Saturday, December 31, 2011

2011 Pushback against Fad OT Interventions

Another significant theme in my 2011 forum conversations was pushing back against fad OT interventions. I think that it is an important enough topic to be re-posted here.

Some of the fad and pseudoscientific interventions that I discussed in forums this year included therapeutic listening and other auditory interventions, deep pressure protocols (brushing programs), weighted vests, and Brain Gym.

Fad interventions were relatively common in health care until research came along - and now we have mechanisms to test and see if people's 'ideas' about something hold up to any scrutiny.

One posting asked about the validity of 'astronaut training' which is something that I get phone calls about in my private practice. I tried running database searches on 'astronaut training' and 'vestibular-visual protocol' and several other iterations that I hoped would capture this protocol and as usual for this kind of fad intervention I was unable to find any research.

I have practiced OT for 24 years. I can tell you that a lot of families contact me and ask me about whether or not I will provide Astronaut Training for their child. I tell them that it is experimental and that there has not been any research to support the specific protocol that they usually found out about through web sites or youtube. I am not going to link to those Internet sources because I don't see the value in spreading information about fad interventions. I would rather that people search the terms and come to the blog and see an opinion about pseudoscience.

Over the course of the last 20 years there have been several fad interventions in pediatric OT. These interventions are generally pseudo scientific in that they reference scientific-sounding concepts, they are promoted by "experts," they require "clinical training programs" that people need to attend so they understand how to do the protocol properly, and they have a "feel-good" quality to them that engenders hope in parents. In the end, they also have an absolute lack of supporting research.

An classic example of a fad or pseudoscientific intervention in OT is the so-called 'Deep pressure protocol.' I remember attending a conference in 1989 (22 years ago now!) and at that time the presenters were promising that there was exciting research available that would support their protocol. That research never materialized and now you can't even find a reference to that protocol in OT pediatric text books. Pseudoscientific interventions are tough to beat back into the bushes though - and even though we have 20 years of no evidence and no current references in major OT textbooks it still remains an entrenched part of what I call 'mythological' OT practice.

Pseudoscientific interventions are so resilient because they may in part have some concepts that are valid. For example, there may be something valid about how some deep pressure stimulation is calming to some people in some situations. Similarly, there may be something valid about trial practice and training for postural responses and visual-auditory orienting - but neither of these should be construed as meaning that you have to use the Fad Intervention therapy brush or you have to purchase the Fad Intervention CDs and you have to do the Fad Intervention protocol exactly the way the Fad Intervention Therapy pushers proselytize. Most importantly, you have to ask if you should be providing the Fad Intervention Therapy to a child and family unless you tell them that it is experimental and there is no supporting research.

It is probably much more important to look for supporting research, make ethical judgement about how you have to inform families about experimental procedures, and don't fall into the trap of perpetuating 'mythological' occupational therapy practice.

With persistence and continued conversation I am confident that we can advance the sophistication of how we bring ideas to a research forum without first setting our ideas loose into the marketplace where people are profiteering off of the hopes of parents and the lack of evidence-based proclivities by some forces within our own profession.

The 2011 Social Justice Debates in occupational therapy

I wondered this morning how much writing I have done on various OT message boards and I started thinking that an awful lot of my opinions are probably documented all over the Internet. I visited the forums on the AOTA website and found the equivalent of over 40 single spaced pages of my writing! Then I thought it might be interesting to see what motivated me to post on professional forums this year. Here is a summary of one interesting forum conversation:

The Social Justice Debates

Early this year there was a motion to rescind part of newly adopted AOTA ethics statements; the concern was that they unnecessarily referenced social justice concepts and that the existing ethics statements already covered that conceptual material and did so without politically charged terms like 'social justice.' The new ethics documents includes:

SOCIAL JUSTICE
Principle 4. Occupational therapy personnel shall provide services in a fair and equitable manner.

Social justice, also called distributive justice, refers to the fair, equitable, and appropriate distribution of resources. The principle of social justice refers broadly to the distribution of all rights and responsibilities in society (Beauchamp & Childress, 2009). In general, the principle of social justice supports the concept of achieving justice in every aspect of society rather than merely the administration of law. The general idea is that individuals and groups should receive fair treatment and an impartial share of the benefits of society. Occupational therapy personnel have a vested interest in addressing unjust inequities that limit opportunities for participation in society (Braveman & Bass-Haugen, 2009). While opinions differ regarding the most ethical approach to addressing distribution of health care resources and reduction of health disparities, the issue of social justice continues to focus on limiting the impact of social inequality on health outcomes.

Occupational therapy personnel shall
A. Uphold the profession’s altruistic responsibilities to help ensure the common good.
B. Take responsibility for educating the public and society about the value of occupational therapy services in promoting health and wellness and reducing the impact of disease and disability.
C. Make every effort to promote activities that benefit the health status of the community.
D. Advocate for just and fair treatment for all patients, clients, employees, and colleagues, and encourage employers and colleagues to abide by the highest standards of social justice and the ethical standards set forth by the occupational therapy profession.
E. Make efforts to advocate for recipients of occupational therapy services to obtain needed services through available means.
F. Provide services that reflect an understanding of how occupational therapy service delivery can be affected by factors such as economic status, age, ethnicity, race, geography, disability, marital status, sexual orientation, gender, gender identity, religion, culture, and political affiliation.
G. Consider offering pro bono (“for the good”) or reduced-fee occupational therapy services for selected individuals when consistent with guidelines of the employer, third-party payer, and/or government agency.



My own concern was with the statements "to abide by the highest standards of social justice" and "provide services that reflect and understanding of how OT service delivery can be affected by factors such as..." Here the politically co-opted definition and political twist that is taken with the term 'social justice' was challenging because of the associated statements about distributive justice which is politically charged. Additionally, there seems to be a suggestion that there is de facto impact on service delivery because of certain issues like age, ethnicity, race, etc., and many people object to that assertion. There is no doubt that prejudices exist, but it is not correct to state that there is de facto impact.

My concern was also related to how 'social justice' was being defined in the current American political context. I tried to compare worldwide Catholic social justice definitions to American social justice definitions. Context and degree seem to be overarching factors when it comes to definitions of social justice - for example, social justice from the perspective of a person in a developing country must be very different than social justice in the United States (which has incredible wealth and where even those who are very poor have their basic needs met).

Also, a core concept of Catholic social justice is in how it is practiced - no bigger than is necessary and no smaller than is appropriate.

Anyway, what I am saying is that I understand the Catholic position of social justice because it is a world-wide religion and the concept is being applied to a very broad spectrum of human existence.

That is all very different than the way that the term is being used in the United States as a redistributive economic policy.

I don't think that the OT professions needs to avoid issues that are politically charged, but it does not seem unreasonable to have a core value of inclusiveness so that we are not disenfranchising our membership - and there were some people who were uncomfortable with including this language in the ethics documents. I don't believe it is unfair to ask the appropriate contextual question of ''What does social justice really mean in the AOTA documents' and if it is such a core concept to our ethics - then why is it just appearing now?

This really was not a new concept for people who read here - I covered this material in depth previously.

The larger issue I was driving at in the conversations was "what constitutes OT practice and how do ethics aspirations suggest us into practice areas or into practice interventions that are beyond our mainstream." In many ways that makes them beyond pragmatic use to many practitioners.

I think that people can use their OT skills in many ways - but that does not necessarily make the interventions occupational therapy - even though some people are calling it that or perhaps want it to be.

I have no objection to giving recognition or praise to efforts that further people's health and participation - even when those efforts are informed by occupational science and are not falling within the mainstream of occupational therapy practice.

My concern is that sometimes it seems like we spend a lot of time in this profession playing in the stratosphere. Lofty ideals are fun, but the atmosphere is pretty thin - and sometimes it is nice to get your feet planted back on the ground again.

I believe that we will serve our profession best if our ideals and ethical aspirations have application to the everyday concerns of practitioners. If our ideals and ethics only help us populate an academic playground to see how many different ways we can apply our concepts then I fear that we will have created a great academic discipline - but one that has very little traction in everyday practice.

As a bottom line concern, AOTA ethics documents are included in some state license laws. That means that failure to abide by generic aspirational and potentially vague language about social justice in ethics documents might cause someone to be in jeopardy with their state license. That's not so good.

I did not believe that there was a need to include ambiguous social justice terminology to maintain our consistency of belief that people who have disabilities should receive services. The proposed motion to remove the politically charged terminology rather clearly outlined that nothing is lost by removing the social justice terminology, and instead the objective is to remove ambiguity that is associated with the term.

I greatly appreciated the distinctions that were argued between political social justice and ethical social justice in those forums - but the fact remains that based on a reading of the current ethics statement and based on a reading of our literature that there has not been such a distinction made between these different iterations of social justice. In fact - the two have been blurred throughout all the conversations as well as in the literature.

It was an interesting debate. The Motion to remove the language failed. So now I will continue the 'social justice watch' to see if any of this ended up having any notable and pragmatic impact on practice.

Monday, December 05, 2011

"It's going to be very, very exciting." Not.

I don't mince words, mostly because I lack time to do so and secondarily because I lack interest in political correctness. Let's talk straight about the Patient Protection and Affordable Care Act of 2010.

For some background and additional reading on the debacles that occur when government intrudes into health care decision making click on the 'health insurance' topics in this blog.

At the 2010 Legislative Conference for National Association of Counties, Nancy Pelosi made her now famous remarks
You've heard about the controversies within the bill, the process about the bill, one or the other. But I don't know if you have heard that it is legislation for the future, not just about health care for America, but about a healthier America, where preventive care is not something that you have to pay a deductible for or out of pocket. Prevention, prevention, prevention -- it's about diet, not diabetes. It's going to be very, very exciting. But we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.
Well we passed the bill and still nearly two years later we are waiting to find out what is in it.

The November 14th edition of OT Practice included an article by Jennifer Hitchon who is AOTA's regulatory counsel. Her article neatly summarizes the recently released Institute of Medicine report Essential Health Benefits: Balancing Coverage and Cost. The purpose of the IOM report was to survey stakeholders (aka insurance companies) about what products and services were deemed 'essential.' In other words - what is the bare minimum that these insurance companies are covering?

Now this is where I start to scratch my head a little - because the government determines that we need a new law to replace/supplement the 'evil profiteering health insurance companies' with government sponsored 'exchanges.' So, the government commissions the IOM to study the issue and the results of the study will go to the policy wonks who write the actual regulations that dictate what is in it. So then the IOM goes and asks the 'evil profiteering insurance companies' for their input so they can tell the policy wonks how to write better regulations than what is currently being done... oh... um.... hm.......

The IOM is non-governmental and advisory to the government and normally the IOM is a source to have faith in - but why survey/invite the fox to the hen house to determine what benefits should be considered 'essential?' I understand that the charge to the IOM was to come up with some package that was 'comparable' to what is being offered by most small business insurance plans - but how is the Affordable Care Act going to improve anything if all we do is base decisions on the cheapest available plans being offered by some small company that is already being squeezed by costs and is now choosing bargain basement health plans for its employees.

The lack of percipience into this issue is stunning, even for a government.

For fun I searched the IOM report for mentions of occupational therapy - you can view the mentions here. Most of the mentions relate to various inclusion/exclusion criteria of selected insurance plans.

The study includes some interesting statements that essential benefits should be medically oriented and not social or educational - which has rather large potential impact on all of pediatric occupational therapy practice. This same issue is being fought out state by state regarding insurance coverage for autism interventions and it will be interesting to see what the federal government does with the issue. I am curious how there will be reconciliation between exchange mandates and statutory requirements that have been written into state law about this coverage.

There are other notable exclusion points in the document related to some chronic conditions like intellectual disabilities and low vision. There is enough controversy for all. This doesn't mean that these will be automatically removed from 'essential' coverage determinations - but this all represents writing on the wall that people need to attend to.

Occupational therapists need to be watching this issue closely. Actually, the entire American public needs to watch this closely - but the complexities are beyond what many people have time or energy to follow, track, and decipher.

I encourage professional associations like AOTA to continue publishing about this issue as events unfold. However, we need straight analysis and not generic 'we will provide formal comments when the opportunity arises.' Practitioners and the public need to know the following:

  1. The government may plan to model their exchange off of the cheapest possible plan that is offered by a small business.
  2. Habilitation services could be on the proverbial chopping block, particularly if they can be labeled as 'educational' or 'social'
  3. The plan may cover things like if your eyeballs fall out of your head, because that is a medical problem. However, if you need therapy or equipment to help you function you might be out of luck because that would be a personal problem and not a medical problem.

Many professional groups (MDs, etc.) are getting out IN FRONT of these issues by publishing position papers about what needs to be covered and why. The OT community needs to do more than simply respond during the comment period. AOTA needs to publish similar position papers about including a wide range of OT services in the act and increase visibility and lobbying about these issues. Practitioners have to start by educating themselves on what they are actually facing.

For the record, I would not characterize this as very exciting. I think it may be the largest boondoggle ever perpetrated on the American public.

Monday, November 28, 2011

The role of the occupational therapist in carpet cleaning

Jimmy was especially active and his mom was having a really difficult time keeping him occupied while she filled out his intake paperwork. His mom was a little frazzled as Jimmy darted around the room, jumped onto the chairs, pulled on the curtains (pulling them off the rod!), and banged on the windows. I intervened at the window banging for safety reasons and as I gently redirected Jimmy he lunged for his mom's coffee, and with a spray of cappuchino across the carpeted waiting room he finally paused.

"Oops," he said, as his mom gave him The Stare. Jimmy froze.

Mom froze too, and after surveying the mess she excused herself to the bathroom. I stayed with Jimmy who suddenly realized he was supposed to be sitting quietly.

Mom returned with some paper towels. The unfinished paperwork sat on the chair, and she cried as she dabbed at the rug. Jimmy knew enough to stare straight ahead at the toy on the child sized table and play quietly.

His mom was upset about the rug and worried that it would leave a stain. "I just don't know what to do!" she said between sobs. "I can't even take him somewhere to get help without it being a disaster."

I really didn't care about the rug because it can be cleaned. Also, cappuchino is relatively benign when I think about all the possible things that can get spilled onto a floor. "It's really ok," I said, attempting to reassure Jimmy's mom. She couldn't hear me and asked for some cleanser.

Soap is an emulsifier because it can take a substance like cappuchino and disperse it into another liquid, like water. Soap micelles have long hydrocarbon chains that help isolate oils or grime so they can be 'cleaned' or 'removed.'

I was thinking that maybe the paperwork was more important than the cleanser and that maybe for the short term the water would be enough to provide a diluted mixture to blot up and reabsorb the coffee into the paper towels. That wasn't enough for the mom though. She wanted some cleanser.

I watched the mom scrub and scrub at the floor, and I figured that is what she did with Jimmy too. I imagined her taking Jimmy against a washboard and scrubbing with all of her might. I bet she tried everything she could so that she could remove the behavioral difficulties that interfered with his participation in school.

You can scrub all day sometimes, and it just isn't enough.

Foaming agents are added to detergent products because somewhere along the line of history people started associating soap bubbles with ACTION. The bubbles might help some, but they aren't really required for the emulsification process. That's my very basic understanding of the chemistry of how this stuff works anyway. The mom wanted ACTION. She wanted to see her scrubbing effort make bubbles. Bubbles meant the rug was getting cleaned.

Maybe bubbles would mean that Jimmy's behavior could improve too, if only we were scrubbing hard enough in the right direction and with the right effort.

I found some rug cleaner and dabbed it into the carpet as I knelt next to mom and handed her a scrub brush. I grabbed a second brush and went to work on the carpet.

"I bet we can get that out no problem," I said hopefully as I scrubbed and scrubbed. Jimmy's mom smiled.

Friday, November 18, 2011

Thoughts about use of weighted vests to promote attending behaviors in children

Please reference an entry earlier this year about seat cushions.

I am essentially re-posting that earlier entry but replacing 'seat cushions' with 'weighted vests.' Let me start this post with congratulations for Amy Collins and Rosalind J. Dworkin who wrote an excellent article in this month's American Journal of Occupational Therapy.

Here comes some mildly edited cutting and pasting from the previous entry - and I will take the liberty of copying my own writing because the issue is identical and this entry will likely be searched separately than the seat cushion entry!

I encourage everyone to open up the current American Journal of Occupational Therapy and read 'Pilot Study of the Effectiveness of Weighted Vests.' This is a fantastic article that looks at the issue of whether or not weighted vests were effective at promoting attending behavior.

I think this is a fantastic study because it take a very common OT intervention and puts it to the test. For many years OTs have been dispensing weighted vests to children in classrooms based on the thought that the vests provided calming/organizing sensory stimulation that would promote attention . This has been done for so many years in so many settings that it becomes a common request from teachers who don't know what to do with children who have attending difficulties. How many OTs hear the request "Can we try to see if a weighted vest will help?"

We have precious little evidence that weighted vests do anything at all for children - and the lack of evidence is reflected in the fact that this intervention is barely mentioned in some common pediatric occupational therapy texts. However, given the formulaic and mythical popularity of the intervention you might think there would be more supporting research!! Now we have a series of recently published articles that when considered in total indicate very little evidence for using weighted vests.

For additional background reading please also reference Hodgetts, Magill-Evans, & Misiaszek (2011); Leew, Stein, & Gibbard (2010); and Stephenson & Carter (2009).

In the AJOT study the authors Collins and Dworkin used an intervention and control group in a blinded and randomly assigned design to measure the impact of wearing a weighted vest on attending behaviors. They used a clever model of removing the weights from the vests in the control group and inserting insignificantly weighted Styrofoam that replicated the appearance of the weighted vests for the data collectors.

The authors were unable to find evidence that weighted vests had any effectiveness for improving attending behaviors. The study was limited because of small sample size and a need for ensuring consistency in coding/recording methods. These limitations are significant enough to warrant the label of 'pilot study.'

The findings of this pilot study are consistent with previous studies and although there are some limitations in the research design there are some other strengths of the study and its confirmation of previous studies is compelling.

My analysis of this is that we should probably make attempts to confirm this with a more tightly controlled design and a larger sample, but based on these results and the consistency of these results with previous studies there is very little support for using weighted vests with the expressed purpose of trying to improve attending behaviors.


References:

Collins, A. & Dworkin, R.J. (2011). Pilot Study of the Effectiveness of Weighted Vests. American Journal of Occupational Therapy, 65(6), 688-694.

Hodgetts, S., Magill-Evans, J., & Misiaszek, J. (2011). Weighted vests, stereotyped behaviors and arousal in children with autism. Journal Of Autism And Developmental Disorders, 41(6), 805-814.

Leew, S., Stein, N., & Gibbard, W. (2010). Weighted vests' effect on social attention for toddlers with Autism Spectrum Disorders. Canadian Journal Of Occupational Therapy. Revue Canadienne D'ergothérapie, 77(2), 113-124.

Stephenson, J., & Carter, M. (2009). The use of weighted vests with children with autism spectrum disorders and other disabilities. Journal Of Autism And Developmental Disorders, 39(1), 105-114.

Wednesday, October 26, 2011

The end product associated with a decided lack of true productivity

We have a lion in my office that was left by a child several years ago. Here is his picture:













I placed him on my cable modem in plain view of everyone who came into the office hoping that someone would claim him. No one ever did, and I felt sad about it because he is a Webkinz and they were rather popular for a while and I am sure that some child was very happy at one time to have this toy. Anyway, I leave him on top of my cable modem just in case his owner ever makes a claim. He is our office mascot, and I have come to enjoy his company every day.

Today I was cleaning and organizing because I couldn't settle myself into documentation. I found a bunch of stray toys. I found the following:

1. a yellow clothespin that goes to a full set
2. an orange sheep that is matched to a full set of parent/baby animals
3. a green peg that goes to a pegboard activity
4. blue and yellow blocks that are part of a construction set
5. a peg from the BOT-2 (a motor test)
6. scissors
7. an ant from Ants in the Pants
8. the letter A from a wooden puzzle
9. a lion that goes with a set of jungle animals
10. an orange pencil gripper
11. the letter P that goes to a bead stringing set
12. a small red lion that goes to Mastermind Jr.
13. a yellow triangle that goes to a parquetry set

Here is the collection:









Undoubtedly, parents are familiar with the phenomenon of stray pieces of toys and games being lost or misplaced. It happens here too and periodically I round everything up and try to return toys to their proper home.

I decided to take a more proactive approach and create a temporary 'home' for all stray pieces and parts. Here is the picture:









I think I want to keep it in a central location, maybe near the lion. It makes sense to me.

Wednesday, October 19, 2011

Product Review: The PenAgain

I was recently contacted by Baumgartens who sent several PenAgain products to my office and asked if I would write a review on my blog. I told the company that I only provide unvarnished reviews and I don't accept any compensation for my reviews - and since they agreed to those terms I was willing to take a look at their products.

My first impression when I saw these pens and pencils was "So, how exactly are you supposed to hold the PenAgain?"

The product doesn't come with any specific instructions so I looked at the packaging to see if that offered any hints. The picture on the package seems to show a person holding the pen in full pronation of the forearm so that there is very little to no ulnar contact with the writing surface. Use of the PenAgain in this position is supported by a few YouTube videos as well - although I don't know if the person who made these how-to videos has any relationship to the manufacturer. The idea of full pronation and the weight of the hand as the source of pressure for writing is not necessarily new. OTs might be familiar with the 'writing bird' product that accomplishes this type of function.

The problem with full pronation and hand weighting is that it does not allow a clear visual of what is actually being written - and often contributes to spacing and accuracy problems. I tried using the PenAgain in this fully pronated position with decreased ulnar contact and I thought it was rather awkward. I don't recommend using the product in this position for people who have the skill to use a more typical forearm position. I suppose that it is equivalently helpful as the 'writing bird' though for people who lack precision grasp or supination.

Then I switched to a more traditional supinated position of my forearm and relatively full ulnar contact with the writing surface, which is generally the way the forearm and wrist would be positioned during a writing task. When in this position I found that the lines and forms of the PenAgain were ergonomically comfortable but the tactile stimulation against the volar surface of the MP joint was very unfamiliar. Personally, my writing was less legible with the PenAgain - probably due to the fact that I have firmly established tactile-sensory expectations of what it is supposed to feel like to write. Altered sensory input has an obvious impact on associated motor accuracy - so there would likely be a learning curve while a person acclimated to the different sensory input of the PenAgain. Most of the kids that I tried the products with said the exact same things: first was "Wow, that's cool!" and then "Wow, that feels weird!"

This all leads to the larger question of whether or not the PenAgain is advantageous from an ergonomic perspective. There have been a few studies done that looked at pencil grasp and writing efficiency/legibility and they have not shown a significant impact of grip on efficiency. I am aware of studies that measured pen force on a writing surface and that a lot of this early work was probably fed into development of pressure sensitivity for tablet PCs and SmartPhones, but I don't know that any of it led to any grand conclusions for learning how to write. I think that the best we can say about this right now is that the jury is still out on whether or not these kinds of writing tools improve performance or skill in writing.

The PenAgain certainly promotes what most people consider to be a more 'mature' dynamic grasp pattern. The question is "Does it matter?"

I don't know.

These products are more expensive than standard pens and pencils but the costs are not prohibitive. Some kids might think they are cool so they will be more engaged in writing. That may have some value.

Should occupational therapists use the PenAgain? I think it could be most useful in special case circumstances where someone has a specific positioning need and this particular product could address that need. It is always nice to have product options because most OTs have run across situations that are unique where you say, "Hey, Product X might be worth giving a shot in this circumstance!" The PenAgain might be good for such situations.

I wouldn't toss out all my pens and pencils though or start suggesting that all children should learn with these products. There just isn't any evidence that different grips and grip patterns have a significant enough impact on function anyway. They might for someone. Or they might not. That means that therapists should continue to evaluate people individually and make determinations about whether or not such a product would be helpful.

My unsolicited advice to the PenAgain folks is to develop a product insert that reviews standard and adapted uses of the product, including some information on forearm rotation and wrist positioning. That would make it a little more friendly to consumers so they would know what to do when they pick up the product and try to write!!!


Background reading:

Benbow, M. (1995). Principles and practices of teaching handwriting. In Henderson, A. & Pehoski, C. (Eds.) Hand function in the child: Foundations for remediation (255-281), St. Louis: Mosby.

Dennis, J. L., & Swinth, Y. (2001). Pencil grasp and children’s handwriting legibility during different length writing tasks. American Journal of Occupational Therapy, 55, 175–183.

Ferriel, B.R., Fogo, J.L., et.al. (1999) Determining the effectiveness of pencil grips: An electromyographical analysis, Occupational Therapy in Health Care, 12(1), 47-62.

Wednesday, October 12, 2011

Annual obligatory rant about health insurance premiums

Background reading:

2009

2010

Well this year the annual increase to our health insurance costs are only 19% but the plan has a higher out of pocket maximum and slightly fewer covered benefits so it isn't exactly the same plan. I thought I would be clever and call my Provider reps for the different plans and tell them that I would be shopping and purchasing based on information they could give me regarding 2012 fee schedules. Historically, even though the cost for these plans goes up exponentially the amount of increase that any provider might see is just a tiny fraction (and often even ZERO PERCENT) of that increase. Also, what happens each year is that the co-pays are increased so even though allowable fees might go up the costs are passed entirely to the consumer with higher deductibles and higher co-pays. In other words, the insurance company's objective is to put all of YOUR skin in the game and as little of their own as possible.

The mechanisms that allow this to happen are primarily attributed to a farce of a regulatory environment, absolute lack of serious competition in the marketplace, increasing federal and state mandates, and gross profiteering.

For the record, corrections and controls for these mechanisms were exactly what was LEFT OUT of the hilariously entitled Patient Protection and Affordable Care Act.

Anyway, I thought I would purchase a plan that at least dropped a few crumbs from the trough where the insurance company pigs feed. No such luck, because even though we are in the fourth quarter and they obviously have the actuarial data to set rates for insurance plans next year they all report that they don't have the data on what the fee schedules will be for providers. I individually asked the local insurance companies why they think I am stupid and why they are trying to make me believe that they set plan costs without already knowing reimbursements and cost outlays to providers. They were all really good at towing the company lines though - I have to give them credit for that. I am not sure if they really think they are fooling anyone and I also don't know if they sleep with a clear conscience at night but oh well.

I will continue to post these things here because I think it is important for people to know that when the insurance company sets a co-pay amount that is IN EXCESS of the allowed reimbursement to a provider - that means you are having your premium money STOLEN from you. Yes, this year we have plans that actually have $50 co-pays for specialist visits (which is what therapy is identified as) and the amount that they allow for reimbursement is just $42.50.

That means that you pay it all - and it also effectively means that your therapy is no longer a covered benefit - except that they are artificially price controlling your medical care to make sure that they will continue to make as much profit as possible.

The net result is that receiving many services like therapies will be restricted to larger hospitals and institutions that cover the cost by other revenue-enhanced activities like $1000 toothbrushes.

More next year... stay tuned...

Saturday, October 08, 2011

When writing gives you the willies: Reconsidering 'tactile defensiveness'

For as long as I can recall most therapists talk about tactile defensiveness as being an oversensitivity to touch - and that it includes a sympathetic nervous system response that is allegedly 'out of proportion' to the incoming stimulus. The result of this characterization is that most people start looking AT the sense of touch as the primary culprit of the problem. This is why you then see therapists struggling to describe what textures a child tolerates and does not tolerate. This structural understanding of the problem is reinforced by sensory integration theory which posits that children are not able to process incoming sensory information accurately.

In the real world this model is poorly described and subsequently notoriously unreliable - and again you will hear therapists explain the inconsistency in sensitivity as a "sensory modulation" problem because sometimes certain kinds of touch will be tolerated and other times it will not be tolerated. Still, the focus often remains on describing the problem in terms of the sensory channel and not as much on the central nervous system mechanism that governs the response.

I would like to see all this evolve to a point where people understand that there is not a problem WITH the sense of touch. The problem can be observed THROUGH the sense of touch.

This is a pretty important distinction because when we continually describe something as 'tactile defensiveness' it leads people down a natural thinking path that the tactile input is the critical issue that requires study or intervention. That causes us to wring our hands over trying to find a way to accurately and reliably measure tactile localization or how we can provide an alternate form of tactile stimulation that will help to 'modulate' the system. We would probably be better served by also looking at central control mechanisms as opposed to only considering these peripheral tactile-based mechanisms.

This reminds me of some rather large fights I had with a neurologist who HATED splinting when I told him we were trying to see if we could achieve an inhibitory effect on spasticity by effectively lengthening the muscle and 're-biasing' the muscle spindle. He understood spasticity as something that was centrally driven by a lesion and not a function of a whole system - so he used to take my splints and toss them in the trash can. Anyway, not to get off topic, but I am saying that I am aware that we might have some impact on a central problem by intervening at the periphery but that doesn't mean we ignore the central problem either. So I am hat tipping to that crotchety old neurologist.

Still, therapists bristle at any threat to their longstanding description and understanding of the 'tactile' problem. Several notable studies have been completed that talk about 'anxiety' constructs but as close as these studies come to hitting what I think will eventually be considered as the pay-dirt of this problem, they tend to veer off and talk about how this 'anxiety' is co-morbid to the sensory processing problem. This is a classic example of several people feeling different parts of the elephant and describing the elephant in absolutely disparate terms.

I've been thinking about all this again lately because I had a young fellow come into my office recently who stated, "I can't write because I can't touch paper. The only way I can write is when I put my papers into these plastic protectors and I use a marker to write on the plastic."

"What do you mean - you can't touch paper?" I said. This was new for me to have a child be THAT aversive to paper - and then I was doubly surprised to see another clinician describe the same level of sensitivity on an online forum - and TRIPLY surprised to see that for the child discussed on the online forum the school came up with the same solution of writing on plastic overlays. So either we are all talking about the same child or people around the country come up with the same 'solutions' to this 'problem.'

"Touching paper gives me goosebumps. See!!!" Then he dragged his index finger across the VMI test booklet and pointed to the piloerection on his forearms. Indeed, he had goosebumps. "Its not just goosebumps. Touching paper also makes my teeth hurt."

The problem with my young friend's story is that as far as I know there are no tactile receptors for paper. Over the course of the evaluation I observed him touching other objects of equivalent texture quality and with equivalent amplitude or force. I also brushed papers against him when he wasn't paying attention and couldn't elicit the same physiological response. I also focused his attention on his hands while I was checking range of motion, and while doing so brushed and rubbed his forearms against the VMI test booklet that was resting on the table. No aversive response. Still, the piloerection that he could automatically elicit by dragging his fingers across paper was very real.

I qualitatively checked his stereognosis using the SIPT Manual Forms Perception subtest and he was functionally unable to discriminate the forms, but he did not have any defensiveness to the plastic pieces of the test. I also checked for defensive responses by trying the Localization of Tactile Stimulation Test and the Graphesthesia test and he was not defensive to that stimulation either. He had no other apparent or reported defensiveness to sound or movement or visual stimulation. He was a very picky eater. Still, none of this helps to explain his defensiveness to paper.

I get a lot of referrals like this, actually. Kids are 'defensive' to their clothing, or they are 'defensive' to their shoes/socks, or they are 'defensive' to having their hair washed. These all tend to be very focal kinds of defensiveness and in fact they cause severe functional difficulties with ADL completion or school. But how can we understand this in 'sensory' terms when there is no physiological explanation or consistency based on what we KNOW to be true about tactile perception?

The answer to this is that we need to understand that sometimes the explanation is best found in behavioral terms and conditioned responses. Although there may have initially been some developmental sensitivity or even a negative sensory experience, the operant cause of the piloerection and tooth pain can sometimes be conditioned fear.

If we consider this as a possibility, our interventions change dramatically. You still might try some 'brushing' technique IN CASE there is some local physiological dampening effect on the overall amplitude of incoming sensory messages to the CNS. You might get equal impact off of the placebo effect of giving the child attention and suggesting that the intervention actually works. You might also try progressive desensitization and relaxation training.

The particular child I saw had many other problems in addition to his 'paper sensitivity.' There were perceptual deficits, hyperkinesis, mood instability, and many other problems that all can cycle around a chicken or egg argument of what was causing what. I can state rather emphatically that he does not have tactile defensiveness (if that even exists). However, we can understand his central emotional regulation problem that is triggered by a conditioned fear to very specific forms of tactile input.

This distinction matters because accuracy in understanding the problem can lead us to correct interventions that respect the scientific evidence and our understanding of how sensory processing actually works.


Quick thoughts for background reading:

Masuda, Y., Suzuki, M., et.al. (1999) Developmental and pharmacological features of mouse emotional piloerection. Experimental Animals, 48(3), 209-211.

Reynolds, S., & Lane, S. J. (2009). Sensory overresponsivity and anxiety in children with ADHD. American Journal of Occupational Therapy, 63, 433–440.