PDF | Occupational therapists contribute to the care of children and adults with intellectual and developmental disabilities (IDD) by focusing on. PDF | On Mar 1, , D.A. Amini and others published Occupational therapy practice framework: Domain & process 3rd edition. PDF | On Jan 1, , Jyothi Gupta and others published British Journal of Occupational Therapy.

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essential tool to reach this goal and improve occupational therapy practice. . Now is the time to familiarise yourselves with the contents of this pdf file and get to. The Swedish Association of Occupational Therapists (FSA). Translation: Michael Eyre. Layout: Gelinda Jonasson. Photo: Colourbox. Printed by: Trydells. Occupational therapy is a client-centred health profession concerned with promoting health and well being through occupation. The primary.

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Evidence-based Practice: Dawes, M. Churchill Livingstone, London Dawes, M. Sicily statement on evidence-based practice.

BMC Medical, 5. Supporting Implementa- tion — Intermediate Care: Moving Forward. Quality of Life Research, 14 5 , — Forsyth, K. British Medical Journal, , — Greenhalgh, T. British Medical Journal, , — Hagedorn, R. Churchill Livingstone, Edinburgh Hamer, S. Churchill Livingstone, Toronto Higgs, J.

Butter- worth-Heinemann, Oxford Hunter, N. Thorofare, Slack Law, M. Clinical Rehabilitation, 17, — Luke, C. Clinical Rehabilitation, 18 8 , — Maguire, G. Measure- ment in Neurological Rehabilitation.

Wade, D. Lancet, , — McDonald, R.

British Journal of Occupational Therapy, 68 5 , — National Institute of Health Consensus Statement Diagnosis and treatment of attention deficit hyperactivity disorder. Clinical Rehabilitation, 15 1 , 42—52 Patel, A. British Medical Journal, , — Piaget, J.

Seminars in Pediatric Neurology, 11 1 , 5—10 Rosenstock, I. Health Education Monographs, 2, — Sackett, D. Churchill Livingstone, Edinburgh Sackett, D. Churchill Livingstone, London Scally, G. British Medical Journal, , 61—65 Shah, S. Physio- therapy, 80, — Shaw, I. Introduction to Evaluating Health Services. Health Economics, 3, — Sherratt, C. Clinical Rehabilitation, 11 4 , — Ubhi, T. Archives of Disease in Childhood, 83, — Unsworth, C. How do pragmatic reasoning, worldview and client- centeredness fit?

Facilitating the educational inclusion of children with developmental coordination disorder Lois M. Addy Introduction The evidence base relating to children with developmental coordination disorder DCD has increased considerably owing to the clarification of definition and diagnostic criterion pertaining to this common childhood condition Polatajko et al.

This has led to distinctive research in areas of motor coordination which have provided occupational thera- pists with significant evidence on which to base their practice.

The current research, utilising systematic reviews, randomised control trials and case study analysis, has challenged traditional practice which sought to identify and address the underlying process skills, i. The evidence supporting this approach in addressing gross motor coordination is very convincing; however, its applicability to skills such as handwriting, which involves cognitive, kinaesthetic and perceptual— motor components, is more contentious Addy, ; Sugden and Chambers, ; Rosenblum et al.

The inclusion of children with special educational needs into mainstream schools has been one of the most positive changes in social and educational policy for decades. It has been influential in encouraging tolerance and the acceptance of difference, while highlighting the unique needs of all children.

Provision for children with overt disabilities, although far from perfect, has developed exten- sively as the inclusion movement has gained momentum. These children present with difficul- ties in motor coordination and perceptual processing which significantly impact on their academic performance.

The ability of the occupational therapist to analyse the motor, cognitive and perceptual components of occupational performance has been instrumental in identifying the occupational therapist as the lead professional involved with many of these children. The extent of this involvement was highlighted in a survey commissioned by the College of Occupational Therapists to determine the numbers of children involved and how this impacts on occupational therapy resources.

Of the paediatric occupational therapy service providers surveyed, These children are characterised by their poor motor coordination gross and fine , planning difficulty, movement organisation and difficulties interpreting perceptual information. This affects their participation in physical education PE and many other aspects of the curriculum involving writing skills, practical skills, manual dexterity, organisation and effective planning.

This chapter follows the journey of Peter pseudonym who was given the diagnosis of DCD at the age of 6. It will show the effect that this has had on his ability to learn and access the UK educational curriculum.

Although his association with the occupational therapy service covered a period of 3 years, only a small part of his therapy will be presented. This will focus on the occupational therapy provided 2 months following diagnosis, and will cover a period of 1 year. Initially it is important to outline the criterion that was used to define and diagnose Peter with DCD. This has a controversial history, as variation in termi- nology has muddied the waters as to what exactly constitutes this childhood condition.

Developmental coordination disorder There have been many terms used to describe children with coordination dis- orders. Sensory integrative dysfunction Ayres, was another term frequently used to explain the pos- sible reasons why a child may be uncoordinated. Perceptual—motor dysfunction Clark et al. In addition, terms such as deficit in attention motor perception DAMP Gillberg, , clumsy child syndrome Cratty, and congenital maladroit are also used.

Indeed, there are so many variations in ter- minology that questions have arisen as to whether they refer to the same disorder or distinctive disorders. However, at a pre- school level this may not seem significant as variability at this age is vast. The child may be able to describe the rules of a game yet cannot physically organise or sequence movements to action the task. Inappropriate timing of movements, lack of fluency in actions and abun- dance of effort in performing simple tasks may also be apparent Missiuna, Problems in ideation forming ideas and plans and position in space will also be evident, and the child may have difficulties generating ideas of what to do in new situations Parnham and Mailloux, In addition there may be concerns regarding dexterity and bilateral coordination which will affect ball control and subsequent participation in ball games Geuze, Perceptual difficulties further impact on motor actions, in particular poor kinaesthetic sensitivity affects motor responses Jongmans et al.

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Form and A. The disturbance in criterion A significantly interferes with academic achievements or activities for daily living. The disturbance is not due to a general medical condition i.

If intellectual difficulties are present, the motor difficulties are in excess of those usually associated with it. Figure 2. In addition to the motor concerns, a small percentage of children with DCD have verbal developmental dyspraxia which affects their expressive language skills. This is an extremely frustrating aspect of DCD as the child may be able spontaneously to respond to an interaction, but cannot repeat this when con- sciously attempting to respond on cue Hill, ; Rintala et al.

Co-morbidity Despite the clarity of the APA diagnostic criteria, many of the symptoms of DCD overlap with other childhood disorders. Kaplan et al. There was also a co-occur- rence between social, emotional and behavioural difficulties, including anxiety and depression, and DCD Rasmussen and Gillberg, ; Sigurdsson and Fombonne, Therefore there are many long-term implica- tions Losse et al.

It is therefore important to appreciate how recent legislation in health and education has impacted on occupational therapy service delivery. Government directives and policies Traditionally, occupational therapists were based in child development centres, special schools or units attached to community NHS centres.

Children were with- drawn from school to attend clinics or therapy groups, which were delivered for a limited period in a specified timeframe. This had the advantage that specialised equipment could be easily accessed and disruptions to therapy time would be limited. Therapy was provided apart from education and the two paths rarely crossed Addy, With the reforms in education initiated by the Warnock Report Department for Education and Skills, , questions were raised regarding the medical versus social model of disability, and the categorisation of disability versus curriculum- based needs.

The Warnock Report was followed by the Education Act, which unfortunately retained an attention to individual deficits. Later the Code of Practice provided guidance in relation to the identification and assessment of children with special educational needs SEN Department for Education, , emphasising the importance of school-based intervention. The Green Paper, Excellence for all Children; Meeting Special Educational Needs Department for Education and Skills, , provided initiatives for improving lit- eracy and numeracy, introducing target setting for schools and opening up new technologies to help children with SEN to reach their full potential.

Around the same time, evidence was emerging of the economic benefits of inclusive schooling versus special school provision with special school costs being consistently higher than mainstream for pupils with similar levels of need Crowther et al. Rather than simply a location change, there was also a change in method of provision, with therapists becoming more involved in advice, consultation and teaching.

The priority of the therapist became to enhance the education of the child, with the therapeutic programme assuming a complementary, supportive role to the education plan. His motor milestones were slow; he sat indepen- dently at 12 months and walked at 20 months. As he was a first child, however, his parents were not unduly worried until the arrival of his brother 3 years later.

This provided an opportunity to compare development and differences were becoming increasingly apparent as Peter commenced the small school in his home village.

However, she felt that he had excellent comprehension and verbal skills. Initially Peter was seen after school at the child development centre where the occupational therapist had time to converse with both Peter and his parents.

This provided an opportunity for the occupational therapist to start to form a relation- ship with the family without disruption from the school routine or possible stigma from his peers unsure of the purpose of occupational therapy.

Peter was 6. Peter presented as a slight, timid little boy whose movements were slow and deliberate. From these initial interviews and observations, the occupational therapist began to formulate strategies from which to gain more detailed information and from which to frame her intervention. At this point theoretical rationale and appropriate models and approaches are selected to direct and inform further assessment and subsequent therapy.

Theoretical rationale One of the key concerns highlighted by Peter was his poor fine motor coordina- tion in respect of his handwriting; in addition, poor gross motor coordination influenced his ability to succeed in PE lessons. It was therefore appropriate to reflect on the variation in theories relating to motor learning. These include: From these, two theoretical positions were particularly influential in consider- ing how to proceed with Peter: Neuromaturational theory Neuromaturational hierarchical theories of motor development McGraw, ; Gesell and Ilg, are based on the assumption that the development of move- ment and motor skills results from maturation of the central nervous system CNS which expands progressively.

Motor skills develop from primitive reflexes to advanced responses which supersede basic reactions to initiate refined control through maturation and experience Barnhart et al. These motor responses are influenced by sensory feedback which serves to help to interpret environmen- tal information.

These develop memory, attention, perception, planning and exe- cution of motor programmes and kinaesthesis. These skills are sequential, orderly and predictable. For example, accurate hand— eye coordination is dependent upon effective motor planning, kinaesthetic regu- lation, visuospatial processing and tactile feedback.

The supposition is that if these areas are addressed, through various therapeutic tech- niques, not only would hand—eye coordination improve, but other skills requiring effective motor coordination would also show signs of increased control.

Dynamical systems theory Dynamical systems theory acknowledges that, although neuromaturational theo- ries provide a general model of motor development, they do not account for the variability in individual performance. Dynamical systems theory proposes that motor behaviours emerge from the interaction of a variety of neural, musculosk- eletal, sensory, adaptive and anticipatory mechanisms in task-specific contexts Kamm et al.

All these components interact in a dynamic, non-linear fashion. This theory leads to the recommendation that the focus of therapy should be directed to a specified task, emphasising the interac- tion between the environment, the task and the individual in the performance of functional activities.

In this sense it is an active rather than a passive view of motor learning Ketelaar et al. Many approaches influenced by this thinking use verbal guidance and cognitive strategies to change motor behaviour Miller et al. The current view is that top-down approaches are consistent with contemporary principles of best practice Dunn, but are not successful in all occupations Henderson and Markee, Peter was assessed after school in the child development centre, so that his typical day was not disrupted.

It was important to help Peter to feel comfortable about the purpose of the assessment and to support his abilities rather than inabilities. Children with DCD have only known what it is like to have DCD and therefore the constant request to conform and change leads to much confusion and frustration. What we as adults distinguish as important may be completely irrelevant to a child.

PEGS is a tool for children to report their perceptions of competence in performing everyday tasks. It provides the occupational therapist with a means to identify the tasks and contexts which may be concerns for children and serve as a focus for intervention. The child is shown a pair of contrasting cards. PEGS is a useful introductory tool, which Missiuna and Pollock claim can be used with children as young as 5—9 years.

Should the occupational therapist focus more on improving his ball skills or address his handwriting needs? This is why collaborative goal setting is essential and may include compromises from both parties.

It is therefore important that the PEGS is not the only assessment used. This is a simple task-specific motor assessment which provides an accurate measurement of manual dexterity, ball skills and static and dynamic balance Croce et al. Impairment scores are interpreted into percentile norms with children scoring below the 5th percentile having a definite motor impairment requiring intervention. Peter was experiencing significant difficulties in writing, a task which involves complex motor and perceptual processes, therefore the occupational therapist felt it appropriate to analyse the underlying process skills demanded by the task of handwriting Erdhardt and Meade, The VMI identifies how well the brain coordinates the visual information it has received with the need to make a motor response.

It requires the child to repro- duce a series of shapes which are developmentally sequenced for difficulty. The VMI has been proposed as a useful screening tool for determining handwriting difficulties Rosenblum et al.

However, Marr and Cermak caution that this is not an appropriate indicator for children under the age of 6, and Goyen and Duff found that there was limited correlation between scores on the VMI and handwriting dysfunction in children aged 9—12 years. However, despite evidence supporting its reliability and validity Diekema et al. This was re-used as an outcome measure following a period of intervention. Despite the common use of these assessment tools with children with DCD, caution should be applied.

There appears to be no theoretical rationale for choice of form in the VMI and no non-normative standards are provided Seitz, The M-ABC does not determine qualitative changes in movement and may not be sufficiently detailed to identify fine motor concerns, such as handwriting Geuze et al.

When using the PEGS, therapists should be aware that young children tend to exaggerate their abilities rather than under- estimate them Missiuna and Pollock, ; Wallen and Ziviani, Movement ABC score at 6. Visual Motor Integration score at 6. Write your name first name 2. Copy the alphabet 3. Write the alphabet assessor can provide a verbal reminder of the alphabet 4. Use 1, 2 and 3 0 Attempted letters are unrecognisable as such 1 1—5 letters are recognisable when copied 2 Name is recognisable when free written along with 1—5 copied letters 3 Name is legible, and 5 additional letters are also recognisable when free written 4 Name is legible, and 10—15 letters are also recognisable when free written 5 All letters of the alphabet are recognisable Accurate letter formation Definition of term The letters are formed, commencing from the line, with correct direction of flow being demonstrated.

Use 3 and 5 0 All letters are incorrectly formed, despite being recognisable 1 1—5 letters are correctly formed 2 6—10 letters are correctly formed 3 11—15 letters are correctly formed 4 16—20 letters are correctly formed 5 All letters are correctly formed Uniformity of letter size Definition of term Letter sizes are consistent; small letters being half the dimension of ascenders and descenders Use 4 and 5 0 Attempted letters are illegible 1 Letters attempted are all the same size 2 Letters attempted are inconsistently small or large 3 5—10 letters are showing differentiation in size 4 4 out of the 7 ascenders are sized correctly b,d,f,t,h,k,l ; 3 out of the 5 descenders are sized correctly p,q g, y j 5 All letters show appropriate differentiation in size Figure 2.

Use 4 and 5 0 Illegible lettering 1 Attempted letters show erratic, inappropriate directionality 2 Some ascending letters show a consistent direction but this is not evident throughout the text 3 Descending letters show a consistent direction, but the direction of ascending letters remains erratic 4 The majority of ascending and descending letters show a consistency in direction and alignment 5 All letters show a consistent alignment Spacing between words and letters Definition of term Spacing between words is emerging.

Letters are grouped together to form appropriate words. Use 4 and 5 0 No recognisable letters and no grouping attempted 1 Few letters attempted but no grouping 2 Spacing reliant on copying skills 3 Attempts are made to group letters into words but spacing is erratic 4 Spaces between words are developing with only occasional errors in spatial planning 5 Appropriate spaces between words are evident Alignment of writing on the page Definition of term Writing will start at the left hand side of the page and transfer across the page in a left to right direction Use 5 0 Unrecognisable letters 1 Attempted letters are placed erratically on the page 2 Words are formatted together but do not maintain a horizontal alignment 3 Alignment across the page is attempted but writing drifts as writing progresses.

Further writing does not acknowledge the original starting margin. These were agreed in collaboration with Peter, his teachers and parents.

Objective 1: The occupational therapist will coordinate and present this information at a date and time negotiated with his head teacher. Objective 2: This will be introduced by the occupational therapist who will liaise with his class teacher, learning support assistant LSA and parent helper. Progress will be measured using the handwriting criterion-referenced scale Fig.

Objective 3: The activities taught in the session will be reinforced during playtimes and within school within PE class. He will attend the group for two school terms approxi- mately 7 months. Objective 4: Success will be measured using a structured reward chart. Occupational therapy Objective 1: One of the most important roles for the occupational therapist, therefore, is that of educator, i.

The emphasis therefore shifts to changing the environment not the child. In a study by Dunford et al. They referred to poor handwriting presentation, erratic letter formation, poor pencil control and discrepancies between handwriting and other skills. Further studies highlighted further concerns in handwriting production: It can therefore be concluded that poor handwriting performance has a marked effect on academic performance Graham et al.

A carefully selected and graded series of graphic activities is used to enable the child to experience various shapes, movements and connections related to writing. Additional sensory—motor activities are also used to reinforce the perceptual and motor experience.

The control trials which followed, involving over children, demonstrated statisti- cally positive changes in many components of handwriting and, in particular, those pertaining to spatial planning Addy, Interventions using a similar approach have claimed positive results Oliver, ; Lockhart and Law, ; Olsen, ; Rutberg, ; Peterson, ; Connor, This incorporated principles of good posture, pencil grip and how to accommodate pressure through the writing instrument Taylor, Following this, they were encouraged to follow the programme for 15—20 minutes each day.

She was able to do this easily after the prin- ciples of the programme had been explained. Participation in a small group helped Peter to see that he was not alone in his struggles with handwriting and was motivated through both the structure and variation of the programme in addition to the support of his peers.

The introduction of the programme to the classroom was in keeping with principles of inclusion Dunn, ; Mu and Royeen, , but also had the benefit that consistency and practice could be established Wright and Sugden, ; Pless and Carlsson, Given the shortage of occupational thera- pists working in paediatrics and volume of referrals, this proved an effective means of providing an intervention.

The occupational therapist visited once a fortnight to monitor progress, address any concerns and provide direction where needed. Legibility, production and volume of output improved considerably.

To accommodate this he was allowed to use a dictaphone to record his weekly diary and key stories. This gave Peter an alterna- tive method of recording his knowledge. The motor difficulties in children with DCD do not go away and have a profound effect on their self-confidence and self-esteem Cantell and Kooistra, The majority of children with DCD are inactive in the play- ground, spending more time looking than participating Smyth and Anderson, ; McWilliams, The resultant social isolation seems much more pro- nounced with boys, who typically will be active in physical sports and games from a very early age.

Systematic evidence based on 23 trials involving chil- dren correlated improved motor skills with improved self-esteem Ekeland et al. As Peter attended a small village school, creating a homogenous group within the school was not feasible. There- fore Peter was invited to attend an after-school programme run by both occupa- tional therapists and physiotherapists.

The venue was located at a local gym away from the hospital setting. Approximately 36 children attended and were divided into three age groups: This considers movement as a problem-solving ex- ercise involving action planning, action execution and action evaluation, each interacting dynamically with each other Larkin and Parker, ; Sugden and Chambers, There are seven key features of this approach which are essential to its success.

To demonstrate the application of this approach, the first goal of catching a ball will be used as an example of how his learning was directed.

To do this Peter was observed during school play time, on the field, in the playground and in the PE hall. This is described by Polatajko et al. Peter was noted to be unable to position himself in order to execute a precise throw; could not calculate the desired effort through his upper limb proprioceptors to propel the ball; and could not accom- modate the speed and size of the ball in order to catch.

For example, initially Peter was expected sit on the floor and roll a ball a distance of 2 m to a partner sitting opposite. Following three successful rolls, the distance is gradually increased by 0. Feedback Peter was then guided through the action by the therapist who provided feedback at each stage.

Feedback served to provide information as to position, effort, posture and grip, as well as a method of motivating Peter Magill, Task adaptation The tasks involved in the programme were selected as they were fun, challenging and could be adapted.

This incorporates graded tasks and games pertinent to those goals being addressed.

Resources for safe practice

In this programme task adaptation is used to ensure success. This involves changing the nature of the demands of the task, i. Additionally the rules of games were changed according to need Dixon and Addy, ; Vickerman, ; for example, floor football was used to encourage precise rolling skills within a competitive game Addy, Generalisation and transfer of skills The sixth component of this approach aims to help with the generalisation and transfer of skills by encouraging the participation by parents and significant others in the learning process.

Intervention structure The seventh and final feature of the CO-OP approach is the intervention struc- ture itself and the time allocated to this. The first block focused on throwing and catch- ing skills; the second on bat and ball skills; the third on kicking and football skills; and the fourth consolidating tasks previously acquired. All pro- vided statistically significant evidence to support this approach. He simply could not get dressed and undressed quickly enough prior to and following PE lessons.

He was being teased by his peers about this slowness. The difficulty proved more of a nuisance than a major concern as out of school he could wear what he liked and had plenty of time to dress. Therefore a com- pensatory approach was adopted so that his clothes were subtly adapted to allow them to be removed on the occasions when Peter had PE.

These adaptations included replacing button holes with Velcro tabs; reattaching the cuff button with an elastic stalk to allow it to stretch negating the need to fasten a complicated button; his trouser waistband fastening was replaced with Velcro; and a matching bootlace was attached to the zipper to allow for an easy manoeuvre.

This was based on principles of backward chaining and was carefully graded to ensure success Turner et al. The undressing aspect was undertaken each evening, and dressing was practised over the weekend when more time was available. This does not reflect the growing use of technology and reduced need to write in adult life. The establishment of a motor skills group could seem alien to the natural context of motor learning. Henderson and Markee demonstrated how it was possible for a child with very poor coordination to succeed in becoming an accomplished rugby player and kung-fu participant.

This relied on the child being self-motivated to become engaged in occupations which were purposeful, self- directed and enjoyable, within a context which would allow flexibility of task adaptation and differentiation. Indeed the relationship estab- lished between the therapist and Peter allowed him to ask for guidance in helping him find a suitable hobby.

The occupational therapist accommodated this request by organising trial sessions in a karate class, piano lessons and a model club before Peter eventually found his niche in a local drama class. Attempt to determine the evidence to affirm or dispute this approach.

References Addy, L. Developing School Provision for Children with Dys- praxia: Jones, N. Sage, London Addy, L. Physical Therapy, 83 8 , — Beery, K. Human Physiology, 31 5 , — Cantell, M. Developmental Coordination Disorder.

Cermak, S. Delmar, Albany Case-Smith, J. Delmar, Albany Chu, S. Teacher Develop- ment, 7 1 , 91— Cousins, R. Descriptions, Evaluation, and Remediation.

Perceptual and Motor Skills, 93, — Crowther, D. Meeting Special Educational Needs. Department of Health, London Dewey, D. Brain and Cognition, 29, — Dewey, D. Practical Strate- gies for Teachers. Routledge-Falmer, London Donaghy, M. Archives of Disease in Childhood, 89, — Dunn, W. Slack, Thorofare Ekeland, E. Teaching Exceptional Children, 30 4 , 54—58 Erdhardt, R. Harper, New York Geuze, R. Human Movement Science, 20, 7—47 Geuze, R. Children with Developmental Coordination Disorder.

Sugden, D. Archives of Disease in Childhood, 88, — Goyen, T. Treatment of handwriting problems in beginning writers. Journal of Educational Psychology, 4, — Harter, S. University of Denver, Denver Henderson, S.

Institute of Education, London Henderson, S. Psychological Corporation, London Hill, E. Evidence from hand and arm movements. Sage, London Jongmans, M. Human Movement Science, 22 4—5 , — Jongmans, M. Physical Therapy, 70, — Kaplan, B.

Human Move- ment Science, 17, — Ketelaar, M. Physical Therapy, 81 9 , — Koziatek, S. Developmental Coordination Disorder, Ed. Delmar, Albany Lockhart, J. A 10 year follow up study. Concepts and applications, 6th edn. Children with Developmental Coordination Disorder, Ed.

Whurr, London Mandich, A. Handwriting Review, 2, 41—47 Mandich, A. Perceptual and Motor Skills, 95, — Marr, D. An integrative approach. Plenum, New York Miller, L. Dyslexia, 8, — Oliver, C. Author, Potomac Panham, L. Occupational Therapy for Children, 3rd edn. Case-Smith, J. Work, 11, — Peterson, C. Paediatric Physical Therapy, 12 4 , — Polatajko, H. Whitmore, K, Hart, H. Physical activity engagement of children with developmental coordination disorder. Integrating Therapy and Educational Services.

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Human Move- ment Science, 17, — Rosenblum, S. Perceptual and Motor Skills, 96 3 , — Rosenblum, S. Educational Psychology Review, 15 1 , 41—81 Rutberg, J. Un- published Doctoral Dissertation: University of Washington Sallis, J. Human Kinetics, Champaign Schoemaker, M. Whurr, London Schoemaker, M. Human Movement Science, 20, — Segal, R. Results from the birth cohorts and the National Child Development Study.

American Journal of Psychiatry, , — Sims, K. Human Movement Science, 20, 73—94 Smyth, M. Paediatric Rehabilitation, 2 4 , — Sugden, D. Whurr, London Summers, J. A Teachers Guide: Multisensory approaches to assessing and improving handwriting skills. David Fulton, London Teodorescu, I. Developing School Provision for Children with Dyspraxia: Sage, London Wallen, M. The perceived efficacy and goal setting system. Human Movement Science, 17, — Washington, K.

Physical Therapy, 82 11 , — Willoughby, C. Early intervention: This chapter focuses on one individual who experienced mul- tiple fractures following a road traffic accident.

Comprehensive research involving randomised controlled trials, meta-analysis and systematic reviews support the contribution made by the occupational therapist working within the traumatic case management team Evans et al. Additional benefits relate to reduced readmission rates Sheppherd et al.

For the young man featured in this chapter, a road traffic accident led to a serious unexpected interruption to his busy daily life. The day before the accident, Darren had had a long day at his physically demanding job after which he met his friends in the pub for a game of pool.

Road traffic accidents occur daily and their outcomes, for many people, lead to hospital admissions and lengthy recovery programmes. The functional implica- tions are diverse. In addition, the unexpected nature of accidents will have a psychological impact on the way that the individual is able to accept and come to terms with the event. Socially there may be a change in roles and responsibilities as well as difficulties meeting up with friends and enjoying hobbies. This chapter details the occupational therapy process from hospital admission to discharge for one particular individual admitted with fractures to an ortho- paedic trauma ward.

The aim of intervention at this initial stage is to facilitate discharge by enabling the client to perform the necessary daily functions required, while adhering to medical advice.

The importance of providing a comprehensive discharge service has been supported in research by Houghton et al. Longer-term needs will be identified and recommendations will be suggested but these will not be addressed in detail in this chapter.

Outline of the condition Every year alarming numbers of people are seriously injured or die as a result of accidental injury.

In , there were casualties reported following road traffic accidents in Great Britain, of which proved fatal Department for Trans- port, Accidents resulting in injury are common during many activities such as home improvements, sports, cooking and gardening.

However the impact of a road traffic accident has a significantly greater risk of resulting in a complex injury. As a consequence, for many people who have been involved in a road traffic acci- dent, there are serious consequences in terms of time away from school or work, ability to care for children and capacity to fulfil many other life roles.

Difficulties resulting from such accidents may be temporary, but for some the implications will be long term and will need to be addressed with on-going therapy intervention. Inevitably, given the vast numbers involved, the financial cost to the National Health Service NHS is immense; two billion pounds each year is spent on treat- ing injury Department of Health, a.

The Government, not surprisingly, made the prevention of injury a priority as outlined in a White Paper entitled Saving Lives: Our Healthier Nation Department of Health, A government task force continues work to reduce the number of accidental injuries, therefore reducing the considerable effects for the individual, society and the economy Department of Health, The most common outcome of trauma is limb injury Apley and Solomon, A fracture is one type of injury which can occur; however, effects of trauma are rarely isolated to a fractured bone.

When a fracture occurs soft tissue damage is likely, the extent of which is greatly influenced by the violence and impact. Soft tissue damage can include severed nerves, torn muscles, ruptured blood vessels or torn ligaments Dandy and Edwards, Traumatic injuries which include bone fractures are commonly addressed within orthopaedic departments.

Reduction of the fracture. Immobilisation of the fracture fragments long enough to allow union. Rehabilitation of the soft tissue and joints.

Figure 3. Trauma is the result of an accident which is unexpected in nature. Trauma, by definition, does not allow the planned, scheduled approach of elective surgery; hospital admissions result- ing from trauma are, therefore, also unplanned and resources to deal with such admissions are more difficult to schedule.

Recovery following a fracture is determined by the timescale of bone healing. Detailed information regarding fracture healing, fracture classification and surgi- cal management can be found in many texts such as Dandy and Edwards , Apley and Solomon and Atkinson et al. The type of fracture dictates whether surgical or non-surgical reduction is required. Immobilisation can be achieved either conservatively, using splints or casts, or surgically with an internal or external fixator Atkinson et al.

Once the fractured bones are united, a haematoma forms around the bone ends. This blood clot coagulates and bone cells which invade it form a hard mass which is gradually converted to callus and then bone. It takes a further 6 weeks before bone consolidation is complete. In the lower limb the healing process is longer; a fracture site around the distal third of the femur takes approximately 12 weeks to unite, whereas a fracture of the distal third of the tibia will take between 16—20 weeks to unite and consolidate Atkinson et al.

Rehabilitation, the final stage, is likely to involve other health care professionals who work with the individual to maximise functional outcomes. Immobilised limbs and reduced weightbearing status are likely to cause limitations in func- tional performance. The NHS Plan Department of Health, outlined targets to reduce waiting times in accident and emergency departments.

This document stated that by the year , no one should wait in accident and emergency for longer than 4 hours from when they arrive to the time they are either discharged, admitted to a ward or transferred.

This goal has had implications on the way that individu- als arriving at accident and emergency departments are assessed and treated. Assessments must be prompt and a timely decision to admit must be made so that treatment can commence without delay.

Bed capacity needs to be managed effectively to meet demand. This document provided practical steps to assist health professionals to improve discharge from the hospital to the community. Discharge plans must be negotiated, discussed and agreed with members of the multidisciplinary team and the client.

Joint documentation is commonly used within integrated care pathways adopted by orthopaedic services to promote this coordinated approach. A shared language and framework to describe health and health-related states, provided by the World Health Organization, was introduced in to enhance communication between health professionals. The International Classification of Functioning ICF provides common definitions of functioning and a means of communicating this information within the team, ensuring appropriate rehabili- tation programmes and discharge arrangements.

These influential factors are identified during the assessment process. Legislation has identified the need to provide housing adaptations for dis- abled people.

The NHS and Community Care Act Department of Health, identified that people with a disability are eligible for an assessment of their needs which may be met with housing adaptations. However, the definition of a disability, outlined in the Disability Discrimination Act Department of Health, , limits services to people who experience substantial and long-term effects on their daily performance. People who are discharged from hospital following fractures will often have substantial difficulties but are not eligible for major adaptations as the effects are not expected to be long term.

For this reason, discharge provisions depend on temporary equipment, avail- able on a short-term basis, which enables safe functioning. This may be far from ideal. He was referred to the occupational therapist the following morning by the senior house officer during the regular morning ward round.

The senior house officer reported that Darren, a year-old male, lost control and fell from his motor cycle when overtaking a car. Darren sustained a closed comminuted fracture to the shaft of his right femur and a closed spiral fracture to his left tibia and fibula.

Darren also sustained a Colles fracture to his right dominant wrist which was reduced in the accident and emergency department and a back slab applied. There was no loss of consciousness and no chest pathology was identified. Darren received analgesics overnight which had adequately controlled his pain.

A radiograph taken after the reduction showed the Colles fracture to be in a good position. The back slab was due to be changed to a rigid cast, once the swelling had subsided. During the ward round the house officer reported that Darren lived with his parents in a semi-detached house. They had a downstairs toilet and all the bed- rooms were upstairs. His sister lived close by. Darren was a mechanic at a local garage. The occupational therapist confirmed with the consultant that Darren was likely to need a wheelchair as the surgical procedures undertaken meant that Darren would not be able to bear weight until the fractures had healed.

With this infor- mation the occupational therapist knew promptly that the provision of a wheel- chair and education regarding its use would be an immediate priority. Darren had expressed concern about how long he would need to stay in hospital and when he could feasibly return to work.

This indicated his desire for prompt dis- charge and eagerness to return to his previous roles. In a small-scale study conducted by Griffin , 19 occupational therapists working in acute orthopaedics were asked to state their aim of intervention. They identified assessment for the purpose of referral to ser- vices on discharge, discharge planning and treatment monitoring. Their interven- tion was characterised by assessment and intervention strategies which fitted with the short-term stay of clients in this clinical area.

Selected frames of reference, models and approaches therefore have to guide prompt and concise assessment and intervention to allow a timely return home for the individual.

Any further needs must be identified and referrals made to ensure these are addressed post-discharge. An intervention approach commonly used in acute orthopaedics is compensatory. This allows for alterations to the way in which tasks are performed in terms of the method and the objects used Holm et al. In addition, environmental changes, aimed to facilitate independent functioning, are often made, for example temporary ramps can be provided to allow immediate access for those who are required to use a wheelchair.

The com- pensatory approach is consistent with the biomechanical model, which predicts that when soft tissue heals and fracture sites unite, range of movement, strength and endurance will be regained which will automatically result in improvements in function Dutton, Restoration, an alternative approach to compensation, is therefore not appropriate, as function will return as a result of the healing process rather than restorative approaches to treatment.

The rehabilitative frame of reference guided the occupational therapist working with Darren. This utilises a compensatory approach to address immediate needs while promoting maximum functional performance in activities of daily living using graded activities. Collaboration between the occupational therapist and the client is central to this frame of reference in order to address and seek solutions for these, often short-term, functional limitations Seidel, It is important that an educative approach is also used in conjunction with a compensatory approach to explain the purpose of selected strategies to help Darren understand the healing process, the reason why precautions should be followed and the necessary timescale involved.

A systematic review of a series of randomised controlled trials found that the provision of verbal and written information significantly helped individuals understand their condition, the healing process and the necessary precautions associated with it.

This also resulted in increased service satisfaction Johnson et al. The provision of information promotes compliance and impacts on the successfulness of recovery Radomski, Darren was expected to continue to use compensatory strategies following discharge which he learnt as a result of an educative approach during his hospital stay. Compensatory strategies were also used by an occupational therapist working with Darren in intermediate care.

Assessment The occupational therapist is central to the discharge arrangements, and assess- ment needs to happen as soon as possible to begin to identify actions which need to be taken to initiate these plans. The initial assessment began the day after surgery. Darren was feeling tired and understandably found it difficult to con- centrate and the process was, therefore, continued the following day. Central to working collaboratively with Darren was ensuring the occupational therapist had gathered an in-depth understanding of his ability and problems performing valued occupations Cohn et al.

Developing a rapport with Darren was fundamental to achieving a full understanding of these factors. This relationship enabled the occupational therapist to provide support and reassur- ance which was necessary at this early stage post-surgery.

A qualitative study by Gustafsson et al. They identified that early psychosocial support had a positive effect on health-related quality of life following orthopaedic injuries.

Further studies by Ponzer et al. Subsequent recovery is enhanced by health professionals being reassuring and building a relationship of trust. One way this was achieved was by giving information about the extent and nature of the injury and the proposed treatment.

The medical notes reported that the surgery had gone to plan with no complications. The surgeon had written instructions for Darren to be bilaterally non-weightbearing for a period of 6 weeks. Communication with the medical staff confirmed that Darren would not be permitted to use his wrist to support his weight until a rigid cast was applied and then only minimally or as pain allowed.

An initial interview is a commonly used assessment procedure and is an essen- tial skill for occupational therapists Henry, The interview took the form of a conversation during which the occupational therapist asked Darren to elaborate on certain aspects of his regular roles and performance areas. Darren was happy for them to stay and listen to the conversation which enabled the occupational therapist to make plans with them.

Darren explained that he had a very active life, working as a mechanic for a business which was owned and run by a friend. His parents worked full-time but were willing to assist Darren at home and make any necessary environmental changes.

It was important to explain to Darren and his parents that he would need to use a wheelchair for at least the first 6 weeks and would be using this when he went home from hospital. After discussing the layout of the property, it became evident that there would be some difficulties with access at home. The United Kingdom based Outsiders arise when people form relationships, or through Club http: Finding out ways to negotiate sexual In addition, the depiction of disability as a relatively encounters successfully can enable them to feel more exclusive identity that comes before all other aspects of the confident in developing partnerships or in their expression person Hanson tends to support an occupationally of sexual functioning.

The assessment of sexual to protect and maintain the client and worker relationship consent capacity might be one means to diminish these is also a factor that should not be overlooked Earle risks, although it is not a panacea and can have an adverse Health and social care workers who have been regulatory effect Lyden Even where professionals are willing to assist problems and physical disabilities, a number of men used people in this or other ways, by helping clients to to visit massage parlours or receive sex services in the masturbate or use sexual aids for example, there may be privacy of their homes.

They felt undesirable, the peer pressure from other people who simply object, see consequence of medical side-effects and personal neglect this as unprofessional or see it as an erosion of their rights or of a negative self-image, but were lonely and wanted to in accordance with their personal beliefs Stoner In some instances, patients would perform Clearly, this issue presents occupational therapists with sexual favours with others in return for commodities, ethical dilemmas that cannot be ignored Penna and such as chocolate, teabags or cigarettes.

Sheehy , Earle The United Kingdom sex industry has a quasi-legal degree of acceptance, with massage parlours evident in most large communities, but prostitution is unregulated Addressing sexual needs and frequently linked to criminal exploitation. Unless safety and freedom from exploitation can be guaranteed Although there have been widespread measures to introduce for sex workers and clients, it would be unethical for user perspectives into the education and practice of therapists to make referrals, for example to develop occupational therapy, the question of sex either is missing confidence in sexual expression Scottish Executive , from professional discourses or is not inclusive of all Home Office and Scottish Executive British and wants is clouded further by the construction of the Journal of Occupational Therapy, 68 7 , Available at: This misrepresents the issues and rights of people Earle S Facilitated sex and the concept of sexual need: However, in the absence of and their personal assistants.

Disability and Society, 14 3 , Journal solutions, each with potential risks both to physical of Advanced Nursing, 36 3 , Although occupational therapists cannot and Paper given at the New Directions in Disability Seminar Series, Centre perhaps should not control the sexual choices of their for Disability Studies, University of Leeds, 22 April. Disability Now, December. Home Office. For example, medication often Laver-Fawcett A Assessment. This was often Occupational therapy and physical dysfunction.

Churchill given as a reason for non-compliance with treatment Livingstone, Penna and Sheehy Li C, Yau M Sexual issues and concerns: Sexuality and Disability, 24 1 , Sexuality and there are few opportunities for people with disabilities to Disability, 25 1 , Disability Now, February. Accessed on Novak P, Mitchell M Professional involvement in sexuality counseling for patients with spinal cord injuries. American Journal of Being client centred Occupational Therapy, 42 2 , Oriel J Sexual pleasure as a human right: Disability Now, May.

Choice and occupational therapists offer sex education to patients with schizophrenia? Journal of Advanced emphasis in the original. If occupational therapists are Nursing, 56 4 , Sexuality and Disability, 24 2 , J Creek, ed. American Journal of Occupational Therapy, Occupational therapy and mental health.

Churchill 60 3 , Livingstone, Collins Paperback English dictionary. British Journal of Occupational Therapy, 69 8 , Couldrick L Sexual issues within occupational therapy, part 1: British Journal of Occupational Therapy, 61 11 , British Journal of Occupational Therapy, 69 2 , Eye Weekly, British Journal of Occupational Therapy, 61 6 , It was important that these needs were identified by the occupational therapist at this acute stage so that services could be arranged to meet ongoing needs at a timely interval by the appropriate service following discharge.

Occupational therapists needed to be skilled not only in the use of constructive activities such as crafts, but also increasingly in the use of activities of daily living. A scoping review of sensory processing and mental illness. Occupational therapy.

Occupational therapy

With entry into World War II and the ensuing skyrocketing demand for occupational therapists to treat those injured in the war, the field of occupational therapy underwent dramatic growth and change. OTs often work with people with mental health problems, disabilities, injuries, or impairments. The priority of the therapist became to enhance the education of the child, with the therapeutic programme assuming a complementary, supportive role to the education plan.

A further belief is the importance of maintaining a person-centred philosophy College of Occu- pational Therapists, In , she began working in higher education, where she currently teaches topics related to stroke rehabilita- tion at undergraduate and postgraduate levels. The purpose of consensus conferences is to inform national practice through the dis- semination in relevant journals and a series of conference presentations.

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