Guideposts of Occupational Therapy 9781487583040

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Guideposts of

OCCUPATIONAL THERAPY

By

Helen P. Le Vesconte, O.T.Reg.

UNIVEHSITY OF TORONTO PRESS

Copyright, Canada, 1959, by University

or

Toronto Press

Printed in Canada Reprinted in 2018 ISBN 978-1-4875-8176-3 (paper)

FOREWORD Occupational therapy provides countless avenues for exploration. Emanating from a central hub mrtin avenues radiate out. These in turn give off side roads which again lead into byways. Advances in medicine and its allied discinlines have resulted in the subject matter required in the training for these disciplines becoming more and more complex. Thus it is all too easy to become lost on a byway if the road plan has not been well learned and its guide signs clearly understood. The purpose of this material is to emphasize the main avenues, and to keep clear the relationship between them and their expanding periphery. It has been by design that a number of references and quotations are included. It is intended that the references be read, for some are essential to proper understanding, some are intended to guide reading toward authoritative sources. Many of the quotations were selected because they do more than introduce an important name to the reader; they give an impression of the personality of the man. While most principles and truths have been said many times and by many people, it is how they are said that makes the more lasting impression upon the memory. To Miss Isobel M. Robinson I am deeply indebted not only for her editorial assistance which has- involved many hours of laborious work, but also for the encouragement and valuable advice which she has given throughout the preparation of this material. I would like to express my thanks to Dr. A.T. Jousse for his helpful suggestions, and to the University of Toronto Press which has done much to make publication possible. . Finally, I would remind my students of the White Queen's words to Alice, "Now, here you see, it takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that."

Toronto, August 1959

H.P.Le V.

iii

CONTENTS Foreword

. iii

Section I

Introduction

Section II

Rehabilitation

Section III

Occupational Therapy

Section IV

Terminology • •

11

Section V

Treatment Media or Tools

18

A. Analysis of Media

20

.

...

1

. . .

8

B. Activities of Daily Living and Assistive Devices

4

••••

24

C. The Disabled Homemaker.

28

D. Handcrafts.

31

E. Industrial Skills and/or Tool of the Trade • • • • • • • • •

34

F. Writing and Typing • • •

36

G. Recreational Activities

41

H. Cultural and Educational Media

45

1. Music 2. Art. • • •

3. Academic

I. The Therapist

• • • • •••• •••••••••

. . . . .

..

.

Section VI

Pre-vocational Evaluation.

Conclusion

. . . . . . . . . . . . . . . . .

iv

45

47

50

52 55 59

SECTION I INTRODUCTION This Manual is intended primarily to meet the needs of students as an introduction to the textbooks of occupational therapy, and in no way to take their place. The textbook, whether it be a general presentation or one devoted to a particular area of the subject, serves to cover scope and detail rather than to emphasize the relative weighting of areas in professional practice. Thus, for the beginner, the apparent mass of detail may appear confusing and even an overwhelming :picture. The result may be that "the woods are not seen for the trees". This is no criticism of the textbook, but it is a recognition of the need for orientation to the proper use of the textbook, and thus to serve as a 'weighting guide' to set the proper focus at the appropriate time. Guidance in setting the focus is needed, as the student must learn to see the basic defined areas of each rehabilitation discipline. Then as she progresses to the further elaboration of the potentials of each, she finds _that there are certain areas of overlapping of occupational therapy and physiotherapy, of occupational therapy and nursing, of occupational therapy and speech therapy, etc. If at this point the basis of each discipline is understood, she is able to see how each may reach certain common goals in a logical and understandable manner. To use a familiar simile, "All roads lead to Rome". The Neapolitan approaches from the south by highway or byway· the Florentine approaches from the north; the Greek coming from the east may use a long overland route alone, or the highways of both sea and land. So it is with rehabilitation. Each member of the rehabilitation team approaches by the route in which he is versed, and guides the patient according to his needs and potentials to make the journey. Some will come mainly by the help of one discipline; some, like the Gree~ may require several different vehicles, each at appropriate times, but each guiding him to the same destination. Therefore all disciplines must know the final destination; they must be aware of other approaches to it in addition to their own. As the final goal is approached, they must be prepared to 1

see that the patient receives the best guide to his final steps. While certain basic principles remain constant, methods and media may change, old methods and media may be adapted or modified, new ones are developed. Also, methods and media may differ in different countries at any one time. Methods and media in any one country alter as the structure and ideals of its society alter. This need for continuing flexibility was aptly stated by the late Dr. Harold Storms (lJ, first Medical Director of the Ontario Workmen's Compensation Board Clinic in Toronto. Describing the occupational therapy approach and programme at this clinic, he said, " ••• we now have ••• a therapy not fixed or inviolate, but one in a constant state of change, ready to devise and invent new forms or modifications of old, to suit an ever new set of conditions." Because this Manual is designed to assist the student in a more thoughtful and discriminating use of the textbook, much of the material is pur~ posely presented in statements and quotations from the more familiar texts and printed material, with the source listed for each section. Thus, having been introduced to the philosophy behind the problems and responsibilities of the occupational therapist, when the principles and concepts of treatment are met in the framework of the text to which they belong, the student should understand more clearly the surrounding detailed material. Over the world there are thousands of different skills which are important to individuals; different goals that to each are of prime importance. Some must know how to run a tractor, some to set type, some to lay bricks. These are the skills of their daily living, contributing to and a vital part of their purpose in life. In summary, the purpose of this manual is to provide a "range-finder" through which correct focus is obtained on the aims, methods and media of occupational therapy, through which its goals may be achieved; it does not include methods of practice nor the application and specific use of the media within the framework of treatment. Only when the fundamental principles, concepts and philosophy are learned and understood, is the stage set for the learning of its application and ·practice. The process from· learning to 2

practice is unending. It starts in the definitive formal study of basic professional training, and it continues throughout professional practice.

Reference 1.

Storms, H.D.: Occupational Therapy in the Treatment of Industrial Casualties. Can. J. Occup. Therapy, 10:2, April, 1943.

3

SECTION II REHABILITATION "Man is like an iceberg - about twenty percent of his capabilities are visible above the level and most are hidden." (1) A broad and frequently used definition of rehabilitation is " ••• the restoration of the handicapped to the fullest physical, mental, social, vocational, and economic usefulness of which he is capable." (2). Pattison (3) describes rehabilitation as 11 • • • a scientific organization of convalescence to hast.e n recovery and guide the disabled to purposeful li~ing." Kessler l2) writes, "The history of the social attitudes toward the disabled is one of harsh and brutal treatment, only slightly mitigated by the Christian tenets of charity and philanthropy. These harsh attitudes have permeated the folk ways and institutions of society down to modern times ••• Out of the cries of the disabled and the catastrophies of two wars, a new philosopoy and attitude has developed which has been crystallized in the general concepts of rehabilitation •.!' The modern hospital is described as a p4ace of active treatment, early ambulation, out-patient services. But the decades-old aura that surrounds medicine and the healing arts is still imbedded in the minds of many laymen - the mysteries of drugs, potions, and the doctor as a miracle worker. "The mere fact that one is ill is accompanied by a certain disinclination to, or disbelief that, one can make the effort ••• Passive treatments are to most people psychologically pleasant - they imply no effort. Thus the patient must free himself from the expectation and hope that it is the doctor or the. therapist who will do that something which will result in cure." (4) Kessler (2) points out that in disabilities of a temporary character such as pneumonia, frac-ture, gastric ulcer, the patient's own "reparative powers" are responsible for recovery after stan- ·· dard types of treatment, but that the convalescent period may be reduced and psychogenic complications prevented by the use of occupational therapy and remedial exercises. The severely disabled present a more difficult 4

problem. They are left with residual impairment, functional and/or structural, which surgery or medical treatment cannot eliminate; some struggle imperfectly against the rigours of day by day living; some surrender to the social struggle, becoming permanently and completely dependent upon their family or community. It is to meet the need of this large group of physically handicapped persons, restricted in their working capacity and in their opportunities for employment, that the larger concept of rehabilitation has developed. But physical handicap alone is only part of the problem. "We must never forget, however," Ravesloot (5) has warned, "that the hwnan being is not specialized; that he combines the physical, the mental, and the emotional. Our task is to strengthen the individual, to train him so that he can do a great deal for himself." O'~"ialley ( 6) points out, "Assessment of the patient's motivation must in the final analysis be the answer to our problem. Until we have studied the patient's motivations, we cannot hope to understand the patient's reactions to his disability, his attitude towards his work, his home and his associates." The importance of the psychological aspects is emphasized by Yonge (7) who states, "Far from being a modern idea, the bearing of psychological influences upon physical health is a very old one. In the ancient world, in the earliest of all known institutions of healing - the temples of Aesculapius - the doctor was at the same time the priest. Medical care involved various lotions and potions as physical measures, various activities which today we might call occupational therapy and physiotherapy, as well as religious ministrations to the needs of the soul. Thus, at the beginning of medical history, medical care was comprehensive or multi-directional. "The trouble in those days was that the practice of medicine and the practice of religion were both mixed up with magic." In the attempt to divorce medicine from magic, unfortunately physicians lost sight of the psychological and spiritual influences upon the physical processes. Even as far back as 400 B.C., Plato recognized that "you could not properly cure the part unless you paid attention to the whole." (7).

5

Yonge continues, "The progress of medical research over the years has now shown that health and disease cannot be considered as purely physical. There is an inseparable interaction between the physical process and the psychological experiences in all illnesses. What the patient thinks and feels has some effect, sometimes profound and crucial effect on his physical well-being ••• The task of rehabilitation ••• is a problem much larger and more complex than, say, the mechanical stimulation of muscular action. All useful muscular activity is controlled by the brain ••• the brain is the terminus not simply of mechanical nerve impulses to all parts of the body, but also a vast, milling crowd of fears, hopes, inclinations and intentions which ••• may largely determine the activity of any part of the body. So much of the success or failure of the physical methods of training a body to renewed activity depends on how the patient feels and thinks about himself and about life in general." In illness the lack of activity quickly results in unhealthy changes, both mentally and physically, which react upon each other. Physically these are apparent in bone, muscle, circulation, coordination patterns. Feelings of pain take hold of the attention and worries result. Mentally there is some degree of 'let-down'. We dwell on worries and fears. These react on the functions - loss of sleep, loss of appetite, we become irritable and are easily upset emotionally. It is natural to react to illness, but some do not show or express their reactions. Some will adjust too well to illness which provides them with protection or withdrawal from responsibility. Then we have to combat invalidism. In rehabilitation, " ••• success or lack of success," says Rusk (8), "can be measured only by the patient, not by those of us who work with the patient ••• Our cardinal theme in rehabilitation is that we work with rather than on patients and that we remember that muscles, bones and joints are not important as entities in themselves but only as they help a man to function in meeting the problems of everyday living."

6

References 1. 2.

J.

5.

6. 7. 8.

Kessler, H.H.: in Proceedings of the 7th World Congress, International Society for the Welfare of Cripples, 1957, p. 294. Kessler, H.H.: Principles and Practices of Rehabilitation. Philadelphia, Lea and Febiger, 1950 pp. 15-17. Pattison, H.A. {Editor): The Handicapped and Their Rehabilitation. Springfield, Ill., Chas. C. Thomas, 1957, p. xii. LeVesconte, H.P.: The 4th Therapist. Can. J. Occup. Therapy 21:2, June 1954. Ravesloot, M.J.: in Proceedings of the 6th World Con~ress, r.s.w.c., 1954, p. 15. O'Malley~ C.J.S.: in Proceedings of the 6th World ~ongress, I.s.w.c., 1954, p. 114. Yonge, K.A.: Psychological Aspects of Rehabilitation. Can. J. Occup. Therapy 25:2, June 1958. Rusk, H.A.: in Proceedings of the 6th World Congress, I.s.w.c., 1954, pp. 151-152.

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SECTION III OCCUPATIONAL THERAPY According to Licht (1), "Occupational Therapy is remedial activity ••• Unlike most other forms of treatment, occupational therapy is used in almost all aspects of patient management, embraces a wide variety of tools and activities from all areas of life and demands the active participation of the patient." The participation of the patient is emphasized also by Spackman and Willard (2) who point out that "The majority of medical treatments are administered to the patient who accepts them with a considerable degree of passivity. On the contrary, in occupational therapy the great majority of the procedures used require the active and cooperative effort of the patient to achieve their ends. The personality of the occupational therapist and his knowledge and ability to understand the patient's reactions, to lead and stimulate him to active effort toward recovery of normal function is of paramount importance. The use of himself as the most important tool of treatment is the occupational therapist's greatest achievement." Licht (1) also states that occupational therapy "extends beyond the sphere of remedial in that some of its applications are in preventive medicine and diagnosis. In addition it is a major factor ••• in aspects of rehabilitation which cannot properly be called medical, as for instance, in vocational exploration." "The first and most basic principle of occupational therapy", West (3) writes, "is its emphasis on treatment of an individual, rather than a specific disease or injury." Therapy means treatment or healing process. Occupational therapy means treatment by means of participation in occupation or activity. Its purpose is to motivate the patient and assist him to achieve through his own efforts, his best possible functional capacity. Occupational therapy is medically prescribed for specific objectives. The occupational therapist carries out these objectives by the selection and use of a variety of methods and 'tools of treatment'. Because the patient must participate he must be motivated. Therefore the approach of the therag

pist is an essential part of the treatment technique. Summary 1.

2.

Aims or Objectives include: physical restoration: to maintain, regain or increase - joint range - muscle power - coordination - tolerance of activity mental restoration: - to maintain, regain or increase attention, observation, etc. - a controlled outlet for motor and psychomotor activity - to serve as a diagnostic aid - to supplement psychotherapy, convulsive therapy, psychosurgery - ego strengthening social adjustment: - to develop satisfactory interpersonal relationships - to provide acceptable outlets for drives (creative, aggressive, etc.) supportive or preventive: - to maintain capabilities; physical, psychological, morale - to prevent secondary disabilities - adjustment to residual handicaps prosthetic training pre-vocational assessment 'Tools of Treatment' include: activities of daily living: - self-help training - assistive devices manual activities: - handcrafts - industrial skills - 'tool of the trade' recreational activities: - remedial games - play and toys cultural and educational: - art, music, drama, etc. - writing, typing - academic adapted tools and equipment special equipment prevocational assessment: 9

2.

J.

(continued) - job samples - work tests the therapist Approaches include: - directive - non-directive - eclectic - permissive

Reference 1. 2.

J.

Licht, s.: Occupational Therapy, Principles and Practice. 2nd ed. Ed. W.R. Dunton, S. Licht. Springfield, Ill., Chas. C. Thomas, 1957, p. 15. Spackman, c.s. and Willard, H.S.: in The Handicapped and Their Rehabilitation, ed. H.A. Pattison. Springfield, Ill.; Chas. C. Thomas, 1957, p. 439. West, W.: in Principles and Practices of Rehabilitation, ed. H.H. Kessler. Philadelphia, Lea & Febiger, 1950, p. 118.

10

SECTION IV TERMINOLOGY Terminology is defined as "A science of proper use of words 11 , and is of maximum use when it properly corresponds to what it is supposed to represent. Our terms or words may not necessarily convey the meaning which we have appointed to them and others may have a different meaning in mind. The terminology of most professions is made up of various groups of words: 1. Some terms are purely technical and are intended to convey fixed meaning. Training in a given profession includes the learning and use of its vocabulary. 2. Some terms are borrowed from other disciplines in order to express similar concepts or facts. For example, many terms are common to both psychology and psychiatry - transference, identification, rationalization, etc. J. Finally there are 'plain English' words. These have an important place not only in communication with the layman and to a degree with other disciplines, but in communication within the profession itself. In the area of common words, the variation may result in confusion of the intended mea~ing. Consequently, careless use of l9osely defined words not only defeats our effort to have. others understand our concept, but actual misinterpretation and erroneous information may result. While these three categories of terms remain constant, it is obvious that there will be changes and additions within the categories as new areas are developed. As the disciplines themselves cannot remain static, neither can their terminology. Presumably the terms of a discipline have specific meaning; if not, then they have no value. Study of the terminology of many professions indicates that it is not the terms which they use that are confusing and even incorrect, but it is the way in which they are used. Some of the more common examples of this are given later in this section and show that probably in the majority of cases, faulty use of terms is the result of failure to distinguish between three basic points: 11

1.

Each discipline or therapy has a specific name (occupational therapy, physiotherapy, etc.) 2. Each specified therapy has specific aims, purposes or objectives. J. Each specified therapy utilizes specific methods, media or tools of treatment. Therefore, an adjective may be used to indicate a specific aim or media of the particular therapy, but the adjective does not replace the name of the therapy. When this is clearly understood there seems little reason for the confusion which all too frequently exists in this area. In the first textbooks and professional writings of occupational therapy there is no confusion in terminology. Occupational therapy is defined; its aims and objectives are defined; its methods and tools of treatment are defined in appropriate and therefore meaningful tenr.s. It is through the years, as medical requirements and professional development expanded, that the use of certain terms as 'labels' for pigeonholes tended to isolate focus of attention to the disability itself, rather than to the result of the disability in the patient. It is significant to note that this tendency caused concern and dissatisfaction in many occupational therapists, but the most vocal challengers of poor terminology have been the physicians. From these criticisms two ccncrete groups of terms are presented. One utilizes simple English terms, understandable to all disciplines and to the layman. The second utilizes explicit terms presumably familiar to, or easily learned by, the professional person. l. Dr. Harold Storms (1',irst Medical Director of the Workmen's Compensation Board Clinic, Toronto, Ontario) following the accepted definition of occupational therapy, designated its aims of treatment. as: (a) physical restoration (b) mental restoration (c) preventive (to prevent the loss of or to sustain morale) 2. Licht (1), in searching for uniformity and clarity of expression, selected four short descriptive words of Greek origin and, he states, "universal recognition." 12

( i)

Kinetic (kinetikos - relating to motion) replacing the old word functional - to restore or improve: (a) muscle strength (b} joint mobility (c} coordination (ii) Metric (metron - relating to measurement) old word grading, used to: (a) improve work tolerance (b) measure progress of tolerance (Note: "Although Kinetic Occupational Therapy employs the principle of progressive exercise, it is the activity rather than the timing which is emphasized in it. Metric Occupational Therapy is graded effort but more important than gradation is the fact that the increase can and should be measured. The physical activity of patients convalescing from cardiac or respiratory pathology should be increased at prescribed intervals and with specified energy increments. This same approach can be used diagnostically to determine the patient's progressive ability or therapeutically to improve such work tolerance ••• ") (iii) Tonic ( tonikos ·- increasing physical or mental tone), old word diversional, used to improve and maintain (a} muscle tone (b) mental tone (Note: "The adjective which has been the subject of greatest dissatisfaction has been diversion~l• The term is descriptive of the act but not of the objective. It is difficult to understand why a better term has not been adopted, especially since the English language is so rich in appropriate terms ••• Tonic is used here in the classical sense of invigorating and well-being ••• 'l'onic Occupational Therapy is not just busywork ••• It must be used intelligently to be worthy of the name 'tonic'.") (iv) Psxchiatric (psyche-iatreia, Medical treatment of the mind) used to favourably influence: (a) psychomotor activity

13

1.

stimulation (a) arouse interest (b) improve concentration 2. sedation (a) energy release (b) lessen destructive tendencies 1. aggression outlet (b) emotional disturbance 1. emotional stability (contentment) 2. mood (c) behaviour 1. behaviour (habit) training (d) abnormal mental content 1. guilt complex 2. paranoid trends la) crowd out delusions (e) psychosocial activity 1. socialization (a) interpersonal relations (b) attitude (i) self-respect (ii) confidence (iii) self control 2. provide obtainable objective {a) gratify narcissism (f) diagnosis 1. reaction to situation in clinic 2. identification of problem (in psychodrama) J. dete.nnine limit of intellectual work capacity 4. pre-vocation exploration (g) mental hygiene 1. overcome restlessness 2. promote good work and play habits Some Areas of Confusion and ~1isapplied Terms On the basis of the premise given at the beginning of this section that each therapy or discipline has a specific name, specific aims, purposes or objectives, specific methods, means or tools of treatment, it is clear that the following are obvious examples of the misuse of terms: Specific Therapy The Oxford Dictionary defines 'specific' as "definite, distinctly formulated; relating to a particular subject; having distinct effect in

14

curing a certain disease; a remedy or medicine." Since all therapy (or treatment) is related to a particular subject, all treatment is specific. The reason for the existence and use of a therapy is 'definitive, formulated attempt to remedy.' The adjective 'specific' describes the physician's 'specific'selection of the particular therapy indicated. (O.T., P.T., Speech, etc.) and the therapist's 'specific' selection of the method and treatment tool indicated. Remedial Theraoy This term is an example of redundancy of words. 1. The medical dictionary defines therapy as "relieving, curative, anything used in the treatment of disease." Thus, as therapy means remedy or healing, the adjective remedial adds nothing to it. 2. To remedy is the aim of treatment, not a branch of therapy, and it applies equally to all patients whether or not they require physical restoration. There has been a tendency in some areas to restrict this term to the treatment of orthopaedic disabilities. This unnecessary emphasis on the term remedial suggests that the therapist might perhaps examine her own attitude and determine whether she is really giving more than lip-service to the concept of preventive medicine. Is it more important and gratifying to the therapist to repair damage that has been done, i.e. to right a wrong, than it is to-prevent disability from occurring, i.e. to maintain well-being? Functional Thera~y This term, like the preceding one, is restricted by some to the physical disability field. Licht (1) criticizes the use of this term on the basis of medical teaching of its use. "The medical student has been taught that functional means physiologic as opposed to anatomical, thus a functional disease is one in which no evidence of structional change or pathology can be determined. This is opposite to its meaning as previously applied in Occupational Therapy, since the muscle or joint involvements thus treated are organic and accurate measurements of strength and range are possible." All living matter has its function - the heart,

15

the glands, the muscles and the brain. It should be noted.that for the past thirty or more years the psychiatrist has divided mental diseases into two categories - organic (those with demonstrable brain pathology), and functional (those with no demonstrable brain pathology). This is a medically correct use of the term. Qiversional Therapy This term, which Licht has pointed out as probably the most controversial, is neither included in nor recognized by the medical dictionary! The standard dictionary defines diversion as "deflecting, deviation." There is no suggestion of control in the deflection, nor that how or where deviation occurs matters in the least. At best it is a poor term in that it implies no element of control or selection which is the basis of therapy. Girdlestone (2) dismisses the term 'diversional' as 11 • • • a stupid name since ••• it conveys but half the truth." Cranfield (J) and others point out that the objective implied by the term is simply and meaningfully stated in the terms 'directional', 'preventive', or 'supportive'. In contrast to the inaccurate use or transfer of adjectives to designate certain branches of the 'parent therapy', it is recognized that within limits, some branches of a parent therapy can be differentiated by a particular method or tool of treatment. For example, physiotherapy has specialties in hydrotherapy and electrotherapy. For some years these branches were almost distinct and in certain European countries are still sometimes separated in training and practice. In Britain and the North American continent the trend has been to include all such divisions and branches in the training of physiotherapists. From the first organized training in occupational therapy, recreation, music, manual skills, etc. were included as the tools of treatment. It was considerably later that certain of these skills, notably recreation and music, because of the scope and specialization inherent in each, became specialties, e.g. music therapy. This has occurred mainly in the United States. While this increase in specialties has not altered the basic training and orientation of the occupational therapist in these areas of activity, it has provided very intensive and specialized programmes in

16

centres which required, and were financially able to include, an increasing nwnber of specialist personnel. Gordon and Wellerson (4) have warned - "'fhat concept is limited which sub-divides therapy into isolated categories (functional, prevocational and the like). For all the demands of rehabilitation must be integrated into a single goal to restore a disabled individual to his appropriate social setting." Because the occupational therapist is concerned with the whole patient mentally, physically, socially, emotionally and economically, she must be familiar with much of the vocabulary of related disciplines with whom she is in frequent communication. Terminology does not remain static. It constantly increases as new areas are developed. New words are sometimes coined; some of these are good - for example, 'orthetics' which originated at the Georgia Warm Springs Foundation. When terms are acquired from other disciplines, proper examination of their meaning should be made in order to avoid misusage.

Reference 1. 2.

J. 4.

Licht, S.: Objectives of Occupational Therapy. Occup. Therapy and Rehab., 26:1, Feb. 1947. Girdlestone, G.R.: Occupational Therapy for the Wounded. Can. J. Occup. Therapy, 9:2, Oct. 1942. Cranfield, H.V.: What Physical Medicine Expects of Occupational Therapy. Can. J. Occup. Therapy, 14:1, March 1947. Gordon, E.F., and Wellerson, T.L.: Does Occupational Therapy Meet the Demands of Total Rehabilitation? Am. J. Occup. Therapy, 8:6, Nov./Dec. 1954.

17

SECTION V TREATMENT MEDIA OR "TOOLS" There have been and will continue to be changes in media of treatment, but even more important is the changing emphasis on the freouencv of the use of certain media. '£his is in part related to: 1. Concurrent development and changes in method in medicine and its allied disciplines. Examples include: cortisone in treatment of rheumatoid arthritis; increased use of convulsive therapy for psychiatric illness; Salk vaccine for poliomyelitis; emphasis on early ambulation following certain traumatic injuries. 2. Social and economic patterns of the country and also of specific communities and districts. For ex·ample, heavy industry and natural resources, such as mining and lumbering in Ontario, result in what are termed industrial accidents; marine shipping and fishing play a larger part than industry in the economy of the ¥~ritimes and Newfoundland; in Scandinavia, in spite of the impact of the industrial era, handcrafts have survived as an important part of daily life and employment. The importance of appropriate selection of the media of treatment in any therapy is obvious, but its importance in occupational therapy cannot be overemphasized. Possibly in no other therapy are so many facets present. This is the inevitable result of the two fundamental principles on which occupational therapy is based: 1. Its conscious direction toward the triad of physical, psychological and vocational. 2. The active participation of the patient, which can be sustained only if he is able to relate his use of the treatment media to his sense of values. As Gordon and Wellerson (1) state: "While simple exercises are readily accepted because the patient understands their intent, therapy through work must have more than a mere physical meaning. This is because the latter involves not only the motor capacity of the patient but also his personality, attitudes, habits and intelligence."

18

Thus, while occupational therapy has many advantages in its variety of treatment media, this results in a greater demand on the therapist's thought and judgement in the selection of the most therapeutic and, at the sane time, most appropriate media. If the therapist fails to give adequate and critical thought to the selection of the treat,. ment media, the fault lies in the therapist, not in the inherent potential of the media as a tool of treatment. The basic media or tools of occupational therapy may be divided into main categories. Each of these categories is elaborated in succeeding sections. 1. Activities of - self-help training Daily Living - self-help devices - problems of the disabled homemaker 2. Manual - handcrafts - industrial skills (tool of the trade) - clerical - testing of aptitude, dexterity, trainability Recreational - psychological and social 3. values - remedial games - play as a treatment media of the child 4. Educational and - music Cultural - art - academic 5. The Therapist Reference 1.

Gordon, E.F. and Wellerson, T.L.: Does Occupational Therapy Meet the Demands of Total Rehabilitation? Am. J. Occup. Therapy, 8:6, Nov./Dec. 1954

19

A. Analysis of Media As the physician's selection of a medicine is based on his analysis of its components and his knowledge of the effects of each, so the therapist's selection of her media of treatment is based on analysis of the components of the media and their potentials for bringing about the desired results. As changes have taken place in the media of treatment, so refinements in analysis have been made. Obviously a complete analysis of all aspects of an occupational therapy medium would be unwieldy, hence analysis of the most important aspects are considered here. 1. Analysis of Physical and Mental Processes Involved This was the original type of analysis which by 1927 had developed to the point that the journal "Archives of Occupational Therapy", Volume 7, published some twelve analyses, each dealing with a specific craft - weaving, knotting, carpentry, etc. This analysis form included: joint actions, muscle groups, degrees of coordination, position of work; the mental processes of attention, concentration, initiative; equipment; economic aspects; suitability to specific disability groups. Prior even to World War I, the need for study and understanding of the then relatively neglected field of functional movements had been emphasized. The text-book Applied Anatomy and Kinesiology (Bowen and McKenzie) included detailed analysis of body movements, not only in games and sports but, of particular interest to the occupational therapist, in industrial occupations such as handling bricks, shovelling, pitching hay, carpentry tools, plastering and extending into the homemaker area, ironing, sweeping and washing. While these analyses were not in tabulated form, they gave an accurate picture of the body actions involved. 2. Kinetic An~lysis This analysis was an important advance over the conventional · and completely objective lists of joint and muscle actions, for it added the factors of energy, rhythm and the part played by the assisting hand. Credit for 20

J.

4.

the development of this approach is due largely to Dr. Sidney Licht (1) and it should be studied by all occupational therapists. Activity Analysis It is apparent that the previous analyses had considered almost entirely the physical aspects of treatment media. Thus there was need for the formulation of an analysis pattern in terms of the therapist's approach and application of treatment to the psychological and emotional needs of the psychiatric patient. "Specific aims," Fidler (2) wrote in 1947, " ••• are of little value unless specific means can be provided for the achievement of these aims." Fidler describes her outline of Activity Analysis as " ••• an attempt to more closely correlate occupational therapy with the principles of psychiatry, the personality, and the emotional needs of the patient ••• ". This outline is comprehensive and the section devoted to 'physical processes involved', including the fatigue factor, is worthy of study. Analysis of Structure Inherent in all functional activities, i.e. activities which are purposeful to man, are two qualities which further provide therapeutic potentials. These qualities vary in degree within the following groups: (a) Structured - Structured acitivities are those in which a definite procedure is laid down. There are right and wrong ways of performing them, or there are degrees of leeway within defined limits. Examples of high structure include - knotting, precision operations in skilled industry, metalwork. Structure is found in varying degrees in - weaving, carpentry, homemakers' tasks. (b} Unstructured - These activities permit a high degree of individual methods and procedures, and therefore utilize ingenuity and creativeness. Examples include finger painting, clay, painting (art), toy play of the young child. Depending on the specific needs of the patient, the degree of structure or non-structure provided in an activity may be a more import-

21

ant consideration than the literal occupation per se. 'fhis approach to the therapeutic activity is important in treatment of the psychiatric patient. Is the aim of treatment to develop the capacity to act within defined boundaries, to accept control, to conform? Is the aim of treatment to encourage initiative, individuality, self-determined action? Or is the aim of treatment to provide a situation which permits the patient to show his capacities and initiate his own actions, or which reveals his dependency on direction and the security of clearly defined boundaries? Eaually, this approach is important in certain stages of treatment of physical disabilities. In the early stages of treatment the therapist may be concerned mainly with how a patient performs; ultimately the employer will be concerned with the auality and/or quantity of the worker's performance. This involves more than correct motions; it involves what the worker sees in the job situation which may vary from a highly repetitive, stereotyped performance, to one in which observation, change and versatility are essential. 'rhe extent of definition or the extent of 'freedom' required in a job is one of the factors to be matched in determining aptitude or capacity for a given job. Thus the relationship between the limitations or the 'freedoms' inherent in the treatment media, and the treatment needs for control or for patientdetermined action, may be summarized as follows: l. If the treatment media is intended to control the patient's response to a defined action, the use of a structured media is indicated. 2. If the treatment media is intended to elicit a self-directed pattern of action, a minimal degree of structure within the media provides the opportunity and the incentive. Finally, there is another point which, to the student and perhaps also to members of other disciplines, may appear a contradiction to the principles of defined treatment. That is the validity, in certain situations, of giving the patient a 'choice' in treatment media. If the preceding concepts have been understood, this doubt has been removed. All goes back to the therapeutic need of the patient. (a) If the patient requires definite boundaries and limitations on how he acts or reacts, 22

then the therapist provides structure in the treatment situation and all that is included in it. Here the therapist is the rider, holding the reins which control the degree and direction in which action takes place. (b) If the patient must extend his boundaries, utilize his full capacity, ingenuity, initiative, then the provision cf opoortunity for the patient to express choice is part of the therapeutic procedure. As the degrees of the structure vary, so the extent to which choice is offered will vary. Though the patient is aware of 'choice', the therapist has actually established the choices made available to him. Again, the selection is by the therapist. In the treatment of the mentally ill, this technique is frequently important. Wittkower and Johnston (3) for example, point out the value of undirected and unstructured media to provide a means of discharging impulses and emotions, as a means of communication when other avenues are blocked, and thus helping to establish a degree of social contact. Used by a therapist well versed in dynamic psychopathology, this technique offers "access to unconscious or preconscious processes in the patient ••• "

1. 2.

3.

Licht, S.: Kinetic Analysis of Crafts and Occupations. Occup. Therapy and Rehab., 26:2, April 1947. Fidler, Gail: Psychological Evaluation of Occupational Therapy Activities. Am. J. Occup. Therapy, 2:5, Sept./Oct. 1948. Wittkower, E.D. and Johnston, A.M.: New Developments In and Perspectives of Psychiatric Occupational Therapy. Can. J. Occup. Therapy, 25:1, March 1958.

23

B. Activities of Daily Living & Assistive Devices Activities of Daily Living, hereafter referred to as AOL, are those skills necessary to care for oneself in the essential acts of toilet, washing, dressing, eating, writing and ambulation. ~ithout the ability to do these for himself, the patient is dependent on and a care to others. Until the patient gains or regains these skills nothing else is as important to him. Assistive devices for self-help therefore may: 1. Serve as a substitute for a part or function which is totally lacking 2. Assist or facilitate defective existing function J. Provide stabilization 4. Permit free motion of a joint in certain directions Most devices are improvised to facilitate essential acts of daily living: eating, toilet, dressing, writing, smoking, page turning; or simply to provide a hand grasp. In paralysis or severe weakness of the shoulder for example, loss of abduction and flexion make the hand useless, as it cannot be moved toward the head. Thus the patient is unable to feed himself unassisted. Here a sling suspension is an essential device. In the upper extremity, the minimal, residual strength of a muscle group can often be made of functional use to enable a patient to feed himself. Devices for such purposes must be simple, correct in design and easy to apply, comfortable, light in weight but sturdy, and acceptable to the patient. According to Zimmerman (1), training in selfhelp may involve: support of the part, hand, arm or wrist, so that the patient can utilize his existing power and control. Such support includes a sling, elevated table, a splint, or stabilization in the case of one hand only. adapted equipment, spoons, long handled comb or shoe horn, glass holder, etc. These devices or adaptations must be fitted to the needs of the individual in many cases. Some simple devices are now available commercially. training the remaining hand to take over the skill of the dominant hand, or increasing the skill of the dominant hand to act without an 24

assistant hand. Any potential of the disabled hand should be developed to the maximum. an assistive device to encourage the use and thus the development of the residual capacity. Hence training in self-help should start as early as possible. It cannot always be predicted for how long a patient will need a device, or whether the need will be permanent. Therefore, it is usually best, both physically and psychologically, to introduce the device as an 'immediate helper' until more function returns. While the habit and acceptance of dependence are ~ore difficult to break than to acouire, it is equally true that the sooner the patient experiences a degree of independence, the more willing he is to continue to make greater effort to increase or retain it. It is important to note that many devices can be used for more than one pathological entity if the result is the functional impairment of similar anatomical regions. The performance of an act during specific treatment sessions only, is obviously of little functional benefit to the patient. These acts are meaningful to the patient when they are encouraged and carried out regularly as the nonnal need for them arises. Only then do they become self-help. Thus, training in AOL should be the joint responsibility of the nurse, the occupational therapist, the physiotherapist, the hospital orderly and the nursing aide, in order that the necessary carryover be achieved. The nursing staff is responsible for bowel and bladder training. As the nurse is the person most frequently and continuously in contact with the patient, she is able to carry over practice in transfer from bed to wheel chair, etc., and in washing, eating and dressing techniques. The physiotherapist is responsible for correct training in ambulation, but her brief treatment periods with the patient are less effective unless the patient puts this training to use and does so correctly. The occupational therapist is qualified and eauipped in the training of upper extremity function, particularly the hand; hence she is able to evaluate the time and the means by which the patient attempts to feed and dress himself. Thus close cooperation between the two therapists and

25

the nurse encourages the patient to benefit, through use, from his treatments, and his recognition of their importance to him is increased. f~rry-Over Between Nurse and Therapists Bowel and bladder training initiated by - nurse follow-up by - nurse Transfer bed to chair initiated by - nurse - physical therapist follow-up by - nurse in ward care Ambulation, gait, crutch walking initiated by - physical therapist follow-up by - nurse in ward care - occupational therapist in treatment activities Eating, dressing, grooming initiated by - nurse - occupational therapist follow-up by - nurse in ward care Writing, typing initiated by - occupational therapist - speech therapist follow-up by - coordination of speech and occupational therapy if brain damage present Speech initiated by - speech therapist - occupational therapist follow-up by - nurse in personal contacts - occupational therapist as part of treatment programme* * "Because of the nature of their training and the aims of their profession, occupational therapists are particularly well suited to increase the aphasic's chance of regaining functional speech." ( 2)

If the patient needs adapted equipment for these activities, frequently its selection and its manufacture are the responsibility of the occupational therapist. By nature of her training she is uniquely suited to design aids to functional patterns of movement and to train the patient in their use, as she has basic knowledge of the potentials of materials and the handling of tools. A prominent function of occupational thera-

26

pists, in the opinion of Mead (3), is the provision of splints, supports and adaptive equipment. This opinion is supported by Swanson (4) who states - "The therapist is more intimately concerned with the prevention and correction of deformity than any other person. She has a personal interest in the patient's welfare. She is therefore far more likely to achieve a good splint, performing its intended function, than a plaster technician who may only see the patient once ••• The occupational or physio-therapist is daily engaged in the assessment of the patient's capabilities and of training his abilities ••• It has already been the experience with DuraFoam that occupational therapists have shown by their enthusiastic acceptance of this material that they are capable of developing it with new designs both for supportive splints and self-help devices." "Leadership in the provision of necessary mechanical assistance is not only a challenge, but a responsibility for the occupational therapist." (1) References 1.

2.

3. 4.

Zimmerman, M.: in Principles and Practice of Occupational 'fherapy: Willard, H.S. and Spackman, c.s. 2nd ed., Montreal, Lippincott, 1954. McGeachy, D.: The Role of the Occupational Therapist in the Rehabilitation of Speech. Can. J. Occup. Therapy, 23:2, June 1956. Mead, S.: Occupational Therapy Five Years Later. Am. J. Occup. Therapy, 10:4, July/ Aug. 1956. Swanson, J.L.: DuraFoam, A New Material for Making Splints. Can. J. Occup. Therapy, 25:3, Sept. 1958.

27

C. The Disabled Homemaker It may be surprising to learn that this category is estimated to be the largest category of occupational disabilities. Extensive work has been done in this area and much valuable material published. The basic approach to the problems of the disabled homemaker has been included briefly in this section because of the importance of devices, of careful selection of utensils, and of training in effective and therapeutic methods of carrying out their daily tasks. This is essentially an area of occupational therapy, but one in which much valuable assistance can be gained from the home economist. Industry has contributed much to the development of time and energy saving techniques and work manaEement principles. These principles are. also applicable to the disabled homemaker in order to teach her to simplify her household tasks. When residual disability is anticipated in these patients, it is advisable to start the practice of fundamental skills while the patient is in hospital. This can reduce considerably the period of adjustment and frustration. Emmett (1) recommends that "primary skill in using one hand can best be developed in an unfamiliar medium. When the patient has had some success with a simple craft and training in basic activities of daily living, the time has come, with the doctor's approval, to introduce homemaking retraining." It is vitally important that the patient's family be kept in the picture. Does the family see the p~tient as an invalid to be relieved of all responsibilities? Or are they prepared to accept her as a participating member of the family? As Cooksey (2) has so aptly said - "The art of living with disability has to be learnt not only by disabled people, but, also, by everyone associated with them." Hossack ()) reminds us that "For the disabled woman, the prospect of resuming household activities and responsibilities can cause much apprehension. She is returning to what has been her former job, but in many instances she no longer possesses her former physical strength and skill. She may fear failure, or that the work involved will be detrimental to her present physical condition." Change of method or procedure may solve cer-

28

tain problems; situations that place undue stress on the handicap may be avoided. When a gadget is thought to be necessary, it is often possible to find the answer in something already on the market, rather than making a special device. In training a patient to use a gadget, or to learn a new method to compensate for a previously known skill, it is important that the therapist demonstrate it as the patient will use it, and do so effectively, otherwise the results may be unfortunate. Possibly the patient's home may need some adaptation to avoid unnecessary limitation of independence. For example, the addition of hand rails may make the difference between confining a person to one room as opposed to enabling her to be activ~ in her kitchen. Suggestions for changes in the home should be studied carefully before they are made, and thought given to how they can be carried out. They should not be left to chance. Slowness is often a major handicap with the disabled. It is important then to plan in terms of simplification of tasks, arrangement of equipment and supplies, and the need to allow the necessary time to accomplish a given task. "Whatever the type or degree of disability," .MacCaul (4) states, "it is fundamentally the individual's personality which will determine the issue, for no amount of physical treatment, advice, or other skilled help can be of real benefit unless the disabled person has the will to help himself ••• It is, therefore, important that some form of assessment of personality be made as soon as practicable, so that any extra time and thought that is available may be given to the individual most likely to benefit ••• " And further 11 • • • the disability must be understood in terms of lack of function as it affects everyday activities ••• Singly the physical disabilities would not be difficult to overcome. It is because they interact on each other that the sum total is so formidable." References

1. 2.

Emmett, R.: Adaptation of Homemaking Skills for the Hemiplegic Woman. Am. J. Occup. Therapy, 11:5, Sept./Oct. 1957. Cooksey, F.S.: Proceedings of the ·7th World Congress, I.S.W.C., 1957. p. 65.

29

3. 4.

Hossack, J.: Home Management for the Disabled. Am. J. Occup. Therapy, 10:4, July/Aug. 1956. MacCaul, G.: Proceedings of the 7th World Congress, I.s.w.c. 1957. p. 126.

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D. Handcrafts Handcrafts provide a therapeutic role because: 1. They are adaptable and gradable: (a) to early treatment in bed and/or restricted positions. (b) to treatment of physical function - joint range - muscle power - coordination - tolerance of activity (c) to treatment of mental function - attention and concentration - observation - judgement - initiative and ingenuity (d) from minimal to unlimited interaction with people. 2. The tools and techniques of crafts are the basis of trades and jobs. The craftsman was the original industrial worker, the skilled tradesman. Many of these craftsmen were artists whose skills have never been surpassed J. They are suitable to all age levels, cultural and social backgrounds. 4. They provide easily available media for realistic assessment of manual dexterity, precision jobs such as watch repairing, radio, etc. 5. They provide motivation through achievement in a wide range of interests. To appreciate the significance of this treatment medium, the two components of the word HANDCRAFT, should first be considered in their appropriate ( and literal } sequence. (a) Hand Bunnell (1) points out that, "Hands from birth are intimately connected with our mental processes ••• the hand develops the brain and the brain the use of the hand." The hand is so intimately rooted into our lives, thoughts and expressions, that it has become a part of our language, e.g. handy, all hands on deck, rule with a strong hand. From the Latin MANUS are derived: manage, manipulate, manuscript,

31

manufacture. In our present-day mechanical age, injuries to hands lead the list of industrial accidents, and are responsible for a large portion of compensation expense. The human hand has been described as the most complex and intricate mechanism that exists. Through its exact mechanism and tissues of great delicacy and refinement, combined with the tough material of which it is composed mainly, the hand serves to provide man with certain knowledge and control of his environment by means of: l. Basic actions with their various modifications: (a) finger tip pinch - grasping a cube between thumb and index or all fingers (b) finger nail pinch - grasping a needle between thumb and index finger (c) lateral pinch - grasping the solid handle of a cup between thumb and radial side of the index finger (d) cylindrical grasp - finger and thumb enveloping a cylinder (e) ball grasp - thumb and all fingers encircling (f) hook or snap grasp - 4 fingers flexed as in carrying a suitcase 2. Sense of touch through which the hand adjusts to physical characteristics of: (a) texture - hard, soft, rough, smooth, pliable, rigid, slippery (b) position of object grasped (c) size and shape of object grasped (d) temperature Bunnell emphasizes that whenever possible a hand should be kept moving, in that hands are prone to stiffen, evidently because the joints are so accurately fitted together and there are more close fitting, gliding parts than elsewhere in the body. "Occupational therapy" writes Bunnell (1), "is of real benefit in reconditioning crippled hands. It should commence soon after the wounds have healed and be continued until the patient is ready for work ••• The tasks prescribed should be of interest to the patient ••• Improvement on use is a natural response to voluntary activity ••• Herein lies the superiority of occupational therapy ••• " Bunnell goes on to say- "Often the badly 32

crippled hand becomes disassociated from the brain and the patient actually inhibits all motions of his injured hand ••• Such a candidate for occupational therapy will, in his response to his interests and desire to work, gradually use his hand and will then find that he can use it ••• Any light occupation with his hands, such as modelling or painting, will serve to reconnect the hand to his brain. Later he may change to occupations of real exercise." And further, "An hour a day of occupational therapy is not of much use. It should be continued all day. It is by repeated motions and continuous use that the hand improves." (For chart of activities see Bunnell: Surgery of the Hand, page 314) (b)

Craft Craft is defined as "skill or ingenuity, especially in the manual arts, and it is applied to the trade or profession in which such skill is displayed; to an association of workmen of a particular trade; a trade gild (guild)." It should be emphasized that the importance of learning handcraft techniques is for two purposes: 1. As a tool of treatment. 2. To gain knowledge of, and skill necessary to use tools and materials. It is the manipulation of tools and materials, not the finished product, that constitutes the treatment tool, and only when the therapist knows through her own experience the feel of the tool, can she accurately analyze its use. The particular tool or technique selected for treatment depends on the immediate need of the patient. For example, a hammer is a striking tool. Striking is used in planishing copper or silver, in driving nails, in driving railroad spikes. The range and power involved in striking varies with the size and weight of the tool, the resistance of the force which is struck, and the position of the patient in relation to his work. This is what the knowledge of tools implies for the occupational therapist. Reference 1. Bunnell, S.: Occupational Therapy of Hands. Am.J.Occup.Therapy.4:4. July/Aug. 1950 33

E. Industrial Skills and/or Tool of the Trade It is interesting to note that the term "tool of the trade" first became official occupational therapy terminology at the Workmen's Compensation Board Clinic in Toronto, in 1936.

Tool of the trade is defined as "Tools, materials, working requirements, on a level with that required in industry."

In treatment these provide a psychologically realistic media of treatment, and provide the only valid testing media for the industrial accident case. Obviously no therapist can be master of a trade, nor is this necessary. But she must know the use and handling of the basic tools and materials, as well as the requirements on which jobs are founded. In woodwork and metalwork for example, she learns the use and handling of hand and power tools, which tools require strength, which.coordination and skill, which joints come into action etc. The therapist does not teach a man his trade; he already knows it. But she provides, at the appropriate time, the best possible means for him to regain the necessary skill, control, endurance, and pattern of movement which he requires. Similarily, the therapist does not train a client in a new job or trade. She provides the test and practice situation to demonstrate his potential ability with given tools, materials, work situations, etc., and observes his attitude toward this line of work. Gordon and Wellerson (1) state: "It is to be emphasized that the use of modern occupations is not for the purpose of training a patient for a vocation. We feel that he can more readily accept those media, exploited primarily for functional exercise and pre-vocational training, which are in keeping with his own sense of work." And further, "It follows that the type of work therapy chosen must satisfy the functional, psychological and vocational requirements of the situation ••• If the chosen medium of work satisfies merely the functional requisites of the disability, the patient may reject it on psychological grounds because it does not conform to his acquired work habits." 34

Reference 1. Gordon, E.E. & Wellerson, T.L.: Does Occupational Therapy Meet the Demands of Total Rehabilitation? Am.J.Occup.Therapy, 8:6 NovDec. 1954.

35

F. Writing and Ty:ping Wr_g_!.!_lg Impairment or loss of ability to write results from various types of trauma which may occur to certain areas of the brain, the spinal cord, and/or hand and arm. The motor pattern of writing is a skill associated with the dominant hand; thus in many cases the factor of dominance will be present. Understanding of the brain processes and the motor patterns involved in handwriting is of major importance to the occupational therapist. Disturbance in these areas is present in an appreciable number of cases for whom her treatment procedures are deeply concerned. In many of these cases her work will be closely coordinated with that of the speech pathologist, while in others it is a part of training in AOL, for obviously a patient who requires assistance in feeding 'himself is likely to need help in writing. Thus in the area of assistive devices, a useful variety of writing devices have been developed. (1) (2) (3). Following are some of the more commonly met problems: (a) Impairment or loss of the motor pattern. Motor function necessary for hand writing consists of holding the writing implement, pressure on the implement, and its movement on the paper to form letters or symbols. While this motor pattern varies with the individual, in general it can be described as a digital holding, with motion occurring at the proximal interphalangeal joints, and/or slight flexion of the wrist and/or elbow (4). Impairment of one or both components of the motor pattern may result from poliomyelitis, rheumatoid arthritis, osteoarthritis, contractures, etc. Assistive devices are freouent°ly valuable in these cases. These will vary from the simple opponens splint (5) to the aluminum platfonn on ball bearing casters designed by Gingras and Hardy (6); from the intricately fitted hand shell designed by Zimmerman (1) to the head band (1). The upper extremity amputee, dominant side, is also included in this group. When amputation has occurred below the elbow, a number of therapists, experienced in pre-prosthetic and prosthetic training programmes, favour writing as one of 36

the first skills to be learned by the patient, using the prosthetic cuff (7). ~any of these patients learn to write well with the pencil held in the terminal device. While some authorities feel that the writing skill should be retained on the dominant side whenever possible, the majority are of the opinion that the patient should make this decision for himself. The patient with multiple sclerosis nay lack control of the writing pattern due to tremor. Some interesting studies carried on at the Kabat Kaiser Institutes in the United States are described by Whitaker (8). These studies indicate that: a) the resistance needed to control the intention tremor can be provided while allowing for free mobility of the arm; b) 11 • • • the writing pattern can be improved without actual writing practice, which tends to tense the patient and bore him." Free painting with tempera poster colour was found to be effective as a substitute for writing practice. (b) Brain Damage This group of patients presents an important and interesting challenge to the occupational therapist. Examples include: (i) Hemiplegia: When damage has occurred in the dominant hemisphere, the patient should be taught to write with the unaffected (subdominant) hand. As speech is involved in these cases, the work of the speech pathologist and of the occupational therapist should be closely coordinated. McGeachy (9) considers that writing should start early, and that the occupational therapist is " ••• probably better able to teach this skill than the average speech therapist. Depending upon the cortical damage sustained, the patient's inability to speak may be reflected in his writing. It is important that he learn to write, both because it removes one disability and because it reinforces his total language recovery." (ii) Cerebral Palsy: In treatment and training of the cerebral palsied, writing is usually started by the occupational therapist. With these children, writing presents a combination of basic motor learning with the development of intellectual and perceptual abilities. Handicap in these areas should be recognized in the areas of training which usually precede writing both chronologically

37

and mentally, i.e. dressing, eating, and very noticeably in the child's attempts to use toys and play materials. 'fhus the therapist is in a unique position to prepare the child for education in the class room. Detailed material on this area is described by Robinault (10), Rood (11), and in a group study of writing techniaues for the cerebral palsied ( 12).

Strauss and Lehtinen (13) emphasize the importance of writing in the development of visuo-motor perception in the brain injured child, and the close relationship between writing and learning to read. All brain injured children are not cerebral palsied. But while the severe motor involvement is not present, equally difficult perceptual problems may exist which are reflected in writing. Left Handed Writing Much of the anticipated awkwardness of learning to write with the left hand can be avoided by following the instructions clearly outlined by Gardner in his instruction manual Left Handed Writing (14). While the majority of adult patients will reouire instruction in the first few steps only, some may require the step by step progression which would be followed in learning to type. Typing The typewriter has long been recognized as an important piece of occupational therapy equipment. In fact, most therapists consider it to be basic equipment in practically every disability field. As eauipment, the typewriter is 'understandable' and acceptable to most patients. Thus it freauently provides a motivation to activity which is psychologically valuable. Typing is one of the few activities which provide individual and equal action for all ten digits. Equally important therape~tically, the typewriter can be operated by substitute methods including hand-grip typing sticks or a mouth-grip stick. Driver and Bennett (15) consider that, "With accurate planning of typing material the activity is an excellent medium for muscle reeducation ••• Although these techniques are in constant use in the treatment of poliomyelitis they are proving to be of ecual value with other neuro-

36

muscular disorders." Based on extensive experience, these authors have outlined an analysis of typing and its application in the treatment of the poliomyelitis oatient, including the equipment and assistive devices used. This material is comprehensive and well organized. For the cerebral palsy child who is mentally educable and physically capable of attending school, the typewriter is often the most practical means of written expression (12). Typin~ may increase the vocational potential of some of these patients in adult life. Unfortunately, suitable employnent for the majority of these people is limited. For the bilateral arm amputee typing is used in both pre-prosthetic and prosthetic traininv,, and continues to be of practical value particularly for those equipped for office or 'white collar' employment. References 1.

2.

3. 4.

5. 6.

7. 8.

New York University - Bellevue Medical Center: Self-Help Devices for ~ehabilitation. Dubuoue, Iowa. W.C. Brown Co. Publishers, 195$. Cerebral Palsy Eouipment. National Society for Crippled Children and Adults, Inc. Chicago. Svensson, V.W. and Brennan, M.C.: The Opponens Splint. Am. J. Occup. Therapy, 7:2, ~ar./April 1953. Zimmerman, M.E.: Analysis of Adapted Eouipment. Am. J. Occup. Therapy, 11:4, July/ Aug. 1957. Silverstein, F.: Occupational Therapy and the Hand Splint. Am. J. Occup. Therapy, 7:5, Sept./Oct. 1953. Gingras, G. and Hardy, G.: Contribution of Occupational Therapy in the Rehabilitation of Quadriplegic Patients. Can. J. Occup. Therapy, 14:3, Sept. 1947. Kessler, H.H.: Principles and Practices of Rehabilitation. Philadelphia, Lea and Febiger, 1950, p. 238. Whitaker, E.W.: A Suggested Treatment in Occupational Therapy for Patients with 1-iultiple Sclerosis. Am. J. Occup. Therapy, 4:6 Nov./Dec. 1950.

39

9. 10. 11. 12. 13 . 14. 15.

McGeachy, D.J.: The Role of the Occupational Therapist in the Rehabilitation of Speech. Can. J. Occup. 'fherapy, 23:2, June 1956. Robinault, I.: Perception Technics for the Preschool Cerebral Palsied. Am. J. Occup. Therapy, $:1, Jan./Feb. 1954. Rood, M.S.: Writing Training as a Treatment Procedure for Cerebral Palsy Patients. Stanford Univ. Libraries, (Interlibrary Loan Service), Stanford, Calif. The Teaching of \'iriting to Cerebral Palsy Patients. Am. J. Occup. Therapy, 7:6, Nov./Dec. 1953. Strauss, A.A. and Lehtinen, L.E.: Psychopathology and Education of the Brain-Injured Child. New York, Grune and Stratton, 1947, chap. 12. Gardner, W.: Left Handed Writinr,, Instruction ~~nual. rev. ed., Danville, Ill., Interstate Pub., 1945. Driver, M.E. and Bennett, H.L.: The Application of Typing in the After-Care of Poliomyelitis, Can. J. Occup. Therapy, 23:2, Sept. 1956.

40

G. Recreational Activities Recreational Theraby According toavis (1), "Recreational therapy may be defined as any free, voluntary and expressive activity; motor, sensory or mental, vitalized by an expansive play spirit, sustained by deep rooted pleasurable attitudes and evoked by wholesome emotional release ••• " Davis further states that it is lt••• above all a feeling process, a psychological phenomena ••• Equally true is the concept of recreational therapy as a doing process." It is prescribed by medical direction as an adjuvant in treatment. The various recreational activities must be structured to produce a therapeutic experience for the patient; therefore they are chosen for their specific therapeutic value to the individual patient. More important than the activity is the emotional atmosphere in which it is carried on, and the relationship established between patient and therapist. The way in which an activity is used and the purpose it is made to serve may vary considerably. For example, dependin~ upon the atmosphere created by the therapist, playing tennis becomes: - an outlet for aggressive feelings - a gratifying experience in learning a new skill - a spo~t to be practised and perfected by a compulsive person - for an impulsive, anti-social person, an experience in adapting to authority, following prescribed rules. (2) Recreational therapy, as distinguished from remedial games, is directed to treatment of the psychiatric patient and to those for whom the psychological effect of the activity is of primary importance. It has been noted that the majority of psychiatric patients respond most readily to sensory stimuli of the visual type, and will repeat movements performed in their presence, whether of the individual or the group. Recognition of the significance of some form of 're-creation' as a necessary part of daily life has become increasingly important in our present day machine age. The increasing technological advances in industry are tending more and more to: - minimize the personal gratification of many

41

jobs - reduce the amount of interpersonal contact within the work situation, for example the assembly line, the supermarket, the automat - increase the amount of leisure time - limit the opportunity for creativeness in many jobs. (2) Remedial Games Remeditlgames are defined as 'simply and commonly used games involving physical activity, in which equipment and/or method of playing is adapted as treatment of physical disability.' Blau (J) divides such games into two categories: 1. Those planned for their "specific kinetic value, highly individualized and preferably played with the therapist who manipulates in such a way that the patient is encouraged to strive against and to excel the therapist." 2. "Group games played among patients with the direct supervision and active participation of therapist." In addition to the kinetic value, other values are promotion of socialization, creation of alertness, improvement in speech and increased attention span. Boeshart and Blau (4) note that remedial games provide: (a} rhythmic contraction and relaxation of muscles (b) coordination (c) adequate range of motion of joints (d) graded resistance (e} interest and competition ( f) minimum preparation In most part they are used: 1. In early treatment: - to mobilize stiff joints - to strengthen weak muscles - to re-establish neuro-muscular coordination 2. In middle and advanced stages: - for gradation of resistance The degree to which kinetic games are beneficial depends upon the proper analysis and application of the game selected. Most games are extremely adaptable and may be played in a variety of ways. Substitution of motion must be prevented by proper positioning of the patient, clear in-

42

struction and suoervision. Examples of the motions involved in some ' commonly used games are given in Dunton and Licht: Occupational Therapy..,_~r-~nciples ~nd Practice, pages 94-97.

Play

In spite of the fact that the meaning of 'play' to the child differs from the meaning of 'recreation' to the adult, both have an equally strong emotional accompaniment and individuality of expression and performance which distinguishes them from other forms of human activity. It is for this reason that 'play' has been placed under the general heading of 'Recreational Activities'. Play is the adult's term for the occupations and activities of children, thoueh to the child, play is a serious business at which he works with effort. Play includes the activities, toys and materials which are recognized as the natural media for the child. For all children, toys and play provide a direct, non-verbal· mode or channel of communication and emotional expression. Hartley, Frank and Gold ens on ( 5) have pointed out that: "For the very young the proximity senses of smell, taste, and touch tend to be more important than the distance senses of sight and hearing • •• that for the child, his body is an organ of expression as well as of perception, and that his attitudes toward himself and the world about him are expressed in the way he uses his body more fully than in his verbalizations.n Treatment of the adult patient is in the main directed toward restoration of capacities previously acquired but which through disease or injury have been lost or diminished. For the sick child, however, it is the development of a capacity or capacities that hav~ been delayed or prevented. Hence, in the treatment of the child the therapist must understand not only the nature of the specific disability and its results, but also the developmental level at which this interruption has occurred. Gesell (6) describes the development or growth of the child as a patterning process both physically and mentally. It is essential, therefore, that the occupational therapist be familiar not only with the development of control and use of the head, trunk and limbs, but also with the seouence of development of the more intricate pat-

43

terns of the hands, fingers, sensory perceptions, language, intelligence, adaptive and social behaviour. Each and all of these follow an orderly plan. Limitation in attention span of the normal child varies not only with age level but with the individual child; hence variety and change in activity are essential. This is even more important with the sick child, particularly those suffering from certain types of trauma. Control of activity is frequently of major importance in treatment of the sick child, but the type and purpose of the control may vary. For example: - it may be reduction in the amount of activity and limitation of the type of activity for the child with rheumatic fever, where the aim is relatively complete rest, but the disease itself does not immobilize the child. - it may be directed toward maintaining a given amount of daily expenditure of physical energy while a diabetic child is under observation in the hospital. In both these situations, control must be carefully set up in a manner acceptable and appropriate to the child. References 1.

2.

J.

4. 5. 6.

Davis, J.E.: in Occupational Therapy, Principles and Practice. 2nd ed. ed. Dunton, W.H. and Licht, S. Springfield, Ill. Chas. C. Thomas 1957. pp. 101-102. Stachowiak, J.G.: Recreational Therapy. Am. J. Occup. Therapy 11 :4, July/Aug. 1957. Blau, L.: in Occupational Therapy, Principles and Practice. 2nd ed. ed. Dunton, W.R. and Licht, S. Springfield, Ill. Chas. C. Thomas 1957, pp. 92-93. Boeshart, L. K. and Blau, L.: Remedial Games as an Occupational Therapy Modality in Treatment of Physical Disabilities. Am. J. Occup. Therapy, 5:2, Mar./Apr. 1951. Hartley, R.E., Frank, L.K., Goldenson, R.M.: Understanding Children's Play. Columbia University Press. Gesell, A. et al: The First Five Years of Life. New York Harper & Bros. 1940 44

H. Cultural and Educational Music In music we find a universal language, a heritage common to man. Throughout the ages, the histories of all cultures from the primitive tribe to modern times, of the religions and of medicine indicate an age old recognition that music exerts certain effects upon the human being. In the early history of medicine the healing effects of music were noted. In fact, the use of music for this purpose is considered by many to be as old as the history of music itself. "Music is not something which we merely hear but it is something we feel. It is an emotional experience ~hich results in response both physical and mental." (l) These physical and mental responses to music can be utilized therapeutically as follows: a. Physiologically, music can stimulate or relax various body processes such as metabolism, blood pressure, response to voluntary activity. Precision is increased by accompaniment of appropriate rhythm. b. Psychologically, attention is attracted and its span is increased; self control is subconsciously induced by the discipline of rhythm; imagination is stimulated. c. Emotionally, music is a powerful agent in creating and changing mood; emotions and drives can be released in a socially acceptable manner. For example, the emotional response to martial music, to church music, to the dance band, are easily recognized in others and in ourselves. d. Socially, music produces a feeling of well being and acceptance through the relaxation of tension. Thus it creates rapport between those with little in common. As a treatment medium, music can provide active participation or passive participation on the part of the patient. It can be used in treatment of the individual or as a group medium. Over a considerable period of time the value of music as a treatment medium in occupational therapy has been demonstrated and has received approval of physicians in the following areas: a. Emotional and psychological disorders in both adults and children. {l) (2) 1.

45

b.

Physical disabilities such as facial paralysis (3), following plastic surgery of the face, respiratory conditions when exercise of the lungs is indicated, in the re-education of muscle and patterns of co-ordination. c. rreatment and training of the cerebral palsied (4) and other patients suffering from brain damage, for example the aphasic patient. In addition to these specific uses, music has therapeutic values in what is termed 'hospital management' of patients, particularly those who reouire prolonged care. In this area special training in music is not necessary, provided the leader has knowledge of the patients' musical preferences and can thus provide suitable material. Finally, it is interesting to note the use of music in certain medical centres before, during and after surgery, E.C.T., etc. References 1. 2. 3. 4.

Kingsmill, E.: Music as Therapy. Can. J. Occup. Therapy, 22:3, Sept. 1955. Van de Wall, W.: Music as a V~ntal Discipline. Arch. of Occup. Therapy, vol. 2, Feb. 1923. Beals, R.G.: A Study of Occupational Therapy in Bell's Palsy. Am. J. Occup. Therapy, 5:5, Sept./Oct. 1951. Snow, W.B. and Fields, B.: Music as an Adjunct in the Training of Children with Cerebral Palsy. Occup. Therapy and Rehab., 29:3, June 1950.

2.

Art The forms of art referred to in this section, and which are those most commonly used as treatment media, are two creative forms - painting and modelling. Art, like music, is a universal form of expression. It is a creative outlet in which individuality is expressed and from which one achieves a certain kind of satisfaction independent of a utility or practical value. There are different theories as to why primitive man first decorated various objects with paintings and drawings which in no way increased their usefulness. Some consider that this was man's basic desire for self-expression from which he achieved personal pleasure.- Others suggest that he first decorated his possessions to gain admiration from others. This latter theory may explain why many people express the desire to paint but are reluctant to attempt it. They fear that their efforts will not gain the admiration of nor give pleasure to others. Yet if the manual or manipulative side of painting is examined, we see that actually it demands far less coordination and dexterity than, for example, watchmaking, engraving or typesetting. Manual skills are learned by practice and persistent effort. In art, however, the learning of rules and the practice in their application play but a minor part. It is the imagination, the intellectual appreciation of the sense of balance, of colour, of form, combined with the drive to express something, that distinguishes the artist from the artisan. In the creative or expressive arts the 'censor' too often plays an inhibiting role. Thus, in treatment of certain psychiatric disorders, painting and modelling become media of expression acceptable to the patient above other forms. An example is the dethroning of the censor in the manic patient. In his excellent text book, Haas (1) has described a manic patient who had had no previous training or experience in art. With the unquestioning self-confidence, lack of inhibition, and disregard of the possibility of criticism of his efforts which are characteristic of the manic, this man painted with skill and a display of artistic ability. But as he began to recover, his freedom of expression and his self-confidence in

47

oerformance, i.e. handling the brush, diminished as self-censorship of his work returned. In the deeoly inhibited patient and the sensitive Psychoneurotic patient.we find that painting and modelling, for example, are outlets for expression of the thoughts, feelings and drives which the oatient is unable and/or unwilling to express v·erbally. Thus the censor, though resented, retains power over the more customary form of verbal communication, is by-passed, and-the patient achieves expression through these other channels of communication. One other type of psychiatric patient for whom expression through the materials of art is important, is the regressed patient. Here we see the patient returning to the early language of the child which precedes his development of useful langua~e and writing with any degree of success. For a considerable time, painting with varicus media, finser nainting, and modelling have been used under direction of the osvchiatrist to oroV:ide diagnostic material. Wittkower and Johnston (2) describe thi use of art " ••• as a device to exolore Preconscious and unconscious processes and to observe changes in personality structure under treatment." Thus it is apparent that in psychiatric occupational therapy, the function of the therapist· is not to teach art but to provide the patient with an opportunity for an emotional experience, the results of which are both therapeutic and revealing. From the field of physical disability, the following are a few examples of the therapeutic use of art: a. The hemiplegic patient with paralysis of the dominant hand frequently gains remarkable early success in oil painting and crayon colouring, for which he uses his sub-dominant hand. Though the affected hand may respond in varying degrees to treatment, it is generally accented that lead hand skill rarely returns. Therefore the sooner the skill of the unaffected hand is increased, the earlier and greater is the degree of independence achieved by the patient. Activities in which these patients can experience early accomplishment with the minimum sense of effort in the performance, are important in helping to reduce the frustration which is frequently

48

present. An interesting case is described by Owen {J) of an accomplished artist who became as adept in using his left hand as he had been previously with his right. b. In the treatment of median nerve lesions, Wynn Parry (4) includes finger painting among the activities which can be used about 24 days after suture, and later pottery to build up muscle strength. Painting, drawing and writing he considers to be contra-indicated due to the prolonged static holding of the thumb. He suggests the early use of pottery for radial nerve lesions, and to encourage use of the extensor d1gitorum in the case of lesion of the ulnar nerve. c. When there has been complete loss of all motor function, we have no better example of vocational rehabilitation than that of Earl Bailey, the well-known Canadian artist from Lunenburg, Nova Scotia. Completely paralysed as the result of poliomyelitis, Earl Bailey learned to paint in oils, holding his brush in his mouth*. The accomplishment of Bailey and others with extreme physical disability, seems to prove the statement that the skill of the artist lies not in the hand but in the head. * Note: One of Bailey's paintings was purchased by the National Gallery, Ottawa. Perhaps even more remarkable than his management of the brush, are the artist's beautiful lino print blocks which were cut with great precision and skill. References 1.

2.

J. 4.

Haas, L. J.: Occupational Therapy for the Mentally and Nervously Ill. ¥dlwaukee, Bruce Pub. Co., 1925. Wittkower, E.D. and Johnston, A.M.: New Developments In and Perspectives of Psychiatric Occupational Therapy. Can. J. Occup. Therapy, 25:1, ¥~rch 1958. Owen, T.: Occupational Therapy and Neurological Disorders. Can. J. Occup. Therapy 22:2, June 1955. Wynn Parry, C.B.: Rehabilitation of the Hand. London, Butterworth & Co. (Publishers) Ltd.,

1958. Pp. 88-90.

49

).

Academic

Study of academic and commercial subjects may constitute an important part of the rehabilitation programme of certain patients, particularily those within the age group in which education is normally gained. It is also indicated for patients whose employment potential will be increased by the development of latent aptitudes, i.e. oatients for whom change of vocation is indicated medically. Psychologically, the building or re-building of a sense of vocational capability may change the patient's whole attitude toward treatment. Education is a long-term process, therefore it provides a sustained motivation which is important for patients who are undergoing a prolonged period of hospitalization, extending over a period of months and .sometimes years. Examples include: the tuberculous, aphasic, children who require extensive orthopedic repair. For the psychiatric patient study of academic and commercial subjects provides mental discipline by utilizing the faculties of memory, concentration and reasoning. Pre-vocational assessment of the psychiatric patient equals in importance that of the physically handicapped. In the attempt to evaluate the patient's potentials for training, his mental acuity must be estimated. Teaching is, of course, a highly developed profession, and the addition of trained teachers to hospital staff has been welcomed by the treatment team. If academic education is to be part of the therapeutic process it must be coordinated with the total activity programme of the patient. Thus the place and contribution of education in treatment should be understood by all members of the team. Because the occupational therapist's contact with the patient occurs earlier, and is more prolonged than that of the t.eacher, the therapist is frequently in a position to introduce academic work in a form which the patient is ready to · accept and from which he will benefit. While most therapists are not prepared to carry out extensive academic teaching, they should know· the sources from which it is available. - In children's hospitals for example, the occupational therapist will frequently include school work in her pro50

gramme with the rheumatic fever child, and with the diabetic child whose total daily activity must be accurately watched and recorded. For further information and guidance on the indications and contra-indications for the use of academic study as a part of the therapeutic programme, the reader is referred to the text, "Occupational Therapy, Principles and Practice" by Dunton and Licht, chapter S.

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I. The Therapist The basic tool of treatment is the therapist. On her depends the success of any and all tools. Her ability to understand and to motivate the patient realistically is essential. Occupational therapy demands that the patient DO for himself. Berkeley (1) describes the voluntary effort of the patient as "the driving force of the programme." The therapist must do more than teach the patient how it is done, she must train him to do it by doing it himself. Therefore the patient must be motivated to DO, whether or not the therapist is there to urge him on. To accomPlish this the therapist must: 1. Know what the patient needs and what the patient thinks he needs. 2. See beyond the immediate goal of a recovered part, to the ultimate goal of the patient in his future life. J. Find a realistic medium and be skillful in adapting it if necessary, but still keep it acceptable to the patient. 4. Have sound medical knowledge combined with her own intelligence and observation, to provide treatment in a form best suited to the patient. There is no 'textbook list' for this. 5. Be continually alert to recognize whether the patient is progressing as an independent person or, as an obedient and conforming child, he is continuing to lean upon her. Huntting (2) writes " ••• it would seem that the therapist need put fully as much thought and effort into how he can use himself as a tool as in what activity he will use and how he is to grade it. I do not mean to minimize the need of planning and grading activity carefully, but rather to stress the fact that for each patient worked with there needs to be two tools- the activity and th.eself." "To know one's self," says Boynton (2}, "is certainly a major step ••• we must also know ourselves in relation to our patients." Boynton proceeds to draw an analogue between the function of the occupational therapist a~ she assists in the recovery process of the patient, and the function of a catalyst. "The therapist,, 11 Boynton continues, obviously

52

enters into the 'reaction' ••• He does not become a part of the final product but some of him is consumed in the process. He is not permanently changed and may be 'used' repeatedly in similar operationS•••'therapeutic catalysts' subtly but definitely change over the years with increasing skill and understanding, this process is one of maturation ••• " As there are different chemical catalysts so there are different types of occupational therapists, i.e. "those who are skillful in developing good interpersonal relationships with neuropsychiatric patients; those whose talents are most evident in working with brain-injured children; and those who are the ingenious gadgeteers who seem to have a limitless supply of useful adaptive devices to assist the disabled patient in achieving independence." The role of the occupational therapist is "essentially a catalytic relationship ••• We cannot properly become a pa.rt of the end result by virtue of the fact that our goal for the patient is to make him independent of us. Should dependency develop we have defeated our own purpose. Dependency on us is permissible during the recovery process but is hot desirable as the treatment periods draw closer to termination." The art of human relations, Bernhardt (4) maintains, can be learned. Through insight, not only into others but equally into ourselves, we can learn to deal more effectively with other people. How then doe~ the therapist learn to understand her patient? 1. By empathy, which is an attempt to see things as the patient sees them; to try to understand the patient's point of view. Consider the uncertainty and the fear which may be the patient's initial reaction to an entirely new situation. 2. By understanding the patient's motivation. He may verbalize very convincingly but his performance may belie his words. The reverse of course may be equally true. ~s the patient motivated to want recovery and self-dependence or does he, like Hamlet, prefer to ••• suffer those ills we have Than fly to those we know not of. J. By recognition and respect for the patient's goals - immediate, intermediate and ultimate. Are we attempting to appreciate the patient's goals, rather than to graft on our own ideas

53

of what he ought to accomplish? It is futile to explore vocational capacities for example, when the patient is unable to take care of his daily needs. So the wise therapist will first control and direct the patient. Then, like the pilot and his trainee, both must share the controls. Only when the controls are taken over by the patient himself is he exerting his maximum capacities to achieve his maximum success. References 1.

2.

3. 4.

Berkeley, J.: Assessment of the Injured Workman. Can.J.Occup.Therapy, 20:1, March 1953. Huntting, I.: The Importance of Interaction Between Patient and Occupational Therapist. Am.J.Occup.Therapy, 7:3, May/June 1953. Boynton, B.L.: Refining Our Resources. Am.J. Occup.Therapy, 8:2. March/April 1954. Bernhardt, K.S.: Human Relations. Can.J. Occup.Therapy, 22:4, Dec. 1955.

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SECTION VI PRE-VOCATIONAL EVALUATION Activities used for pre-vocational evaluation involve a sampling of actual jobs; the patient is tested for both the quality and quantity of his performance. In this manner his potentials can be matched against the standards used by the employer. The pre-vocational evaluation progratlnle brings the atmosphere of -the world of work to the patient. Therefore, in this situation actual working conditions should be simulated as realistically as possible. Because the occupational therapist has had particular experience in observing people at work, relating to others and to situations, her observations of the patient in the controlled work situation can add materially to the information concerning his vocational potentialities. Psychological tests make an important contribution but alone do not give complete information on the patient's actual performance and his reactions in work situations. Patients who have had little or nc work experience, or those for whom extreme changes in occupation are required, are assessed on several different jobs within the mental and physical capacity in which his employment is feasible. The type of jobs selected will differ to a certain degree in different communities, depending on local employment opportunities. The occupational therapist must therefore gain broad, over-all knowledge of job requirements and the demands of industry. 'Samples' of jobs appropriate for the evaluation programme are available from various sources. Fot- example: - subcontract worl(. may be obtainable from manufacturers. This work includes such operations as packaging by count or weight, small articles or materials (cup hooks, screws, thumb tacks, paper in assorted colours); assembling 'Do-It-Yourself' kits; machine stitching and bundling paper showerslippers, etc. - a series of sample projects may be selected which involve handling of the tools and materials commonly used in the production of a variety of commercial articles. The 55

procedures required in these test areas enable the therapist or the vocational supervisor to appraise fundamental hand skill, manipulation of gross and fine objects, the patients's reaction to noise, tempo, etc., his ability to understand and follow directions, etc. (1). This procedure has been successfully us~d at the Institute for the Crippled and Disabled, New York City. - any ingenious occupational therapist will find that she already has many potentials for such tests in her standard equipment and supplies. The concept of pre-vocational assessment or evaluation is not new, but increasing interest in· and recognition of its function in today's rehabilitation process is challenging. While its value and purpose are obvious in rehabilitation centres, it should not be limited to these. An outstanding example of the value of such a programme has been demonstrated at the Highland View Hospital, Cleveland, Ohio (2). Here a sheltered workshop has been developed in which the procedures of pre-vocational testing, sub-contract work, and carefully selected and adapted testing methods have been carried out with most gratifying results. All occupational therapists concerned with the needs of long term treatment and/or severely disabled persons should familiarize themselves with the illuminating material which has been published on this programme. The pre-vocational evaluation area has important implications also for those practising in the psychiatric field. Referring, for example, to the effects of the ataraxic drugs, Scheeley (3) states: "More pati_ents will be ready medically to return to the community. Many of these patients were in their teens when they became ill and were admitted to the hospital. They never learned a trade. Others ••• have forgotten their trade ••• The occupational therapist will, therefore, have more patients taking the first steps toward a trade or a skill. Occupational therapy will be expected to serve as the gateway to industrial therapy, vocational training and vocational placement." Work Tests and Assessment The best test of work capacity is work itself. Tolerance for work can be measured by the 56

patient's reaction to work, which can be of prognostic and rehabilitative value. In these situations the occupational activities should be carefully selected to provide, as far as possible, a reality situation which is comparable to the future vocation or avocation of the worker. "The use of occupational therapy to develop work tolerance in a controlled situation has long been recognized in the treatment of tuberculosis cases. It is well recognized in the field of industrial injuries where the patient must be graded up to activity eauivalent to that of his job. It is of equal importance for cardiac patients and many others with debilitating conditions." (4) The terms Work Test and Work Assessment are both used in the final stages of the physical medicine programme. An example of these procedures in the field of industrial accidents and outlined by Hood (5), is taken from the program.~es of the Ontario Workmen's Compensation Board Rehabilitation Centre, Malton, and of the Vancouver Workmen's Compensation Board Clinic, Vancouver, B.C. A Work Test is ordered by the doctor on the presumption that the patient will return to his former job or some soecific job. The occupational therapist therefore keeps this job in mind when setting up and directing the Work Test. The Test takes approximately five days during which the patient carries out t1.~ specified programme for six hours daily. Other physical medicine treatments are discontinued during the Test. In this trial situation, the occupational therapist observes the patient's performance, recording speed, coordination, attitude, pain, and any other pertinent factors. As all tools and eouipment cannot be duplicated, the therapist must at times improvise and borrow from other trades, using tools which give similar movements and- require approximately the same degree of physical capacity and performance. She must learn to understand the reauirements of many types of work, tools used, physical strength-required, and working conditions. !_IJ.9rk Asses~_!Tient. The occupational therapist proceeds on the understanding that because of the degree of remaining disability, the patient must be placed in another tYPe of job.

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Therefore his physical capacity must be measured and charted, as a guide in selecting other suitable employment. This Assessment generally takes about three days to complete. Here the occupational therapist is attempting to assess the physical capacity of the patient by observing and charting how long he can stand, how far he can walk, what weights he can carry, how long he can sit, etc. The findings are charted on a special form and may be used by the doctor and the rehabilitation officer, as a guide to helping the patient return to suitable employment. References 1. 2.

J.

4. 5.

The Pre-vocational Unit in a Rehabilitation Center. Office of Vocational Rehabilitation, Washington, D.c. Izutsu, S. : A Sheltered Workshop in a Hospital Setting. Can. J. Occup. Therapy, 26:1, March 1959. Scheeley, W.: The Ataraxic Drugs and Occupational Therapy. Am. J. Occup. Therapy, 11:4, July/Aug. 1957. Soackman, c.s. and Willard, H.S.: in The Handicapped and Their Rehabilitation. ed. H.A. Pattison, Springfield, Ill. Chas. C. Thomas, 1957. p. 443. Hood, M.: Occupational Therapy - Work Tests and Assessment. Can. J. Occup. Therapy, 2J:2, June 1956.

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CONCLUSION In the last analysis, successful rehabilitation can be achieved only when eaual attention is given to both the disabilities and the capabilities of the patient. It might even be said, that emphasis on the importance of an individual's capabilities is one of the major contributions of the rehabilitation concept. The craftsman of the Uiddle Ages was not only a master of a tool, he was master of his trade. Thus he had the skill to adapt or devise ways in which to meet the particular problem at hand. The tools of occupational therapy are the tools of daily living, the tools of accomplishment. Properly selected and adapted, these tools provide treatment of the disability, and at the same time utilize the capabilities cf the patient. As the tool must be carefully selected, so must the instrument to measure the tool's effectiveness be carefully selected, and the specific point which represents capability marked on the measure. To locate this point correctly demands understanding of the total individual. It is here that the science of treatment must be combined with the perspective of the artist. '£his whole philosophy has been so well expressed by Rusk (1) that it is fitting to conclude with it. "Society only pays for two things: the skill in your hands and what you have in your head. But I am afraid we have carried out subconsciously through the generations - a strong mind in a strong body. To be able you must be physically able. Nothing could be more fallacious. Everyone knows that the average person only uses a fraction of his physical capacity in daily living because with modern transportation and modern technology it is not necessary to use more. We have forgotten the fact, however, that you don't have to run a foot race or play tennis or be violent in sports to be the finest doctor, lawyer, diamond cutter, clerk, elevator operator or one of the thousand occupations, yes a thousand times ten thousand occupations, and yet only until recently have we begun to feel the actuality of the situation. Once you understand it, you realize that the normal person is often handicapped because of the fact that we do not use all our capacities and ~he other people 59

with handicaps must use them and develop them to their full capacity ••• "It was beautifully expressed to me recently in my own country by a friend who said: 'You know, I think if you analyze the whole problem critically and philosophically, you will find it is the so-called normal who are handicapped. ~le are handicapped because we have never had to go through the heat of the kiln. Fine china is not made by putting clay in the sun. It is only when it goes through the heat of the kiln and once it passes the firing test it is no longer clay but porcelain. Unfortunately, because of the fact that some of us have not had to work to our capacity, we remain unbaked or partially baked clay, when a crisis might have made us porcelain'." Reference 1.

Rusk, H.A.: in Proceedings of the 6th World Congress, I.S.W.C. 1954, p. 213.

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