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.

7 comments:

Karen said...
This comment has been removed by the author.
Barbara @ TherExtras said...

This is a good end of year review - well, except kind of a downer.

Speaking of deja vu presenters without evidence back-up - I found a couple of circa '80s OT speakers still making the rounds about 3 years ago.
http://www.therextras.com/therextras/2008/09/introducing-senory-gurus.html

Kathy said...

Wow-you really need to do your research a little bit better. There is research documentation regarding sensory brushing protocol and Therapeutic Listening. The research you are looking for regarding Astronaut Training is in the manual, not on some weblink on the internet. The I have been an OT for 24 years, all specializing in pediatrics. It is sad that someone in our field is so negative about new techniques to use in our practice. I hope you are nearing retirement. We need people with more open minds in our field.

Christopher Alterio said...

Thanks for your comment Kathy - I included it in my post that highlights my favorite comments or reviews that I have received. I really wish you would have the courage to leave your full name though.

I would like to retire, but when I get comments like yours and it makes me think that there are still people who actually might benefit from my opinions.

Just so you know - I am interested in new concepts as they come to our field. You may have missed one that made its debut around 2000 - called evidence based practice. I admit that it is not so shiny and new right now but you might look into it sometime - it is quite interesting!

Christopher Alterio said...

11/19/13

I received this in email and wanted to post it here:

Christopher,

I just read your blog (posted in 2011) about Astronaut Training, and the lack of evidence supporting it. I appreciate your thoughts and ability to think critically about what we as Occupational Therapists are doing. I am in an awkward situation in which a private OT is recommending things that I as the school OT don't necessarily agree with. Do you know if there is any new evidence supporting Astronaut training in specific and spinning followed by heavy work in general? Many Thanks

+++++
Here is my response:
Thanks for your note.

There is no new research re: 'astronaut training' that I am aware of.

The general question about the impact of rotational stimulation and 'heavy work' is a little more difficult. Both of these techniques are grounded in concepts originally described by Sherrington and then clinically expanded upon by Rood - in general we know that rotational stimulation can produced varied effects from increased alerting to autonomic dysregulation (pallor and vomiting). Heavy work/proprioception is known to 'close the gate' (as originally described by Melczak and Wall) on sensory stimulation. The more important question is whether or not eliciting these responses clinically will do anything meaningful from a 'treatment' perspective for children who have sensory/neurologic dysregulation. The bottom line at this time is that although individuals may have responses we can't predict what those responses will be for anyone in particular - and so a 'protocol' is not something that is really appropriate.

Additionally, we have to look at what is the best way for us to be spending our (generally restricted) treatment time. You can certainly 'try' some type of stimulation regimen (commonly called a 'sensory diet') and see what kind of anecdotal responses you get. So, if a child has arousal and alerting difficulties, the concept of physical activity to support attention is not out bounds at all. The problem is when we start getting prescriptive on these 'sensory diets.' Perhaps it is better to just promote recess and phys ed participation (reference the AAP policy statement on recess at http://pediatrics.aappublications.org/content/131/1/183.full). You could also try 'movement breaks' if the classroom context is overly focused on desktop learning. It is not correct to be overly prescriptive because there is no evidence that suggests these prescriptive therapy approaches are effective.

We know that promoting recess is important. We also know that children who have attending and regulatory difficulties can have modest benefits from parent and teacher training, cognitive behavioral interventions, and functional skills training to support their academic participation. For now I would stay away from prescriptive 'astronaut training' programs.

Thanks for writing,

Chris

Anonymous said...

Just came across this. As a parent of a young child with ASD, his very well-meaning OT insisted he needed intense spinning and the astronaut protocol despite the fact that it caused intense visual stims, causing him to be unable to take part in many activities, fall over things at the playground, etc. My son had those stims for a year. Each time the spinning activities were done the stim got worse so I asked her to stop. Then the stim would subside. She pushed doing them again several months later, I let her, the stim came back.

I was told that the problem was I didn't spin him enough, that these things get worse before they get better, etc. I let the spinning experiment go for 6-8 weeks each time and for my child I found it seriously deregulating and detrimental.

Also it strikes me that good OTs should be able to assess and individualize approaches and realize not all interventions will work for all folks.

Steve said...

Kathy - you illustrate the ongoing problem with fad therapies: "the evidence is right there in the manual". Forgive me if I'm not swayed by "evidence" created by the same individuals creating (and profiting from) these methods. It's this blind faith in sensory gurus that led the American Academy of Pediatrics to fire a legitimate and well-deserved shot across the bow of OTs and other practitioners of sensory therapies. Until we are explicit that these strategies "may work for some" but that "we're really not certain of why it works" because "the research is extremely limited or outright faulty", we're damaging our reputation and legitimacy as providers of effective interventions. We instead relegate ourselves to snake oil sales. The research in the manual is as bad as the research passed on via DPPT - poor design, biased, flawed. I'm not rejecting this outright (too many anecdotal stories of success), but this "because I said so" reseacrh makes me very wary.