By: Mary Ann McColl, PhD, MTS
What can occupational therapists do to integrate spirituality in practice? First, let’s think about how spirituality might arise in the day-to-day interactions in occupational therapy. There are usually two ways that clients let us know that they have spiritual issues on their minds, or that their functional problems may have a spiritual dimension – directly and indirectly (McColl, 2000). Some clients will be explicit about their religious beliefs and convictions, their public or private faith practices, and their relationship with a Higher Power. Others will approach the issue indirectly, by displaying symbols of their faith, by asking questions about issues such as life after death, reasons for things that happen, search for meaning, loss of hope or faith.
There are at least four ways that occupational therapists can engage with clients in response to either a direct or an indirect overture about spirituality (McColl, 2011).
- The first thing an occupational therapist can do, and something that every therapist should be prepared to do (regardless of his or her own faith experience or preparation), is to listen for and recognize the words, symbols, ideas or themes that clients may use to alert the therapist to the potential for a spiritual issue. Spiritual issues are sufficiently sensitive in our culture that clients may be insecure about raising them. It would be a shame indeed if a therapist was unable to appreciate the depth and importance of a spiritual issue that a client was trying to raise, and therefore left it unattended.
Although discussions of spirituality requires a significant degree of cultural competence, one need not know about every religion to be able to talk to someone about his or her spirituality. Discussions of spirituality may deal with generic concepts, like the relationship with a higher power, hope for the future, meaning in life, or belonging in a faith community. There are two difficulties that therapists typically encounter when clients raise spiritual issues. Either they do not have language or concepts to respond confidently and professionally, or they are worried about imposing their own beliefs on the client. Both are legitimate concerns, but both can be dealt with by simply acknowledging the depth and importance of the issue the client is raising, and asking if he or she would like to discuss it further.
- Another very legitimate option for therapists encountering spiritual issues is to offer to help clients find someone who is qualified to have in-depth spiritual conversations with them. This may be an officiant of the client’s own faith tradition, or it may be a multi-faith chaplain, such as work in many health and social service facilities. Referral to a spiritual counsellor can be a very effective therapeutic contribution for a client who is struggling with a spiritual issue.
- Indirect spiritual interventions are a third way that therapists may choose to engage with clients whom they suspect have spiritual issues affecting their occupation. A review of the literature revealed six modalities that offer the opportunity of a spiritual experience or discussion, but that are not inherently spiritual or religious (McColl, 2011; 2016). These modalities can be used by therapists even if they are not spiritual or religious themselves.
- Narrative: The process of creating and relating narratives is a vehicle for spiritual exploration and growth, allowing the narrator to create meaning, to connect to spiritual themes (like hope, healing and redemption), and to make connections across past, present and future (Kirsch, 2011).
- Ritual: Rituals are ordinary activities that are invested with symbolic meaning when performed to celebrate, commemorate or sanctify important events or ideas ( Thibeault, 2011). They have the power to mark passages, transitions and milestones.
- Appreciation of nature: Experiences in the natural world can make one more aware of the mystery and connectedness of all things. The sense of awe and wonder that often accompanies experiences in nature can evoke thoughts and feelings about beauty, creation and the divine (Unruh, 2011).
- Creativity: A fourth type of indirect spiritual intervention is creative activity, or what Peloquin (1997) refers to as “making rather than doing” (p. 168). Creative activity affords an opportunity for unconstrained expression of spirit and communication of universal truths (Toomey, 2011; Woodbridge, 2011).
- Work: Work is an occupational medium that offers individuals an opportunity for service and contribution, for participation in a shared mission, for the dignity associated with a job well done, and for the rhythm of work and the orderliness of time structured by work routines (Baptiste, 2011).
- Movement: Movement therapy can evoke spiritual remembrance of our physical connection to the earth, to our bodies and to each other. Embodiment is a fundamental aspect of what it means to be human, even when the body is physically limited or constrained (McColl, 2016).
- The fourth option is direct spiritual intervention, meaning specific faith practices, such as prayer, meditation, worship, or spiritual counselling. These interventions usually require additional training and qualifications, and most therapists will feel that these are outside of their professional scope of practice, unless they have obtained some specialty certification. McColl & Farah (2011) offer guidelines for the use of direct spiritual interventions. They suggest that a therapist ask him or herself the following four questions:
- Is the client’s problem inherently spiritual in nature?
- Is the client receptive to spiritual intervention?
- Is the therapist qualified to offer the spiritual intervention?
- Would the therapist’s employer support him or her in offering this type of intervention?
If the answer to all four questions is “yes”, then a therapist may consider offering to pray, meditate, worship or engage in other spiritual practice with a patient. There are a number of cautions outlined in McColl and Farah (2011), such as the need for a secure therapeutic relationship, the necessity for the practice to be genuine, and the assurance that it is in no way forced or imposed.
In summary, there are a number of options for occupational therapists to acknowledge and honour the spiritual dimension of their clients. They fall on a continuum from simply recognizing and giving voice to spiritual concerns, all the way to engaging in direct spiritual practices. Therapists will vary on the extent to which they are comfortable with these options or even interested in this area of practice – and that is nothing to be ashamed of. What would be a shame indeed is to fail to recognize spiritual suffering in a client, or to recognize it but not know what to do. I hope this brief article reassures occupational therapists that they can not only identify spiritual issues, but also that they can do something helpful –
- by acknowledging the issue,
- by referring to a qualified spiritual health professional,
- by providing opportunities within familiar therapeutic modalities for spiritual expression and exploration, and
- in some carefully considered cases, by sharing in a spiritual practice with a client.
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About the Author:
Mary Ann McColl, PhD, MTS is a Professor of Occupational Therapy in the School of Rehabilitation Therapy at Queen’s University in Kingston, Ontario, Canada. She is also Associate Director of the Centre for Health Services and Policy Research, Professor in Public Health Sciences, and Academic Lead for the Canadian Disability Policy Alliance. Dr. McColl is author of Spirituality and occupational therapy (2nd ed.), as well as the Canadian Occupational Performance Measure (5th ed.), Theoretical basis of occupational therapy (3rd ed.), Disability & social policy in Canada (2nd ed.), and Inter-professional primary health care.
1. Baptiste, S. (2011). Work: Understanding spirituality and work. In M.A. McColl (Ed.), Spirituality and occupational therapy (2nd ed.) (pp. 201-208). Ottawa, ON: CAOT Publ.
2. Krisch, B. (2011). Narrative: What makes narratives spiritual and how can we use them in OT? In M.A. McColl (Ed.), Spirituality and occupational therapy (2nd ed.) (pp. 201-208). Ottawa, ON: CAOT Publ.
3. McColl, M. A. (2000). Muriel Driver Memorial Lecture: Spirit, occupation and disability. Canadian Journal of Occupational Therapy, 67 (4) 217-229. http://dx.doi.org/10.1177/000841740006700403
4. McColl, M. A. (2011). Spirituality and occupational therapy (2nd ed). Ottawa, ON: CAOT Publ.
5. McColl, M. A. (in press). Spirituality among older adults. In Bonder, B. (Ed.) Functional Performance in Older Adults (4th ed.) Phildelphia: F.A. Davis.
6. McColl, M.A., & Farah, J. (2011). Guidelines for direct spiritual intervention. In M.A. McColl (Ed.), Spirituality and occupational therapy (2nd ed.) (pp 193–200). Ottawa, ON: CAOT Publ.
7. Peloquin, S. M. (1997). Nationally speaking-The spiritual death of occupation: Making worlds and making lives. American Journal of Occupational Therapy, 51, 167-168. doi: 10.5014/ajot.51.3.167
8. Thibeault, R. (2011). Ritual: Ceremonies of life. In M.A. McColl (Ed.), Spirituality and occupational therapy (2nd ed) (pp. 233-240). Ottawa, ON: CAOT Publ.
9. Toomey, M. (2011). Creativity: Spirituality through the visual arts. In M.A. McColl (Ed.), Spirituality and occupational therapy (2nd ed) (pp. 233-240). Ottawa, ON: CAOT Publ.
10. Unruh, A. (2011). Appreciation of nature: Restorative occupations. In M.A. McColl (Ed.), Spirituality and occupational therapy (2nd ed) (pp. 249-256). Ottawa, ON: CAOT Publ.
11. Woodbridge, M. (2011). Creativity: Soul sessions. In M.A. McColl (Ed.), Spirituality and occupational therapy (2nd ed) (pp. 223-232). Ottawa, ON: CAOT Publ.
McColl, M. A. (in press). Spirituality and client-centred practice. In Humbert T (Ed.) Occupational therapy & spirituality. AOTA Publ.
McColl, M. A. (2002). Occupation in stressful times. American Journal of Occupational Therapy, 56(3), 350-353. http://dx.doi.org/10.5014/ajot.56.3.350
McColl, M. A., Bickenbach, J., Johnston, J., Nishihama, S., Schumaker, M., Smith, K., …Yealland, B. (2000a). Changes in spiritual beliefs after traumatic disability. Archives of Physical Medicine and Rehabilitation, 81(6), 817-823. http://dx.doi.org/10.1053/apmr.2000.5567
McColl, M. A., Bickenbach, J., Johnston, J., Nishihama, S., Schumaker, M., Smith, K., & Yealland, B. (2000b). Spiritual issues associated with traumatic-onset disability. Disability and Rehabilitation, 22(12), 555-564. http://dx.doi.org/10.1080/096382800416805
By: Stephanie Kokesh, OTD, OTR/L
Addressing sexual health within occupational therapy is vital to providing comprehensive care. It requires skill, tact, and access to appropriate resources. In both clinical practice and the related literature, occupational therapy efforts traditionally focus on restoring independence within productive, self-care and leisure activities (Sakellariou & Algado, 2006). Often overlooked, sexual activity is an activity of daily living that enables well-being through the engagement in “activities that result in sexual satisfaction and/or meet relational or reproductive needs” (American Occupational Therapy Association [AOTA], 2014, p. S19). Although a majority of occupational therapists support holistic, “whole” person care (Jones, Weerakoon, & Pynor, 2005) sexual activity does not receive the same attention as does the more typically addressed activities of daily living (ADL) such as bathing, grooming, and dressing (Hattjar, Parker, & Lappa, 2008). Sexual health – of which includes sexual activity – should be regularly addressed within occupational therapy services for adults with an accepting, problem-solving attitude (Solet, 2007) in order to address the needs of patients from all backgrounds.
Access to and knowledge of related resources have the potential to improve efforts of addressing sexual health from the OT perspective. Oftentimes, one of the most difficult steps is simply opening the door to discussion. Two useful methods, of which can be used partially or in combination, include the PLISSIT Model and the Sexual Assessment Framework (McBride & Rines, 2000).
The PLISSIT model has been a longstanding model for addressing any topic that may be considered “sensitive.” The PLISSIT Model involves: Permission, Limited Information, Specific Suggestions, and Intensive Therapy (see Figure below). The “levels” of information are arranged as such because a majority of clients typically receive the necessary information as related to Permission and Limited Information (and do not require further formal intervention).
Permission may refer to either clinician initiated discussion, or clinician response to a client remark, from which a clinician can normalize the challenges the client is experiencing.
A very simple way to obtain Permission for further discussion is through use of the normalizing “3-Step Method” (McBride & Rines, 2000):
- “Many men/women with (condition) have concerns or questions about the sexual part of their lives.”
- “Have you thought about this at all?”
- “Would you like to talk to someone about it?”
Oftentimes, Permission can easily lead to Limited Information of which involves situating general and basic sexual health related education alongside typically addressed ADL/IADL:
E.g. “We have discussed your sternal precautions as related to your everyday tasks. In addition, a lot of folks have questions about sexual activity after open heart surgery. I want to briefly discuss safety modifications for the next few months.
If further information is desired or required, one is able to provide an individual with Specific Suggestions accordingly. This would involve discussion related to the individual’s unique practices, roles and routines, with subsequent activity analysis and joint problem solving in order to provide the client with relevant individualized education. This is also a point during which the Sexual Assessment Framework can further guide focused discussion (McBride and Rines, 2000).
Intensive Therapy is outside the scope of usual OT practice, and includes referral to or intervention by specialized clinicians including but not limited to the areas of: sexual medicine, gynecology, urology, psychiatry, psychology, etc.
The Sexual Assessment Framework is a road map for addressing the many components that are involved in sexual health. Borrowed from nursing literature (McBride & Rines, 2000), the framework includes: Sexual Knowledge; Sexual Behavior; Sexual Self-View; Sexual Interest; Sexual Response; Fertility and Contraception; and Sexual Activity.
Sexual knowledge involves an individual’s values and beliefs about sex and sexuality. (McBride & Rines, 2000). An OT clinician can provide a client with education regarding anatomy/physiology as impacted by the client’s condition or change in health/functional status. For example, an individual who has sustained a spinal cord injury, will greatly benefit from education regarding changes in neurological function, including impact on sexual function.
Sexual Behavior involves the “ability to initiate or maintain a social/sexual relationship” while Sexual Self-View encompasses one’s self-concept and body image. An OT clinician can explore the client’s former social/relationship roles in order to re-define one’s self as a person, a man or woman, and as a sexual being so as to develop new or modified roles and routines. The Canadian Occupational Performance Measure can be used to identify and prioritize facets related to one’s sexuality and sexual self-view.
Sexual Interest refers to the physical and psychological drive behind sexual activity engagement. Oftentimes, anxiety, fear, depression, and pain often interfere with sexual desire or “libido.” An OT clinician should consider targeting alternative pain management strategies, guided relaxation/meditation, or stress management.
Sexual response refers to the physical response and arousal that accompanies sexual activity. We traditionally define this as including: penile erection/vaginal lubrication, nipple erection, ejaculation, and orgasm. Depending on one’s health status, it is important to know how the client’s response has changed. For example, if related to a spinal cord injury, increased physical stimulation may be required to achieve erection, orgasmic threshold may be elevated, and/or increased duration for the refractory period may exist. An OT clinician can empower the client to participate in body/sensory mapping – with self or partner – so as to determine what forms of physical input are pleasurable. In addition, employ the client to consider or explore non-penetrative sexual/intimate activities. Furthermore, an occupational therapist might provide basic education surrounding sexual response in order to assist a patient in identifying challenges and referring patients to the appropriate professionals.
Fertility and Contraception involve family planning, safe sex, and integration of birth control. Depending on the client’s practices, OT may be involved in medication management strategies, or mechanical device management as related to UE function and coordination to manage a male condom; female condom or diaphragm; or feminine hygiene products. In addition, OT can target childcare as related to the necessary motor, process, and social skills (AOTA, 2014; McBride & Rines, 2000).
Lastly, Sexual Activity includes the “motor abilities, hand function, balance, strength, management of bowel and bladder programs…dressing and undressing, transferring, and affectionate activities such as hugging and petting” (McBride & Rines, 2000, p. 10). Patients can be assisted with identifying any challenges related to body functions (e.g. pain, sensation, neuromusculoskeletal and movement-related functions) and performance skills (e.g. motor and praxis skills, sensory-perceptual skills, emotional skills, cognitive skills, and communication/social skills) that may be interfering with the occupational performance of sexual activity. Such information can help the occupational therapist in designing an appropriate plan that meets the patient’s goals while aligning with his/her sexual values and beliefs (AOTA, 2014; McBride & Rines, 2000).
Addressing sexual health within occupational therapy is imperative but infrequently occurs. Often, patients expect clinicians to initiate discussion about sex, whereas clinicians expect the patients to make the first move. Therefore, sometimes a “don’t ask, don’t tell” attitude exists, thus preventing initiation of a sexual health conversation altogether (Forsythe & Horsewell, 2006). Occupational therapists should adopt an active role within sexuality education and support programs (Summerville & McKenna, 1998) for adults receiving occupational therapy services.
The infrequent attention to sexual health related issues could potentially hinder the redefinition of the sexual self or the psychosocial adjustment within a person who has experienced a traumatic event or change in health status (Ide, 2004; Walters & Williamson, 1998). Studies have shown that patients rate sexual fulfillment and sexual reactivation as a high priority during rehabilitation (Northcott & Chard, 2000). In addition, patients who are more knowledgeable regarding sexual health information are more successful in achieving a satisfying sex life following an injury (Forsythe & Horsewell, 2006), thus contributing to increased well-being and quality of life (Jones, Weerakoon, & Pynor, 2005).
The foundation of approaching sexual health consists of maximizing existing or remaining function of both mind and body while adapting to any limitations with an optimistic, positive, and open attitude (Elliott, 2009). An occupational therapy clinician is well suited to encourage a patient to reconceptualize and explore new possibilities of sexual activity (Solet, 2007) through intervention and discussion surrounding sexual health. It is hoped that the suggestions and resources offered can assist occupational therapy clinicians with addressing sexual health and routinely including the discussion of sexual activity into practice.
Special thanks to the clinicians of the Sexual Health Rehabilitation Service of Vancouver Coastal Health, Vancouver, B.C., for sharing your vast amount of skill and knowledge.
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About the Author:
Stephanie Kokesh, OTD, OTR/L, CSRS is the Director of Clinical Education/Academic FW Coordinator for the OTA Program at (Community Based Education and Development d/b/a) CBD College, Los Angeles, CA. She continues to also practice clinically at Cedars-Sinai Medical Center. Stephanie is involved in professional organizations – AOTA, OT Association of CA (OTAC), ACOTE Educational Standards Review Committee, and the Los Angeles OT Leadership Forum (LAOTLF). Stephanie received her entry-level OTD from Creighton University in Omaha, NE. Her “excitement” for sexual health and OT began during her time at Creighton. She was extremely fortunate to have completed her 16-week professional rotation with the Sexual Health Rehabilitation Service at the G.F. Strong Rehab Centre in Vancouver, B.C.
Patient Friendly Resources (not all inclusive):
- PleasureAble Manual: Sexual Device Manual for Persons with Disabilities **FREE!!
- Kaufman, M., Silverberg, C., and Odette, F. (2007). The ultimate guide to sex and disability: For all of us who live with disabilities, chronic pain, and illness. Publisher: Cleis Press Inc.
3. Tepper, M. (2015). Regain that feeling: Secrets to sexual self-discovery. Publisher: CreateSpace Independent Publishing Platform
Videotape/DVD for Patient/Partner Education (not all inclusive):
Alexander, C. J. & Sipski, M. (Producers). (1993). Sexuality reborn: Sexuality following spinal cord injury. [Videotape]. (Available from the Kessler Medical Rehabilitation Research and Education Corporation, 1199 Pleasant Valley Way, West Orange, NJ 07052).
BC Rehab. (n.d.) Talking about sexual issues and spinal cord injury: A guide for professional caregivers. (Available from The BC Rehab Education Resource Centre, 700 West 57th Avenue, Vancouver, BC, V6P 1S1, (604) 321-3231).
Hebert, L. A. (Producer). (n.d.). Sex and back pain: How to restore comfortable sex lost to back pain. (Available from IMPACC USA, PO Box 1247, 7 Washington Street, Greenville, ME 04441).
Orner, E. (Producer). (n.d.) Untold Desires [Videotape]. (Available from Filmakers Library, 124 East 40th St, NY, NY 10016, (212) 808-4980).
Donnelly, S., Falardeau, K., Falardeau, M., & Gallagher, J. (2012). SexAbility. (Landmark Media, 3450 Slade Run Drive, Falls Church, VA, 22042) Can be purchased at: http://www.landmarkmedia.com/videos_detail.asp?videokey=1713.
Hattjar, B. (Ed). (2012). Sexuality and occupational therapy: Strategies for persons with disabilities. Bethesda, MD: AOTA Press
- Sipski, M. and Alexander, C. (1997). Sexual function in people with disability and chronic illness: A health professional’s guide. Maryland: Aspen Publishers, Inc.
- Sexual Health Rehabilitation Courses (for Allied Health) through British Columbia Institute of Technology
- American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process, 3rd Edition. American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. http:// dx.doi.org/10.5014/ajot.2014.682006
- Anderson, K. D. (2004). Targeting recovery: Priorities of the spinal cord-injured population. Journal of Neurotrauma, 21(10), 1371-1383.
- Elliott, S. (2009). Sexuality after spinal cord injury. In E. C. Field-Fote (Ed.), Spinal cord rehabilitation (pp. 513-529). Philadelphia: F.A. Davis
- Esmail, S., Esmail, Y., & Munro, B. (2001). Sexuality and disability: The role of health care professionals in providing options and alternatives for couples. Sexuality and Disability, 19(4), 267-282.
- Forsythe, E. & Horsewell, J.E. (2006). Sexual rehabilitation of women with a spinal cord injury. Spinal Cord, 44(4), 234-41.
- Greco, S. B. (1996). Sexuality education and counseling. In S. P. Hoeman (Ed.), Rehabilitation nursing: Process and application (pp. 594-623). Louis, MO: Mosby Inc.
- Hattjar, B., Parker, J. A., & Lappa, C. L. (2008). Addressing sexuality with adult clients with chronic disabilities: Occupational therapy’s role. OT Practice, 13(11), CE-1-CE-7.
- Ide, M., Watanabe, T., & Toyonaga, T. (2002). Sexuality in persons with limb amputation. Prosthetics and Orthotics International, 26, 189-194.
- Jones, M. K., Weerakoon, P, & Pynor, R. A. (2005). Survey of occupational therapy students’ attitudes towards sexual issues in clinical practice. Occupational Therapy International, 12(2), 95-106.
- McBride, K. E. & Rines, B. (2000). Sexuality and spinal cord injury: A road map for nurses. SCI Nursing, 17(1), 8-13.
- Northcott, R. & Chard, G. (2000). Sexual aspects of rehabilitation: The client’s perspective. British Journal of Occupational Therapy, 63(9), 412-418.
- Sakellariou, D. & Algado, S. S. (2006). Sexuality and disability: A case of occupational injustice. British Journal of Occupational Therapy, 69(2), 69-76.
- Solet, J. M. (2007). Optimizing personal and social adaptation. In M. Vining Radomski and C. A. Trombly Latham (Eds.), Occupational therapy for physical dysfunction. 6th (pp. 924-950). Philadelphia: Lippincott Williams & Wilkins.
- Summerville, P., & McKenna, K. (1998). Sexual education and counseling for individuals with a spinal cord injury: Implications for occupational Therapy. British Journal of Occupational Therapy, 61, 275-279.
- Townsend, E. A. & Polatajko, H. J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. Ottawa: CAOT Publications ACE.
- Walters, A. S. & Williamson, G. M. (1998). Sexual satisfaction predicts quality of life: A study of adult amputees. Sexuality and Disability, 16(2), 103-115.
Occupational Therapy’s Distinct Value in the Intensive Care Unit (ICU)
Many might pose the question “What is occupational therapy’s (OT’s) distinct value in the ICU setting?” OT plays an important role in facilitating early mobilization, restoring function, preventing further decline, and coordinating care—including transition and discharge planning.
OT offers a unique perspective and focuses on a holistic view, in which many factors can influence the success of a patient’s recovery and rehabilitation process. “OT practitioners believe that intervention provided for people with physical disabilities should extend beyond a focus on recovery of physical skills and address the person’s engagement, or active participation, in occupation” (American Occupational Therapy Association, 2008). OT uses a systematic process of client-centered evaluation, intervention, and task modification to facilitate progress toward performance-based goals. This process begins by identifying activities the client needs and/or wants to do, as well as analyzing pre-hospitalization role and determining the supportive abilities or barriers to participating in those activities/roles.
In the critical care setting, OT practitioners perform a variety of skilled evaluations and interventions, which are essential to long-term patient wellness post-ICU discharge. The following are some examples of OT interventions in the ICU setting:
- Evaluate the need for splints and other positioning devices to preserve joint integrity and decrease risk for skin breakdown due to prolonged pressure from bed rest;
- Perform bedside evaluations to promote safety with eating and swallowing;
- Train families and caregivers to assist with range-of-motion exercises, safe transfers and mobility, and skin checks;
- Educate patients on post-surgical protocols, including appropriate weight bearing and other post-surgical precautions during activities of daily living (ADLs);
- Teach compensatory strategies/techniques and use of adaptive equipment for maximizing independence with ADL function (i.e. teaching hemi-dressing technique after stroke to improve independence with upper extremity dressing, educating energy conservation techniques during ADL performance while patient is on the ventilator, teaching the use of a adaptive feeding utensils to improve feeding independence of a patient with poor grip strength after prolonged bed rest in the ICU);
- Develop exercise programs and instruct patients, family members, and caregivers in how to use the programs during their ICU stay;
- Fabricate or provide assistive devices and train patients in their use to promote healing and maximize independence;
- Teach specific techniques for safety during functional mobility;
- Teach stress management techniques and the development of coping skills;
- Evaluate and treat ICU-acquired neurological-cognitive impairment (executive functioning, memory, and attention) to improve functional occupation-based outcomes;
- Recommend home safety modifications and durable medical equipment during discharge planning.
In addition, OT practitioners understand the interplay between the patient’s needs, abilities, and environment, which assists with the patient’s successful transition to the home, community, or next level of care. OT programs in the ICU can alleviate some of the problems of isolation, sensory and occupational deprivation, and cognitive inactivity, which are risks to long-term wellness. ADL programs, including bed mobility, functional transfers to the commode or toilet, sitting tolerance, and light hygiene can restore a sense of daily routine and personal independence. These programs can also include relaxation techniques in combination with reality-orienting programs to provide organized, patterned stimulation and to develop an increased sense of control. These individualized programs can use client-centered, meaningful tasks to promote cognitive and motor recovery in patients (Affleck, Lieberman, Polon, & Rohrkemper, 1986; AOTA, 2014; Brummel et al., 2012; Brummel et al., 2013; Foreman, J., 2005; Hogan-Kelley, D., 2007; Schweickert et al., 2009).
Acquired Physical and Cognitive Impairment in the ICU
Patients who experience critical illness in ICUs are likely to acquire long-term physical and cognitive impairments, which affect the patient’s ability to function autonomously after discharge from the hospital. Due to bed rest and prolonged immobilization as well as increased use of sedation, patients can develop ICU-acquired weakness and motor/sensory neuromyopathy; sensory deprivation and stress; increased ventilator-dependent days; development of secondary medical complications, such as blood clots, pneumonia, and pressure ulcers; and acute brain dysfunction, manifesting as either delirium or coma. Therefore, occupational therapy has value in this setting and can assist in minimizing these complications.
Long-term physical impairment affects between 25% and 60% of ICU survivors. In addition to physical dysfunction, long-term cognitive impairment can be observed in one half to three fourths or more of ICU survivors. More specifically, delirium – defined as an acute change in mental status and fluctuating course of inattention and disorganized thinking – affects 60% to 80% of patients who are mechanically ventilated and is associated with several adverse outcomes including: prolonged mechanical ventilation, delayed hospital discharge, an increased risk of mortality, and long-term cognitive impairment (Brummel et al., 2012; Brummel et al., 2013; Mendez-Tellez, Nusr, Feldman, and Needham, 2012). Since many patients experience cognitive impairment in addition to physical complications when in the ICU, occupational therapy—in addition to physical therapy—should be incorporated into ICU programs and research studies.
Benefits of Early Rehabilitation in the ICU
Whole-body rehabilitation programs in the ICU—consisting of interruption of daily sedation combined with physical and occupational therapy in the earliest days of critical illness—are safe and well tolerated and result in better functional outcomes at hospital discharge, a shortening of delirium duration, fewer days on the ventilator compared to standard care, and decreased risk of mortality and re-hospitalization (Brummel et al., 2012; Brummel et al., 2013; Mendez-Tellez, Nusr, Feldman, and Needham, 2012).
These early rehabilitation programs demonstrate cost-saving data. One study outlined a length of stay reduction of 22% in the ICU and 19% reduction for the floor patients with a cost-savings of $817, 836. In this study a financial model projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. The projected net cost of implementing an ICU early rehabilitation program is modest relative to the substantial improvements in patient outcomes and cost-saving measures related to decreased length of stays, reduced number of days on the ventilator, and a decreased rate of re-hospitalizations (Lord et al., 2013).
A Peek into the ICUs at the University of Colorado Hospital
The OT department at the University of Colorado Hospital (UCH) strives to advocate for OT services in its six ICUs—neurological (24 beds), medical (24 beds), surgical (10 beds), cardiothoracic (17 beds), burn/trauma (9 beds), and cardiac (12 beds). The OT department recognizes the potential for overlap of services with other disciplines, particularly physical and speech therapy; however, OT is able to differentiate their role among other disciplines and highlight the distinct value of their services to patients and other health care personnel through sound clinical reasoning, appropriate timing of intervention, and occupation-based intervention tailored to patient and family. OT at UCH focuses on any functional deficit that will improve with OT intervention, such as ADL retraining; cognitive, vision, and sensory screening/assessment/treatment; upper extremity splinting, and establishment of routine to maximize functional independence.
When deciding which patients to treat in the ICU setting, the OTs developed an ICU triage system to improve the focus of OT, improve consistency among practitioners, and increase efficiency. The following characteristics have been identified as important for consideration when prioritizing ICU patients:
- Acute rehabilitation candidacy;
- Patients who are pending discharge;
- Ventricular assistive device candidates (VAD) who need pre and post-VAD placement screening for identification of possible brachioplexus injuries, cognitive impairment, and UE dysfunction to determine if the patient will be able to manage the VAD post-operatively;
- Patients after lung transplant (screening for possible radial nerve injury);
- Patients with neurological and orthopedic issues (need to be acknowledged, screened, and charted on within 36 hours of initial OT order);
- Patients with forearm free flaps, for splinting and follow-up
- Patients with prolonged time on the ventilator (>3 days), general prolonged ICU stay (>3 days), or with greater than three chronic conditions (Hobbs, Boysen, McGarry, Thompson, & Nordrum, 2010).
The OTs at UCH evaluate patients status post coronary artery bypass grafts, aortic valve replacements, mitral valve replacements, video-assisted thoracic surgery, and Whipple procedure on post-operative day two as through practice based evidence it was determined these patients were mostly limited by post-operative pain, cognitive issues related to pain medication with subsequent difficulty remembering precautions instructed on post-operative day one, and numerous lines/tubes limiting what the OT could do on the first day after surgery (i.e. Swan Ganz Cathetor). Therefore, these patients were better suited to be evaluated and treated on post-operative day two.
When determining type of treatment the OT will facilitate in the ICUs at UCH, the Richmond Agitation Sedation Scale (RASS) is used as a guide for treatment. Each level of the RASS scale correlates to a specific treatment regimen. For example, if the patient has a RASS score of -3 or -2, which is moderate to light sedation and movement and eye opening to voice, the OT may perform guided active range of motion/active assist range of motion, ADL retraining (i.e. basic grooming) in bed to chair position, and initiate cognitive re-training (i.e. call light training, basic card game to improve attention, etc.). In addition, if patient scores a 0 or +1 on RASS scale, which is alert and calm or restless, the OT focus may be ADLs in bathroom seated or standing; instrumental activities of daily living (IADLs), such as medication management, financial management, self-care strategies; OT functional cognitive screen (Cognistat, Montreal Cognitive Screen, or Allen’s Cognitive Level Screen), and cognitive behavioral retraining (Ely et al., 2003; Sesslar et al., 2002).
UCH has established an ICU Progressive Mobility Program for nurses to assist with mobilization of patients. The nurses are responsible for following this protocol to determine at which level their patient should be mobilizing, such as positioning patient in chair mode in bed, sitting edge of bed, transferring to chair, and ambulating around room/unit. The nurses are provided with inclusion criteria for mobilization, including neurologic, respiratory, and cardiac stability as well as exclusion criteria including but not limited to unstable intracranial pressure (ICP) or presence of femoral sheaths (Perme & Chandrashekar, 2009; Timmerman, R.A., 2007) . The progressive mobility program allows OTs and PTs to focus on treatment beyond the scope of routine mobilization of each patient.
To maximize safety during OT intervention, UCH has recently developed an ICU competency program for new staff members. Ideally, the OTs will mentor a trainee for approximately three months and be available to answer any ICU-related questions. The ICU therapists (PTs and OTs) have developed an ICU Skills Check List so that the trainee has to identify each line (i.e. standard monitoring, tubes, ICP monitoring, cardiac support devices, oxygen delivery devices, and mechanical ventilation). The trainee also has to understand hemodynamic monitoring, delirium/sedation monitoring, and common medications used in the ICU.
It is encouraged to consider use of the ICU program at UCH as a model for the development of both early rehabilitation programs and patient management. OT has a distinct and valuable role in the ICU setting – facilitating minimization of physical and cognitive impairment as well as optimization of overall functional patient outcomes, while reducing institutional financial burden. It is essential that OTs advocate for their role in early ICU intervention programs in their respective hospitals in order to ensure that the value of OT is not overlooked; and more importantly, so that patients receive comprehensive, quality care as they begin their journey to recovery.
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About the Author
Melissa Sixta, OTD, OTR/L is an occupational therapist at the University of Colorado Hospital (UCH), which is a 568-bed teaching hospital in Aurora, CO. Melissa graduated with her Doctorate in Occupational Therapy at Creighton University in Omaha, NE in 2009. She has experience working in acute care, sub acute and acute rehabilitation, and outpatient therapy. Melissa is currently the Student Program Coordinator at UCH. She is also the Public Policy Chair and Board Member for Occupational Therapy Association of Colorado (OTAC). In 2013 she was on the Legislative Committee of which contributed to passage of licensure for occupational therapy practitioners in Colorado. She is published in the Journal of Neurotherapy, OT Practice, and has contributed to a chapter in OT Manager.
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The Core Values of Occupational Therapy: Supported by Evidence-Based Task-Oriented Training for Clients with Stroke
By: Sara E. Benham, OTD, OTR/L, ATP
Upper extremity impairment is a strong focus of occupational therapy treatment for clients who have experienced stroke. It is estimated that there are over 700,000 incidents of stroke in the United States each year with 4.8 million stroke survivors alive today (AHA, 2003). Approximately 70-80% of the survivors experience upper extremity impairment (Parker, Wade, & Hewer, 1986) which impacts occupational participation. Driven by AOTA’s Centennial Vision (AOTA, 2007) members are motivated to meet the occupational needs of clients with science-driven and evidence-based interventions. Occupational therapists have multiple treatment options from which to choose regarding upper extremity impairment mitigation. Recent high-level evidence from randomized control trials (RCTs) has supported novel approaches, such as robot-assisted therapy (Wu, Yang, Chuang, Lin, Chen, Chen, & Huang, 2012) and constraint-induced movement therapy (CIMT) (Wolf, Thompson, Winstein, Miller, Blanton, Nichols-Larsen, Morris, Uswatte, Taub, Light, & Sawaki, 2010). Emerging neuroplasticity-based exercise treatments may address and improve impairment; however occupational therapy long-term goals are usually related to the client’s participation in occupation. Task-oriented training is an intervention that focuses directly on client-centered participation in functional activities.
While task-oriented training may be more aligned with the values of occupational therapy (AOTA, 2008), clients may expect to participate in traditional and potentially beneficial exercise and strength training. Motivated by the profession’s core values to integrate task-oriented occupation, this author completed a Critically Appraised Topic (CAT) focusing on how task-oriented training compares with traditional strength training to improve upper extremity function for persons with stroke. It is important to note the limitation of this CAT: It has been individually prepared and not peer-reviewed.
A focused clinical question guided the CAT: Among people with unilateral upper extremity hemiparesis, how does task-oriented upper extremity treatment compare with upper extremity strength training on improving functional upper extremity motor return as measured on the Wolf Motor Function Test (WMFT), the Fugl-Meyer (FM), and/or the Functional Test of the Hemiparetic Upper Extremity (FTHUE)? The question was summarized from a PICO question (Patient, Intervention, Comparison, and Outcome) (Lou & Durando, 2008) to intentionally guide a client-centered search for the accurate, relevant, and high-quality evidence. Clinicians should seek the highest-quality evidence from a systematic review rather than a primary RCT, if it is available.
The CAT summarized a total of five relevant, Level I studies that included two systematic reviews. A study that investigated task-oriented training as compared to strength training was identified as ‘best evidence’ because it directly related to the PICO question (Winstein, Rose, Tan, Lewthwaite, Chui, & Azen, 2004). Both functional task practice and strength training (in addition to standard occupational therapy sessions) are superior to standard occupational therapy alone with regard to improvements in functional impairment and strength. Subjects with less stroke severity demonstrated greater improvements in both functional task practice and strength training groups. Subjects who participated in functional task training continued to improve strength at follow-up.
Two publications included in the CAT concluded that task-oriented training is an effective intervention to improve functional upper extremity performance for individuals with stroke (Timmermans, Spooren, Kingma, & Seelen, 2010) at post-intervention and follow-up (Arya, Verma, Garg, Sharma, Monia, & Aggarwal, 2012). With regard to strength training, one publication concluded that it is an effective intervention to improve grip strength and upper extremity function for individuals with stroke, however does not improve ADL performance. (Harris & Eng, 2010). Another randomized control trial concluded that self-directed exercise was effective with statistical significance to improve functional use of the upper extremity at post-intervention for subjects with chronic stroke. The amount of improvement was comparable to other novel treatment approaches previously mentioned such as CIMT and robot-aided exercise training (Pang, Harris, & Eng, 2006).
The clinical bottom line is that both task-oriented training and strength training are effective treatment interventions to improve upper extremity function after stroke. The evidence suggests that task-oriented training contributes to greater functional long-term results. Emerging evidence supports task-oriented training that includes clear functional goals and random practice components to improve functional performance at follow-up (Timmermans, Spooren, Kingma, & Seelen, 2010). These findings are most significant for clients who demonstrate mild to moderate upper extremity functional impairments.
These findings support that client-directed occupational therapy treatment with a functional task focus is an effective intervention for clients with stroke. The profession of occupational therapy is built on solid principles that support goal-directed functional participation. Therefore, it seems intuitive for occupational therapists to integrate functional, task-oriented practice in neurological treatment interventions. The advantages are easy to see: The intervention is cost-effective, statistically significant, and can be applied in any treatment setting. However, the potential disadvantages of occupational therapists overlooking the consistent utilization of task-oriented treatment may be detrimental in the near future. In an editorial of the Journal of American Physical Therapy Association, Jette and Latham (2011) reported that “task-oriented training is significantly more effective at improving function than standard impairment-focused training” (p. 1709). Now, the American Physical Therapy Association’s guidelines for practice include the alleviation of impairment and functional limitation, including “functional training in self-care and home management” (APTA, 2011, p. 57). As we progress toward the Centennial Vision of 2017, it is imperative for occupational therapists to meet society’s occupational needs. It is the responsibility of every occupational therapist to protect our unique contribution of integrating occupational, task-oriented treatment in upper extremity impairment mitigation.
About the Author
Sara Benham, OTD, OTR/L, ATP is presently assistant professor at the University of the Sciences in Philadelphia. She graduated with her master’s degree in occupational therapy from the University of Indianapolis in 2006, and in 2014, obtained her doctorate degree in occupational therapy from Thomas Jefferson University. She has 8 years experience in rehabilitation; in addition, her specialization is in assistive technology and stroke rehabilitation. She obtained an advanced certification in assistive technology from the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). She has instructed an OT neuro-rehabilitation course for a rehab technician program in Haiti in the recent past. She presented at the Annual AOTA Conference in Baltimore on wellness apps appropriate for clients in an inpatient rehabilitation program.
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