you haven’t worked it out, “nuclear engineering” covers a whole range of topics - one of which is nuclear medicine/physics read wikipedia for more info). What, do I hear you say “We don’t have time to look on wikipedia what nuclear engineering is!”?? Im afraid that I would equally say “this isn’t a luxury - its part of your job!”

* My Brother believes that there is a more sinister reason for me not being able to make tea: that it gets me out of making the tea. A clever approach that can get you out of doing all sorts of things but I have to say in this example its simply not true.

** I admit I hold onto this line of thought for quite sometime. If they were nurses then it could be more of an argument for OT’s on that ward which turns the argument into something entirely different..!

Is it really all good?

What is it like to be the recipient of OT services? This is a question that needs to be asked more often, particularly with regard to older service users, as over 65 year olds represent around 2/3 of hospital in-patients and are main users of nearly all parts of the hospital system (Help the Aged, 2004). To date there is little research exploring how patients experience ADL interventions. Understanding interventions from the patients’ perspective is essential for client-centred practice, (MacKinnon, 2001) and focus group participants have stressed that recipients of OT have a lot to share with service providers about the effectiveness or not, of treatment and rehabilitation strategies, (Corring & Cook, 1999). Some of the research is reviewed here. Studies regarding patient values in ADL interventions and therapist perceptions were included, as well as those regarding patient perceptions, as these provide valuable perspectives on this topic. (Click here to read on..)

10 minute guide to Activity Analysis
Activity Analysis: What is it?
The ability to analyse activity in minute detail is one of the unique skills of an OT (Hagedorn 1992). Activity analysis or "the exploration of the typical contexts, demands and potential meanings that could be ascribed to activity" (Crepau 2003 p191) has two main purposes - to identify difficulties and problems experienced by the individual in activities and provide specific interventions that are meaningful and purposeful to the individual.

How?
The content of the activity must be analysed and evaluated. Note that there is no one set way to achieve activity analysis - different authors vary in their approach and terminology. The first stage in any method however is to understand what is required of an individual to perform the activity competently. Items to consider should include (Hagedorn 1992):

• Performance components required (e.g. cognitive, motor, interpersonal - the headings for each may depend on the model being used)
• Degree of complexity
• Positive or negative social or cultural aspects
• Structured or Unstructured activity?
• Familiar to a person?
• Tools and environment required to perform the activity
• Safety and risk concerns
• Potential for engagement of patient interest and participation
• The tasks that make up the activity:
• sequence and flexibility of order
• task components (some define this as "task analysis")

Remember this first stage is to investigate activity - which remember is context-free (See box). Think of it as how someone would 'normally' perform the task*.

The next stage is to investigate the activity in context and discover how the person in question performs the required elements. Although often innately achieved by a therapist, there are a number of formats to achieve this. Lamport, Coffey and Hersch (2001) give some suggested forms to discover expected performance and for therapeutic intervention. The AOTA (in Crepau 2003) suggest one format that breaks down performance components into motor skills, process skills and communication/interaction skills (Crepau 2003 p193). A form that investigates expected and actual performance for a activity can be downloaded to use for your own use here (word, pdf). This is largely based on the Lamport et al text and you will need to refer to descriptions of the performance components to understand this form although its relatively straightforward. Note that some elements are missing from the form; these are mainly the performance contexts and should be taken into account within any activity analysis.

What now?
With the understanding of normal function and ability and being able to highlight those areas of difficulty seen by the individual it is possible to combine the two and formulate meaningful treatment plans. This will typically involve the use of graded activity - sequentially increasing the demands of an activity on a person to stimulate improvement in their functional ability (Crepau 2003). This will differ depending on the nature of the identified problems and theoretical approaches being taken (including Model, Approaches and Frames of Reference). Adapting the activity may also be required. Both adaption and grading requires modification and planning of not only the activities steps but also the context (e.g. environment).

* Im not keen on the word 'normal' but for clarity it is used here.

References
Lamport N.K., Coffey M.S, Hersch G.I (2001) Activity Analysis & Application, 4th Edition, NJ: Slack
- A nice text. Its slightly unrealistic to expect a practitioner to carry out all 5 forms suggested in the book but note that it has been designed to facilitate learning rather than for practice. What is useful is that the authors have gone to some effort to create steps to perform activity analysis and use terminology that is common - making full use of the AOTA Uniform Terminology; repeated for reference in the appendix of the book. If you buy it you also get access to the forms for downloading (once only).

Crepau E.R. (2003) Analyzing occupation and activity: A way of thinking about occupational performance in Willard & Spackman's Occupational Therapy pp 189-198

Hagedorn R (1992) Occupational Therapy: Foundations for Practice, Edinburgh UK: Chuchill Livingstone

Trombly, C.A (1995) Occupation, purposefulness and meaningfulness as therapeutic mechanisms (Eleanor Clarke Slagle Lecture), American Journal of Occupational Therapy 47, 960-972

An interesting prototype of a "intelligent" toy can be seen here.

"When children play with toy cars they tell stories; they provide their own narration, voice-overs, and special effects - rolling cars over and over in slow motion and making dramatically stretched crashing noises.

The HotCam is a manual control (not remote control), toy car with an onboard (driver’s view) video camera and microphone. The HotCam car enables children to record certain ”˜scenes’ in their own stories. The children can then ”˜play’ their captured scenes through a television. In this way HotCam stories can be shared with parents, siblings and friends, and children can re-experience their stories."

Seems like a fantastic opportunity to observe and monitor children during play in real-life situations - unhindered by adults standing over them, or by going to an unfamiliar room with a huge black one-way mirror (observation room I mean!). Note the footage shows not only the child at play but also the social interactions with his sister. Although it is just a prototype Mattel did take on the original designer as an intern so you never know it may be hitting the shelves soon (at a ridiculously high price I dare say)

via Make

Find below my rather rapidly put together handout on Sensory Integration. Please note the disclaimers regarding referencing at the bottom! (Full post, )

Sensory Integration (SI)

• Quick History & Theory
• Terminology
• Sensory Integrative Dysfunction/Sensory Procesing Disorder
• Signs/Symptoms of Sensory Procesing Disorder
• Treatment
• Inteventions
• Research
• References

I promised some time ago to publish the quick play therapy presentation me and a few others did so here it is in brief. Note that along side this goes the mastercards with flickr game. Please at the very least email me if you ever would like to use some or all of this..

This presentation was brought to you by the letter “C”: Adil Chernajovsky, Caroline Milne, Christina Eraclides, Emma Belton, Hannah Connery, Nick Holland-Smith, Will Wade, Kate Harvey, Catherine Bensberg & Lisa Fallon

History

• During the late 1800s it emerged that play was important and it was considered to be a meaningful behaviour
• It was not until the early part of the 20th century that play became prevalent in OT literature and became an integral part of OT intervention with children. Play was viewed at this time as connecting the body towards wellness by acting as a diversion from any thoughts of illness

Definitions:

• Although many agree on the value of play there is little agreement on its definition (Turner, Foster & Johnson, 2002)
• Many definitions exist including “play is action on humans and non-human objects” (Florey, 1971)
• Play is used as a context for learning and practising adaptive responses in a variety of settings including schools e.g. schools for children with learning difficulties.
• Play is viewed as the main occupation of childhood (Ziviani, Boyle & Rodger, 2001) OT’s consider play to be an important vehicle for the assessment of children & help to ensure play is varied, developmentally appropriate and fun

Why Do We Play?
Reasons for play are complex and uncertain but have been described as :-
Ӣ An opportunity to develop and learn physical, social and emotional skills
Ӣ A way of learning skills in concentration, problem solving and judgment
Ӣ Opportunity to perform for the process or feeling rather than the product
Ӣ A mechanism for exploring and defining motivation
Ӣ A foundation for interpersonal relationships
Ӣ An arena for learning role behaviours
Ӣ Play behaviours may be lost or limited if a child experiences physical limitations e.g. they are on a ventilator or if there is low availability of peers and playmates and perhaps due to a child being placed in a special school or different classroom

its fun!

OT is used within schools for those children requiring additional support which isn’t covered by the curriculum such as ADL skills, personal hygiene and extra preparation for moving on after school. Since “play” is seen as one of the crucial occupations to a child’s development, particularly in their formative years, OT uses play therapy as part of a intervention plan.

Refs:
for web based material see http://del.icio.us/metaot/play
for books and documents see: http://www.citeulike.org/user/willwade/tag/play-lecture

On friday me and a few others are giving a quick presentation on Play & Occupational Therapy*.
Part of it includes a couple of games for everybody to play - and in particular one that involves "turn-taking" as a intervention with a case study "Luke" who has Autism.

Games for the brain is a excellent site that has some online mind games to get you thinking. Although these are fantastic - they lack any way to customise the images or features such as length of game. As a result I hacked Philipp's code to run with Flickr. Check it out. It has a few bugs to say the least but you get the idea..

Any ideas for improvement stick em' in the comments.

URL: Mastercards with Flickr

*I'll be posting the slides and notes incase anyone is intrested!