AOTA T H E A M E R I C A N O C C U P A T I O N A L T H E R A P Y A S S O C I A T I O N

Reducing Hemiplegic Shoulder Pain

UE Function & Home-Based CIMT

Stroke & Ankle Foot Orthotics

Community Integration

& More

PLUS

OCTOBER 8, 2012

Occupational Therapy News Going Beyond the Vote: AOTPACContinuing EducationEmployment Opportunities

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AOTA • THE AMERICAN OCCUPATIONAL THERAPY ASSOCIATIONV O L U M E 1 7 • I S S U E 1 8 • O C T O B E R 8 , 2 0 1 2

FEATURES

Shoulder Pain and Stroke 9 Reducing Hemiplegic Shoulder Pain Through Practical Handling SkillsJan Davis provides guidance for occupational therapy practitioners on

reducing the incidence of shoulder pain in their poststroke clients.

Improving 14 Upper Extremity Function Through a Home-Based Modified Constraint-Induced Movement Therapy ProgramEllen Herlache, Donald Earley, Jill Ewend, Alissa Pasant, Caleb Johnson, Chelsea Schwab, Nicole Farrand discuss

the benefits of home-based therapy for increasing the use of upper extremities poststroke.

DEPARTMENTSNews 3

Capital Briefing 6AOTA to Cast Historic Shadow on Capital

Careers 7Stroke and Ankle Foot Orthotics: An Entrepreneurial Solution

Perspectives 19Promoting a Renewed Focus on Community Integration for Stroke Survivors

Calendar 22Continuing Education Opportunities

Employment Opportunities 27

Questions and Answers 32Rebecca Dutton

OT PRACTICE • OCTOBER 8, 2012, 2012

SPECIAL

Going Beyond the Vote: 21 Support AOTPAC Today!

• Discuss OT Practice articles at www.OTConnections.org in the OT Practice Magazine Public Forum.• Send e-mail regarding editorial content to otpractice@aota.org. • Go to www.aota.org/otpractice to read OT Practice online. • Visit our Web site at www.aota.org for contributor guidelines, and additional news and information.

OT Practice serves as a comprehensive source for practical information to help occupational therapists and occupational therapy assistants to succeed professionally. OT Practice encourages a dialogue among members on professional concerns and views. The opinions and positions expressed by contributors are their own and not necessarily those of OT Practice’s editors or AOTA.

Advertising is accepted on the basis of conformity with AOTA standards. AOTA is not responsible for statements made by advertisers, nor does acceptance of advertising imply endorsement, official attitude, or position of OT Practice’s editors, Advisory Board, or The American Occupational Therapy Association, Inc. For inquiries, contact the advertising department at 800-877-1383, ext. 2715.

Changes of address need to be reported to AOTA at least 6 weeks in advance. Members and subscribers should notify the Membership department. Copies not delivered because of address changes will not be replaced. Replacements for copies that were damaged in the mail must be requested within 2 months of the date of issue for domestic subscribers and within 4 months of the date of issue for foreign subscribers. Send notice of address change to AOTA, 4720 Montgomery Lane, Suite #200, Bethesda, MD 20814-3449, e-mail to members@aota.org, or make the change at our Web site at www.aota.org.

Back issues are available prepaid from AOTA’s Membership department for $16 each for AOTA members and $24.75 each for nonmembers (U.S. and Canada) while supplies last.

Chief Operating Officer: Christopher Bluhm

Director of Communications: Laura Collins

Director of Marketing: Beth Ledford

Editor: Ted McKenna

Associate Editor: Andrew Waite

CE Articles Editor: Maria Elena E. Louch

Art Director: Carol Strauch

Production Manager: Sarah Ely

Director of Sales & Corporate Relations: Jeffrey A. Casper

Sales Manager: Tracy Hammond

Advertising Assistant: Clark Collins

Ad inquiries: 800-877-1383, ext. 2715, or e-mail sales@aota.org

OT Practice External Advisory Board

Donna Costa: Chairperson, Education Special Interest Section

Michael J. Gerg: Chairperson, Work & Industry Special Interest Section

Dottie Handley-More: Chairperson, Early Intervention & School Special Interest Section

Kim Hartmann: Chairperson, Special Interest Sections Council

Gavin Jenkins: Chairperson, Technology Special Interest Section

Tracy Lynn Jirikowic: Chairperson, Developmental Disabilities Special Interest Section

Teresa A. May-Benson: Chairperson, Sensory Integration Special Interest Section

Lauro A. Munoz: Chairperson, Physical Disabilities Special Interest Section

Linda M. Olson: Chairperson, Mental Health Special Interest Section

Regula Robnett: Chairperson, Gerontology Special Interest Section

Tracy Van Oss: Chairperson, Home & Community Health Special Interest Section

Jane Richardson Yousey: Chairperson, Admin-istration & Management Special Interest Section

AOTA President: Florence Clark

Executive Director: Frederick P. Somers

Chief Public Affairs Officer: Christina Metzler

Chief Financial Officer: Chuck Partridge

Chief Professional Affairs Officer: Maureen Peterson

© 2012 by The American Occupational Therapy Association, Inc.

OT Practice (ISSN 1084-4902) is published 22 times a year, semimonthly except only once in January and December, by The American Occupational Therapy Association, Inc., 4720 Montgomery Lane, Suite #200, Bethesda, MD 20814-3449; 301-652-2682. Periodical postage is paid at Bethesda, MD, and at additional mailing offices.

U.S. Postmaster: Send address changes to OT Practice, AOTA, 4720 Montgomery Lane, Suite #200, Bethesda, MD 20814-3449.

Canadian Publications Mail Agreement No. 41071009. Return Undeliverable Canadian Addresses to PO Box 503, RPO West Beaver Creek, Richmond Hill ON L4B 4R6.

Mission statement: The American Occupational Therapy Asso-ciation advances the quality, availability, use, and support of occupational therapy through standard-setting, advocacy, edu-cation, and research on behalf of its members and the public.

Annual membership dues are $225 for OTs, $131 for OTAs, and $75 for student members, of which $14 is allocated to the subscription to this publication. Subscriptions in the U.S. are $142.50 for individuals and $216.50 for institutions. Subscrip-tions in Canada are $205.25 for individuals and $262.50 for institutions. Subscriptions outside the U.S. and Canada are $310 for individuals and $365 for institutions. Allow 4 to 6 weeks for delivery of the first issue.

Copyright of OT Practice is held by The American Occupational Therapy Association, Inc. Written permission must be obtained from the Copyright Clearance Center to reproduce or photo-copy material appearing in this magazine. Direct all requests and inquiries regarding reprinting or photocopying material from OT Practice to www.copyright.com.

Focus onSTROKE

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Occupational Therapy in Acute CareEdited by Helene Smith Gabai, OTD, OTR/L, BCPR

Occupational Therapy in Acute Care is designed specifically for therapists work-ing in a hospital setting to acquire better knowledge of the various body systems, common conditions, diseases, and pro-cedures. Students and educators will find this new publication to be the most use-ful text available on the topic.

The book features color illustrations of the human body’s systems and functions, as well as tables delineating the signs and symptoms for various diseases.

Read Up on Occupational Therapy in a Hospital Setting

Order #1258 AOTA Members: $109Nonmembers: $154

To order, call 877-404-AOTA, or visit http://store.aota.org/view/?SKU=1258

BK-289

AOTA CEonCD™An Occupation-Based Approach in Postacute Care to Support Productive Aging

Authors: Denise Chisholm, PhD, OTR/L, FAOTA; Cathy Dolhi, OTD, OTR/L, FAOTA; and Jodi L. Schreiber, MS, OTR/L

With contributions from Genesis Staff: Susan M. LaCroix, MS, OTR/L; Bronwyn Keller, MS, OTR/L; and Jeanne Coviello, OTR/L

Earn .6 AOTA CEU (7.5 NBCOT PDUs/ 6 contact hours).

Enjoy the portability of this CEonCDTM. CDs will play in DVD players.

KEY STRATEGIES FOR EXCELLENCE IN POSTACUTE CARE

Order #4875 AOTA Members: $210, Nonmembers: $299

To order, call 877-404-AOTA, or visit http://store.aota.org/view/?SKU=4875

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3OT PRACTICE • OCTOBER 8, 2012

N e w sAssociation updates...profession and industry news

AOTA News

Register for AOTA’s Stroke Specialty Conference

If you work with older adults, be sure to attend the AOTA Adults With Stroke Specialty

Conference, to be held from November 30 to December 1 in Baltimore, Maryland. An estimated 5.4 million people in America live with the disabling effects of stroke, and that number is predicted to increase as the population ages. Occu-pational therapy helps those recovering from a stroke resume valued activities through a holis-tic approach to intervention. Join keynote speaker Carolyn Baum, PhD, OTR/L, FAOTA, and other renowned experts offering comprehensive sessions, while earning up to 13 contact hours (1.3 CEUs/13 NBCOT PDUs). Register now at www.aota.org/confandevents/stroke.

Sign Up for Student Conclave

Occupational therapy students and soon-to-be new practitioners can get

a head start on a successful career by attending the 2012 AOTA/NBCOT National Student Conclave, to be held from November 9 to 10 in Columbus, Ohio. For more information, or to register, go to www.aota.org/confandevents/conclave. The Conclave will provide attendees with evidence-based knowledge about current issues and emerg-ing practice areas, exclusive opportunities to speak with leaders and experts, opportuni-ties to meet with job recruiters and have résumés critiqued, and much more.

Attention Students

Interested in being a student leader on the national level? Run for a position on AOTA’s

Assembly of Student Delegates. The deadline to apply is Octo-ber 22. For more, visit www.aota.org/students/asd.

Chats Ahead

Know someone interested in joining the occupational therapy profession? Direct

him or her to AOTA’s prospec-tive student chats this fall, to be held on October 17 and November 15 at 7 p.m. EST. To participate or listen to archived chats, head to www.aota.org/students. Meanwhile, AOTA’s next pediatric chat, OT Excellence in the Inclusive Classroom: The ASD Nest Model, will be held October 19 at 2:30 p.m. EST. For more, visit www.talkshoe.com/tc/73733.

AOTA Award Nominations Deadline Approaching

The AOTA Recognitions Committee encourages you to recognize colleagues

who have made significant con-tributions to the profession by nominating them for one of the awards offered by the Associa-tion each year. The deadline to submit nominations is October 25. Description of the awards, nominations forms, FAQs, and the general point system can be found on the AOTA Web site under Practi-tioners/Professional Develop-ment/Awards or www.aota.org/practitioners/profdev/awards. Questions can be directed to awards@aota.org.

AOTA Hosts 2nd Annual Leadership Development Program

AOTA recently brought together a select group of occupational therapy man-

agers from around the country to discuss professional leader-ship strategies and tactics, in a 3-day program at its headquar-ters in Bethesda, Maryland. “Cultivating Your Power and Influence: The AOTA Leader-ship Development Program for Managers,” held from Septem-ber 11 to 13, included partici-pants from Alaska to Alabama working in settings from public health to pediatrics, with a range of experience levels.

The meeting’s agenda, facilitated by Maureen Peterson, MS, OT/L, FAOTA, AOTA’s chief professional affairs officer, included discussion on leadership formation, values, and sustainability that was led by AOTA Vice Pres-ident Ginny Stoffel, PhD, OT, BCMH, FAOTA, and Nancy Stanford-Blair, PhD; a seminar on power and confidence led by AOTA President Florence Clark, PhD, OTR, FAOTA; and a presentation on strategic planning by Brent Braveman, PhD, OTR/L, FAOTA. Speakers also included Sue Bowles, OTD, MBA, OTR/L; Christina Metzler, AOTA’s chief public affairs officer; and Chris Bluhm, AOTA’s chief operating officer.

For more on the pro-gram, including a listing of all the participants, go to http://aota.org/practitioners/resources/leadership-develop-ment-program-for-managers/leadership-development-2012.

Industry News

Manual Medical Reviews began October 1

The Middle Class Tax Relief and Job Creation Act of 2012 requires that

outpatient therapy claims of more than $3,700 ($3,700 for occupational therapy services, and $3,700 for physical therapy and speech-language therapy services combined) be subject to manual medical reviews. Last month, the Centers for Medicare & Medicaid Services announced that reviews would begin on October 1. Occupa-tional therapy practitioners providing services to Medicare beneficiaries will be affected, including those working in private practice, Part B skilled nursing facilities, home health agencies (TOB 34X), rehabil-itation agencies (outpatient rehabilitation facilities), and comprehensive outpatient reha-bilitation facilities.

For updates, visit www.aota.org/news/advocacynews.

A World of Opportunity for Occupational Therapy

world Occupational Ther-apy Day 2012, on October 27, is an opportunity

to promote and celebrate the global profile of the profes-sion. For ideas on ways to take part, check out www.wfot.org/resourcecentre.aspx. A related initiative, the OT Global Day of Service (OTGDS), calls for occupational therapy practition-ers and students to volunteer a small amount of time to promote

4 OCTOBER 8, 2012 • WWW.AOTA.ORG

the profession. The World Federation of Occupational Therapists is partnering with www.promotingot.org to support OTGDS. In addition, OT4OT (www.ot4ot.com) is hosting an OT 24-Hour Virtual Exchange from October 29 to October 31 (depending on participants’ locations). The virtual exchange is a way for occupational therapy practitioners around the globe to share ideas about occupational therapy practice, education, and research.

New AOTPAC Chair

Gail Fisher, MPA, OTR/L, is the new American Occu-pational Therapy Political

Action Committee (AOTPAC) chair. Learn more about Fisher by visiting www.aota.org/practi tioners/advocacy/aotpac/news/new-chair.

AOTF Co-sponsors Workshop to Develop Senior Services

seven occupational therapists sponsored by the American Occupational Therapy Foun-

dation (AOTF) participated in a 3-day workshop organized by The Evangelical Lutheran Good Samaritan Society’s Vivo: Inno-vation for Well-Being to develop new services for seniors and their families. The 3-day work-shop, held in Omaha, Nebraska, involved nearly 60 individuals organized into four design teams who were challenged to imagine creative new ways for address-ing age-related issues such as isolation, dementia, and informal caregiving. The Good Samaritan Society, which is the largest nonprofit provider of senior care and services in the United States, plans to apply the concepts in developing services for a 20-acre mixed-use site under devel-opment in Papillon, Nebraska. The event was co-sponsored by AOTF and AIGA-Nebraska—the

Nebraska chapter of AIGA, which was originally founded as the American Institute of Graphic Arts. The AOTF-sponsored par-ticipants were Julie Bass, PhD, OTR/L, FAOTA; Charles Christian-sen, EdD, OTR, FAOTA; Lisa Ann Fagan, MS, OTR/L, CALA; René Padilla, PhD, OTR/L, FAOTA; Dory Sabata, OTD, OTR/L, SCEM; Patricia Schaber, PhD, OTR/L; and Catherine Sullivan, PhD, OTR.

Resources

What Is OT?

w ant to help others under-stand OT? The new AOTA What Is Occupa-

tional Therapy? brochure is a valuable resource for consumers and other professionals to better understand the role of occupa-tional therapy and the important service it provides for people with injuries, disabilities, and illness. For more, search “What is OT?” on the AOTA store at myaota.aota.org/shop_aota/index.aspx.

Health Care Changes and State Essential Health Benefits

The Affordable Care Act requires that everyone in the United States have health

insurance beginning in 2014. To facilitate this, the law also calls for the establishment of state-run health insurance purchasing “exchanges” to help improve insurance access, choice, cost, and coverage. Qualified insur-ance plans participating in these exchanges are required to cover, at a minimum, a package of “essential health benefits,” and AOTA helped ensure that reha-bilitation and habilitation were included. AOTA has also been working with state associations to keep them updated on the law’s implementation. For details about essential health benefits

A O T A B u l l e T I N B O A r d

Ready to order? Call 877-404-AOTA or go to http://store.aota.orgEnter Promo Code BB

Questions? Call 800-SAY-AOTA (members); 301-652-AOTA (nonmembers and local callers); TDD: 800-377-8555

Occupational Therapy Practice Guidelines for Adults With StrokeJ. Sabari

Details the significant contribu-tion of occupational therapy

in treating adults with functional limitations after stroke. Appendixes

include valuable resources, such as CPT™ codes relat-ed to occupational therapy for stroke survivors.

$59 for members, $84 for non-members. Order #2211. http://store.aota.org/view/?SKU=2211

Screening Adult Neurologic Populations: A Step-by-Step Instruction Manual, 2nd EditionS. Gutman & A. Schonfeld

Provides detailed steps for cognitive, functional-visu-

al, perceptual, sensory, motor, cerebellar function, cranial nerve function, neuropathy and peripheral

nerve function, and dysphagia screening, as well as a new section on mental status. Each chapter has

screening forms that can be printed from the enclosed CD. This book is ideal for occupational therapy stu-dents and remains an essential tool for clinicians working in community and home health settings.$59 for members, $84 for nonmembers. Order #1226A. http://store.aota.org/view/?SKU=1226A

Bulletin Board is written by Amanda Fogle, AOTA marketing specialist.

OUTSTANDINGRESOURCES

FROM

Using the Occupational Therapy Practice Guidelines for Adults With Stroke to Enhance Your Practice(CEonCD™) J. SabariEarn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours).

Course participants will learn key considerations for occupational

therapy inter-vention, whether their clients are in the acute phase after stroke, the

rehabilitation phase, or the con-tinuing adjustment phase. Findings from published research that guide best practice in occupational therapy intervention with the stroke population are presented. For those interested in this area of practice, Occupational Therapy Guidelines for Adults With Stroke is essential reading.$68 for members, $97 for non-members. Order #4845. http://store.aota.org/view/?SKU=4845

Hand Rehabilitation: A Client-Centered and Occupation-Based Approach (CEonCD™) D. AminiEarn .2 AOTA CEU (2.5 NBCOT

PDUs/2 contact hours).

Covers best practices for

evaluating clients, creating occupational profiles and occupation-focused interventions, and setting short- and long-term goals. Includes case examples to illustrate clinical application.$68 for members, $97 for non-members. Order #4832. http://store.aota.org/view/?SKU=4832

6 OCTOBER 8, 2012 • WWW.AOTA.ORG

c a p i t a l b r i e f i n g

OTA has been working diligently throughout 2012 to expand its reach and presence on Capi-tol Hill. Attendance at AOTA’s annual Capitol Hill Day in Washington, DC, has grown by more than 400 participants over the past 5 years, with attendance at the latest Hill

Day, on September 24, totaling more than 500. In addition, local universities within driving distance of the capitals of New York, North Carolina, Ohio, and other states have scheduled their own Hill Days with the help and support of AOTA Federal Affairs staff.

This year, AOTA’s advocacy on the ground in Washington was emphasized by two Congressional briefings that helped educate Congress about the scope and breadth of the profession of occupational therapy. In May, AOTA held the first ever Congressional brief-ing on occupational therapy mental health practice, featuring AOTA Vice President and President-Elect Ginny Stoffel, PhD, OT, BCMH, FAOTA. The briefing was well attended by Con-gressional staff and advocates from the American Psychiatric Association, the Mental Health Liaison Group, and the Consortium for Citizens with Disabilities, who learned details about occupational therapy’s contributions to the treatment and recovery of people with mental health conditions. More recently, AOTA partnered with the American Physical Therapy Asso-ciation (APTA) and the American Speech-Language-Hearing Association (ASHA) to organize and present a Congressional briefing sponsored by Representative Mike Michaud (D-ME) on the value of rehabilitation for veter-ans and wounded warriors, including

many recovering from traumatic brain injury and posttraumatic stress disor-der. The briefing provided clinicians representing AOTA, APTA, and ASHA with the opportunity to highlight to Congressional staffers the role each profession plays in helping wounded warriors.

Although Congressional briefings are a high-level format for educating members of Congress and their staff, there is no grassroots activity more valuable than an energetic, passionate, and well-attended Hill Day. Every year, AOTA works to facilitate the ability of AOTA members to come to Capitol Hill with their peers and advocate collectively in support of occupational therapy and to drive AOTA’s legislative agenda forward. Successful advocacy combines grassroots action and a direct lobbying presence in Washing-ton, which for occupational therapy is provided by AOTA’s Federal Affairs staff and its key advocacy consultants. Both aspects, grassroots and direct lobbying, depend on each other to achieve maximum success. Although Federal Affairs staff pride themselves on the knowledge and passion with which we represent the profession on Capitol Hill, nothing can take the place of constituents like you taking the time and initiative to come to Washington to advocate for yourselves and the clients you serve.

AOTA’s members are the best advo-cates and representatives of occupa-tional therapy. Your personal stories of challenge, perseverance, and success with your clients make the best arguments for the profession. Because member advocacy is the key to AOTA’s continued and expanding presence and success on Capitol Hill, we are

announcing the “50 for 50 Campaign” for 2013.

“50 for 50” will be focused on deliv-ering an advocate from every state to Washington, DC, for AOTA’s Capitol Hill Day in fall 2013. Although attendance at Capitol Hill Day has grown seven-fold over the past 5 years, we have yet to achieve participation from more than 37 states. Next year, AOTA is engaging in an effort to ensure there is represen-tation at Hill Day from every state in order to truly maximize our advocacy footprint on Capitol Hill. To achieve this goal, AOTA will need the support of all 50 of its affiliated state associations, and the hundreds of schools of occupa-tional therapy and student associations across the country. From doctorate programs to occupational therapy assis-tant programs and every other program in between, we can together raise the funds and provide other resources needed to ensure someone from every state can come to Washington to be the voice of occupational therapy. Collectively, we can achieve this goal and bring 50 for 50 to Capitol Hill.

More information will be forthcom-ing about the 50 for 50 Campaign. In the meantime, AOTA will be working with affiliated state associations, student associations, and the schools of occupational therapy in every state to ensure we reach this critical and ambitious goal. Together we can bring something special to fruition in 2013 and ensure that we expand the reach of AOTA’s advocacy on the Hill more than ever before. For more information on our advocacy efforts, visit http://capwiz.com/aota.

See you in Washington! n

Tim Nanof is AOTA’s director of Federal Affairs.

AOTA to Cast Historic Shadow on Capital

Tim Nanof

c A p I T A l B r I e f I N G

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C a r e e r s

am a polio survivor. I’m also a dreamer. Perhaps that’s why over the past 2 decades in my career in the rehabilita-tion profession, I have tried my best to develop innovative ways for my clients to complete meaningful tasks that are problematic for them due to their dis-ability. Since I was 4 years old, I have not had the use of my right shoulder due to the effects of polio. As an inquisitive child, a blossoming adoles-cent, a young adult, and now an active senior, I have stockpiled an arsenal of strategies that have facilitated my life’s journey while living with a disability. As a therapist, I have shared many of these strategies with those under my care.

I’ve always had a dream of inventing something that could change the life of at least one person. This is my story of how my dream, plus one challenge, created a life-changing moment for a client.

My career in the rehabilitation profession as both an occupational therapist and a physical therapist assistant has given me the opportunity to work with clients ranging in age from birth to end of life—many of whom have personally touched my life. However, one in particular, a person recovering from stroke, gave me the opportunity to make a real difference in his.

For many people recovering from stroke, the occupational performance area of lower body dressing—specifically, independently donning an ankle foot orthosis (AFO) and shoes—is quite daunting. Throughout my years of practice, when it came time to assist a client with hemiplegia with donning an AFO, I would often say (with some frustration in my voice), “I wish someone would make something

that would hold the AFO in an upright position so you could easily slip your foot into it before it falls over.”

Joe was a 35-year-old male who had a stroke that resulted in right

hemiplegia. He lived alone and was determined to be totally independent with his dressing. Although Joe was making marvelous progress with his upper body dressing, he was unable to independently don his AFO and shoe. In my experience, both occupational therapists and physical therapists have found the task of donning an AFO with one hand to be particularly problematic. Joe was so determined to succeed with this task that he challenged me to make something that would help him achieve his goal. It was his challenge that re-ignited my dream to make something that could change someone’s life for the better.

I went home that evening and searched for items in my garage that could be used to keep an AFO in a stable position to allow placement of the foot using a one-handed approach. Lo and behold, I spotted a plastic mitre box (yes…that’s the box a carpenter uses to cut special angles in wood). It was light enough to easily maneuver and wide enough to accommodate Joe’s AFO, and its flat bottom would keep it stable during the donning process. With some minor adjustments, I was excited that this first prototype would be successful.

The following morning, Joe arrived in the gym and I couldn’t wait to begin our training. As he sat in his wheelchair watching me, I demonstrated for him how to use the device using only one hand. While seated in a long-sitting position on the mat, I placed the adapted mitre box near my foot and positioned the AFO within the mitre box. I then used a leg lifter to lift and place my leg into the AFO. Success! Needless to say, I was thrilled, and Joe couldn’t wait to try his luck at it.

Stroke and Ankle Foot OrthoticsAn Entrepreneurial Vision

Diane Vitillo

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November 9–10, 2012 • Columbus, OhioAs an occupational therapy student and soon-to-be new practitioner, you have already started setting up the field goals for your career. The 2012 AOTA/NBCOT National Student Conclave is a terrific opportunity for you to know how to score those points and be an OT pro!

Here’s why you should attend—

• Evidence-based knowledge about current issues and emerging practice areas

• Exclusive opportunities to speak with leaders and experts

• Perfect chances to meet with job recruiters and have your résumé critiqued

• Important information on the NBCOT certification exam

• Super networking with peers from your school and across the country

Register today at www.aota.org/conclave!

2012 AOTA/NBCOT National Student

Conclave

®

Go For Your Career Touchdown!

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He was successful on his first attempt and his smile said it all.

On the days that followed, Joe and I discussed my plans to add another design feature to this device. The current design allowed him to don the AFO while in a long-sitting position. But what about clients who preferred to sit at the edge of the bed or in their favorite chair to don the AFO? Back to the drawing board for me! I now enlisted the help of my husband (an engineer by trade and a skilled craftsman) to come up with a design that would allow the AFO to articulate from the originally designed long-sitting position to either a 90° or 45° angle, depending upon the client’s donning preference.

The design of this device evolved over many months of beta testing a prototype (made from wood and PVC) not only with clients recovering from stroke but also with clients who had other medical conditions that warranted the use of an AFO for safe ambulation.

My dream of becoming an inventor came true, but, more importantly, my dream of changing the life of at least one person, Joe, became a reality. n

Diane Vitillo, MS, OTR, PTA, is the owner of Home

Heart Beats, LLC and the inventor of The Original AFO

Assist (patent pending). Home Heart Beats provides

evaluative home assessments to clients who wish to

successfully and safely age in place. For more informa-

tion, contact Vitillo at homeheartbeats@comcast.net or

visit www.homeheartbeats.com.

The device can be used to facilitate the donning of different types of foot orthotics.

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Become a Member

AOTA’s Online CommunityCONNECTIONS

www.otconnections.org

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Reducing Hemiplegic Shoulder Pain Through Practical Handling Skills

ne day, as I was walk-ing through the din-ing room of a rehab center, I overheard a

physician tell a family member, “Shoulder

pain is one of those things that goes along with having a stroke.” I nearly stopped in my tracks. I was shocked and saddened at the same time. But not surprised. I used to feel the same way before I learned how to prevent shoulder pain.

Many years ago, our inpatient rehab center was experiencing the same problem. Nearly half of our clients who were recovering from stroke experi-enced debilitating shoulder pain at the time of discharge. We tried everything we could think of, reviewed the liter-ature, and consulted physicians, but nothing seemed to make a difference.

Then I took courses from master clinicians who provided the in-depth knowledge and practical handling skills I needed to be successful. I learned how the structures of the shoulder were compromised following a stroke, how to prevent trauma, and specific handling methods for preparing the upper extremity for skilled function. I took meticulous notes, practiced the clinical skills in class, and returned to work to give it a try. The results were immediately evident. Not only did fewer of my clients complain of pain, but those with pain began to improve.

KNOWLEDGE + IMPROVED CLINICAL SKILLS = REDUCTION OF SHOULDER PAINAs I shared my new skills with col-leagues (occupational therapy, physical therapy, and nursing), we saw the incidence of shoulder pain decrease dramatically within our facility. Within a year, the incidence of hemiplegic shoulder pain (HSP) at our center dropped from nearly 50% to less than 15%, by just changing the way we handled, moved, and positioned our clients. Within 2 years we had almost eliminated HSP altogether. I began to wonder: Had we been contributing to HSP, unknowingly, all along? As years went by and other members of the rehab team were trained and began to use these methods, the evidence became clear: HSP can be reduced when proper handling methods are used to treat clients recovering from strokes. I am convinced that with a bet-ter understanding of the shoulder com-plex and improved clinical skills, other occupational therapy practitioners can also dramatically reduce the incidence of HSP in their treatment settings.

HSP INTERFERES WITH QUALITy OF LIFEHSP is reported to affect anywhere between 7% and 88% of all persons poststroke.1 HSP can adversely affect a client’s entire therapy program as well as his or her overall quality of life.2 A client with a painful shoulder may have difficulty sleeping, require pain medica-tion, and refuse to get out of bed or get dressed.3 Poststroke clients in acute care, rehabilitation, or skilled nursing settings may choose not to participate in occupation-based activities due to the severity of their shoulder pain.4 Therefore, it is extremely important for occupational therapy practitioners to be up to date on current evidence, hone their clinical skills, and implement effective treatment programs to pre-vent hemiplegic shoulder pain.

But there is much controversy and confusion about managing the hemiplegic

Guidance for occupational therapy practitioners on reducing the incidence of shoulder pain in their poststroke clients.

JAN DAVIS

Shoulder Pain and Stroke

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shoulder. Occupational therapy prac-titioners today face a dilemma in trying to determine the evidence and best practice for treating HSP. A full literature review can be an overwhelm-ing and daunting task, as it entails reading through hundreds of articles, many with opposing views and each supported with evidence. Numerous studies address questions related to HSP such as: Does subluxation cause shoulder pain? Should slings be used? What are the causes of HSP? With an abundance of research, but few practical guidelines for intervention, even well-informed therapists often look elsewhere for guidance in deter-mining effective therapeutic treatment methods based on evidence.

I encourage occupational therapy practitioners to implement an evi-dence-based approach using their own clinical experiences. Sharpen your observation and handling skills. Expand your knowledge. Reevaluate your client. Do you observe any changes? At the end of every treatment session, you should be able to observe positive changes. Every practitioner should be able to see, however small, changes that demonstrate effectiveness during each treatment session. If no mea-surable changes are observed, then your handling methods and treatment plan must be modified. If occupational therapy practitioners are to be effective change agents in treating clients with stroke, we must have the clinical skills to make a difference.

POSSIBLE CAUSES OF HEMIPLEGIC SHOULDER PAINOur first experience with HSP may begin with a client clutching his or her shoulder, or it may be initiated by a physician’s referral. Next we’re con-fronted with the big question, “What do I do?” For occupational therapists to determine the most effective plan of treatment, an accurate clinical diagnosis of the source of the shoulder pain should be made. Unfortunately, this is difficult for physicians to do. Multiple impairments related to stroke, such as sensory, motor, and language deficits, along with the complexity of the shoulder structures, can make it difficult to get an accurate diagnosis. Physicians typically order an x-ray,

but the results are often inconclusive. Problems involving soft tissue typically do not show up on an x-ray, and most physicians decide that expensive tests (such as MRI or arthrogram studies) are not warranted for a painful upper extremity that is also nonfunctional.

Consequently, physicians and prac-titioners are at a loss of how to proceed and often fall back to “old ways of practice” based on common misconcep-tions. For decades, the HSP spotlight has been on glenohumeral subluxation as the major source of pain, with reduc-ing subluxation a treatment priority. In fact, no fewer than 19 studies have been published on the association between shoulder subluxation and pain (eight studies supported the role of subluxation in pain, and 11 studies did not support the role of subluxation in pain).1

This is where a review of the most current literature can be extremely helpful. Fortunately for all of us, Robert Teasell, MD, and his team have cre-ated an excellent resource, available on the Internet (www.ebrsr.com), that reviews, summarizes, and provides conclusions based on a comprehensive

review of evidence related to stroke. Included in the review are lists of the possible sources of HSP, such as muscle imbalance, spasticity, trauma of the rotator cuff, humeral fracture, bursitis, tendonitis, glenohumeral subluxation, adhesive capsulitis, and reflex sympa-thetic dystrophy.1

Contrary to what many occupational therapy practitioners have learned in the past, the evidence does not support subluxation of the glenohumeral joint as the primary source of hemiplegic shoulder pain. The strongest evidence, according to Teasell’s team at www.ebrsr.com, supports the following conclusion: “Although many etiologies have been proposed for hemiplegic shoulder pain, increasingly it appears to be a consequence of spasticity and the sustained hemiplegic posture.”1

Based on the current evidence, occu-pational therapy practitioners should focus on the following guidelines to get a head start on reducing the incidence of shoulder pain in their setting:

1. Develop an in-depth understand-ing of the shoulder complex.

2. Know what to avoid.3. Learn advanced clinical skills.

Don’t force range of motion (ROM).

When performing passive or active ROM, range only to the point of resistance or discomfort. Any resistance against shoulder flexion or abduction can be an indication that the scapula is not gliding. Discomfort can indicate trauma or impingement to the soft tissue structures of the joint.

Never use reciprocal overhead pulleys. The evidence strongly concludes that using reciprocal overhead pulleys markedly increases the incidence of painful shoulders.

Do not raise the arm in flexion or abduction (past 90˚) without external rotation of the humerus and scapular gliding.

ROM is safe as long as the scapula is gliding and the humerus is in external rotation.

Never pull on the hemiplegic arm to help move a client. Place your hand on the trunk or scapula when helping a client transfer or stand up. Pulling on the involved arm can easily cause a traction injury.

Avoid placing your hands under the client’s arms. Lifting or repositioning a client under the arms can put the shoulder structures at risk for impingement.

Avoid static positioning of the upper extremity (UE) in internal rotation and adduction.

The use of slings, or any device that maintains internal rotation and adduction while sitting in a chair or resting in bed, contributes to soft tissue tightness and shortened muscle length.

Avoid strapping the UE to an arm trough. A weak arm strapped to an arm trough is at risk for impingement and traction injury. For clients attempting to stand or who have poor postural control, that “slide” down in their wheelchair while their arm is strapped to an arm trough can cause an impingement through malalignment of the glenohumer-al joint.

Figure 1. Key Points to Remember

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Understanding the shoUlder ComplexThe shoulder is one of the most com-plex structures in the human body, made up of seven joints that need to work synchronously in order to have full, pain-free range of motion.5 An in-depth understanding of how the shoulder structures work can help in understanding the importance of proper alignment and its role in pre-venting shoulder pain.

The scapula has three primary planes of motion: elevation/depression, protraction/retraction (also referred to as scapular abduction/adduction), and upward rotation/downward rotation.

Most functional movements require a combination of all three planes of motion. There are 16 muscles that attach to the scapula, and care must be taken to maintain full excursion in order to maintain mobility and avoid impingement.

Every time clients are handled, they are at risk for injury. Even well-inten-tioned health care providers or family members can unknowingly cause trauma to the shoulder. Moving clients incorrectly (such as taking hold of their arm to help them out of a chair) or poor positioning (an arm trapped or pinned beneath them) can contribute to impingement and HSP. Aggressive

therapies and range of motion (ROM) performed incorrectly are also sources of HSP.1 Avoid the use of inappropriate exercise equipment, such as overhead pulleys, as there is strong evidence that they contribute to a markedly increased incidence of shoulder pain.1 For more on proper handling, see Figures 1 and 2 on pp. 10 and 11.

learn advanCed CliniCal skillsNew practitioners, afraid of hurting their clients, may avoid handling the shoulder altogether. Don’t let fear keep you from using the clinical skills nec-essary to prevent shoulder pain. Learn how to mobilize the scapula and move the arm correctly, avoiding trauma to the shoulder and better preparing the upper extremity (UE) for functional gains. Develop sharp observation skills. Learn to evaluate tone of the UE. Always work within a pain-free range.

As treatment begins, I ask my clients for feedback: “If anything hurts or is uncomfortable, let me know.” If your client expresses pain or discomfort, discontinue the movement and deter-mine the source of the pain. Ask, “Is it a pulling pain or a stabbing pain?” A sharp pain may indicate an impingement or problem with alignment. A pulling pain can be more indicative of soft tissue tightness due to immobilization.3 Pain, whether caused by impingement or soft tissue limitation, can interfere with daily care activities such as brushing hair (shoulder external rotation with abduc-tion), dressing, or any overhead activity.

Practitioners should focus on main-taining muscle length through scapular mobilization and ROM, most specifically on the muscles that contribute to spas-tic internal rotation and adduction of the arm: the subscapularis, pectoralis major, teres major, and latissimus dorsi. “Shortened muscles inhibit movement, reduce range of motion, and prevent other movements especially at the shoulder where external rotation of the humerus is necessary for arm abduc-tion greater than 90˚” (p. 14).1

Your hands should be firm but never forceful. Pain or discomfort can be an indication of impingement or trauma to the shoulder structures. For optimal alignment of shoulder structures, be sure your client is in a good starting position. In sitting, position the client

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Figure 2. protecting the hemiplegic shoulder

proper Bed positioning (1)Although supine is the most common position, the most therapeutic position for clients poststroke is sidelying on the hemiplegic side. Make sure your client is lying on the scapula and not on the head of the humerus. A fully protracted scapula feels smooth along the thoracic wall, not “winged,” and is comfortable for the client.Watch the video: http://www.icelearning-center.com/bed-positioning-involved-side.

proper Wheelchair positioning (2)Good seating allows for better alignment of the entire shoulder girdle and reduces the possibility of impingement. Use a seat insert to provide a good base of support and reduce a posterior pelvic tilt. Position the arm on a lap tray or half lap tray if your cli-ent exhibits problems of edema or neglect.

moving in and out of the Wheelchair

(3,4) When transferring clients, helping them stand, or repositioning in the wheel-chair, always assist through the scapula and trunk. Never pull on the involved arm.

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Figure 3. Scapular Mobilization

Starting Position:

Position the client with the feet flat on the floor and pelvis in a neutral position (not in a posterior pelvic tilt).

Elevation and Depression: (1, 2)

1. Cup your hand and place it over the head of the humerus. Don’t apply pressure on the head of the humerus; apply pressure with the heel of your hand on the pectoralis, medial to the humeral head.

2. Place your other hand along the medial and inferior border of the scapula. Use the heel of your hand, not your thumb, to cradle the inferior border of the scapula.

3. Bring your elbows down to your side. You will have more strength and protect your wrists by keeping them in good alignment.

4. Apply pressure through the heels of both hands and bring the entire shoulder girdle into elevation.

5. Elevate the scapula to end range (or the point of discomfort). Hold for a few seconds and allow it to return to a resting position. It may feel heavy or tight. With repetition the movement will get easier.

Variations: Position your patient in supine or sidelying (on the strong side) if your client is unable to sit unassisted, has poor trunk control, or has an extremely heavy arm.

Watch the video: http://www.icelearningcenter.com/mobilizing-scapula-elevation.

Protraction (scapular abduction) and Retraction (scapular adduction) (3)

Handling:1. Stand in front of your client.2. Gently take the hemiplegic arm and bring it into forward flexion of less than 90˚.3. Support the arm at the elbow and tuck it along your side. This helps to keep it in

neutral and doesn’t allow it to fall into internal rotation.4. With your other hand, reach along the scapula and find the medial border. With a flat

open hand, press along the medial border and glide the scapula forward into protrac-tion. Do not hook your fingers around the scapula.

5. Maintain protraction for a few seconds and then allow the scapula to return to the resting position.

6. As the scapula returns to its resting position, allow it to follow the natural curvature of the rib cage.

Variations: If you client has poor trunk control, use a supine or sidelying position. (4)Watch the video: http://www.icelearningcenter.com/mobilizing-scapula-protraction.

Upward Rotation (5)

Handling:1. While the scapula is forward in protraction, slide one hand from the client’s scapula to

the elbow and use a lateral grip to hook onto the epicondyles. This will keep you from grasping and stimulating the biceps.

2. Slide the other hand from the elbow to the client’s hand (as if you were shaking hands).

3. Put your middle finger along the base of the metacarpophalangeal joints, your index finger along the thenar eminence, and your other fingers along the client’s fingers.

4. Keeping the arm in forward protraction, give a slight amount of external rotation and gently bring the arm past 90˚ and into forward flexion.

5. Remember: Go only to the point of resistance or discomfort and no further.6. Carefully watch the client’s facial expression for any signs of discomfort.

Tip: If your client does not have full range of motion in scapular excursion, check the other shoulder. The non-affected side may also have a loss of range that is unrelated to the stroke.

Watch the video: http://www.icelearningcenter.com/mobilizing-scapula-upward-rotation.

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with the feet flat on the floor and pelvis in a neutral position (not in a posterior pelvic tilt).

Mobilization begins with scapular elevation—it is safe, does not cause impingement, and helps you evaluate excursion of the scapula. Is there any resistance? A scapula that has been immobilized may feel tight and, if there is an increase in tone, you may feel resistance against movement. In con-

trast, a flaccid or low tone arm will feel heavy but the scapula will glide easily.3

After the scapula is gliding in elevation, carefully bring the arm into forward flexion, no more than 90˚. With your hand on the scapula, glide the scapula forward into protraction. Never pull on the humerus to bring the scapula forward; use only the scapula. With repetition, the scapula will begin to glide more easily. Mobilizing the

scapula in upward rotation, the third plane of motion, is last. Only when the scapula has been prepared and glides in elevation/depression and protrac-tion/retraction can upward rotation of the scapula be attempted. For step-by-step instructions, see Figure 3 on p. 12.

SummaryThe incidence of shoulder pain in clients who have had a stroke can be dramatically reduced. Clients who are managed correctly can avoid many of the painful syndromes that frequently occur during recovery, allowing for greater participation in activities of daily living (ADLs) and instrumental ADLs and improved quality of life. Each and every person working with the cli-ent, including all practitioners, nurses, family members, and caregivers, should be trained in protecting the shoulder from injury. Occupational therapy prac-titioners, with skilled expertise and an in-depth knowledge of the shoulder complex, can take the lead in training staff, educating families, and empower-ing patients in properly managing and caring for the hemiplegic shoulder. n

references1. Teasell, R., Foley, N., & Bhogal, S. K. (2011).

EBRSR: Evidence-based review of stroke reha-bilitation, module 11: The painful hemiplegic shoulder. Retrieved from http://www.ebrsr.com/uploads/Module-11_hemiplegic-shoulder.pdf

2. Chae, J., Mascarenhas, D., Yu, D. T., Kirsteins, A., Elovic, E. P., Flanagan, S. R.,…Harvey, R. L. (2007). Poststroke shoulder pain: Its relationship to motor impairment, activity limitation, and quality of life. Archives of Physical Medicine and Rehabilitation, 88, 298–301.

3. Davis, J. (2009). Teaching independence: A ther-apeutic approach to stroke rehabilitation (2nd ed.). Port Townsend, WA: International Clinical Educators.

4. Jonsson, A., Hallstrom, B., Norrving, B., & Lind-gren, A. (2007). Prevalence and intensity of pain after stroke: A population-based study focusing on patients’ perspectives. Journal of Neurology, Neurosurgery and Psychiatry, 77, 590–595.

5. Cailliet, R. (1980). The shoulder in hemiplegia. Philadelphia: F. A. Davis.

6. Davies, P. (2000). Steps to follow: The compre-hensive treatment of patients with hemiplegia (2nd ed.). Heidelberg, Germany: Springer-Verlag.

Jan Davis, MS, OTR/L, is president of International

Clinical Educators. She specializes in creating state-

of-the-art training materials filmed with real patients

and real therapists. For more information, go to

www.icelearningcenter.com or e-mail jandavis@

icelearningcenter.com.

F O R M O R E I N F O R M A T I O N

resources for Stroke: http://www.aota.org/Con-sumers/consumers/Adults/Stroke.aspx

Functional Treatment Ideas & Strategies in Adult Hemiplegia (2nd ed.). By J. Davis, 2009. Port Townsend, WA: International Clinical Educators. (Earn 1.5 CEUs [18.75 NBCOT PDUs/15 contact hours]. $195. To order, call toll free 888-665-6556 or shop online at http://www.icelearningcenter.com.)

Teaching Independence: A Therapeutic Approach to Stroke Rehabilitation (2nd ed.). By J. Davis, 2009. Port Townsend, WA: International Clinical Educators. (Earn 1.5 CEUs [18.75 NBCOT PDUs/15 contact hours]. $195. To order, call toll free 888-665-6556 or shop online at http://www.icelearningcenter.com.)

Treatment Strategies in the Acute Care of Stroke Survivors. By J. Davis, 2007. Port Townsend, WA: International Clinical Educators. (Earn 1.5 CEUs [18.75 NBCOT PDUs/15 contact hours]. $195. To order, call toll free 888-665-6556 or shop online at http://www.icelearningcenter.com.)

CD Course. ASHT Management of Upper Extremity Problems: Cadaver Demonstrations and Thera-peutic Management. By P. Bonzani, D. Kline, K. Landrieu, M. Robichaux, & H. Stokes. Mt. Laurel, NJ: American Society of Hand Therapists. (Earn .6 AOTA CEU [6 NBCOT PDUs, 6 contact hours]. $70 for members, $95 for nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=4851. Order #4851. Promo code MI)

DVD: Basics and Beyond: Everything You Need to Know—Shoulder To Finger: Part 1 (CHT Prep Course). By N. Falkenstein & S. Weiss, 2011. St. Petersburg, FL: Treatment2Go. (Earn 3 AOTA CEUs [30 NBCOT PDUs, 30 contact hours]. $399 for members & nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=4858A. Order #4858A. Promo code MI)

CD: Basics and Beyond: Everything You Need to Know—Shoulder To Finger: Part 2 (CHT Prep Course). By N. Falkenstein & S. Weiss, 2011. St. Petersburg, FL: Treatment2Go. (Earn 2.5 AOTA CEUs [25 NBCOT PDUs, 25 contact hours]. $349 for members & nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=4858B. Order #4858B. Promo code MI)

CD: Basics and Beyond: Everything You Need to Know—Shoulder To Finger: Part 1 & 2 (CHT Prep Course). By N. Falkenstein & S. Weiss, 2011. St. Petersburg, FL: Treatment2Go. (Earn 5.5 AOTA CEUs [55 NBCOT PDUs, 55 contact hours]. $649 for members & nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=4858. Order #4858. Promo code MI)

DVD: Cumulative Trauma Disorders: An Evidence- Based Approach. By P. Bonzani. St. Petersburg, FL: Treatment2Go. (Earn 1.2 AOTA CEUs [12 NBCOT PDUs, 12 contact hours]. $359 for members and nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?-SKU=4863. Order #4863. Promo code MI)

Hand and Upper Extremity Rehabilitation: A Practical Guide, 3rd Edition. Edited by S. Burke, J. Higgins, M. McClinton, R. Saunders, & L. Valdata, 2006. St. Louis, MO: Elsevier. ($93.95 for members, $133.50 for nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=1348. Order #1348. Promo code MI)

Occupational Therapy Practice Guidelines for Adults With Stroke. By J. Sabari, 2008. Bethes-da, MD: AOTA Press. ($59 for members, $84 for nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?-SKU=2211. Order #2211. Promo code MI)

DVD: Orthotics: Creative Mobilization Splinting— Dynamic & Static Progressive Splinting (SPS)By D. Schwartz, 2011. St. Petersburg, FL: Treat-ment2Go. (Earn .9 AOTA CEU [9 NBCOT PDUs, 9 contact hours]. $299 for members & nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=4857. Order #4857. Promo code MI)

DVD: Orthotics: Creative Static Splinting Made Simple. By D. Schwartz, 2011. St. Petersburg, FL: Treatment2Go. (Earn .7 AOTA CEU [7 NBCOT PDUs, 7 contact hours]. $249 for members & nonmem-bers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=4856. Order #4856. Promo code MI)

Discuss this and other articles on the OT Practice Magazine public forum at http://www.OTConnections.org.

CONNECTIONS

14 OCTOBER 8, 2012 • WWW.AOTA.ORG

Every 40 seconds, someone in the United States has a cere-bral vascular accident (CVA), also known as a stroke.1 CVA is the third-leading cause of

death in the United States and the leading cause of serious, long-term disability. CVA involves a sudden interruption of blood supply to the brain that can be caused by occlusion or hemorrhage in the arteries that lead to the brain. When the brain loses part of its supply of oxygen, many functions of the body, such as speech, vision, and motor abilities, can be seriously impaired. An individual’s ability to participate in meaningful or necessary daily tasks, including activities of daily living (ADLs), depends on the effects of the CVA and the various anatomical structures compromised.2

One consequence of CVA that is experienced by many stroke survivors is learned nonuse. Learned nonuse is a loss of extremity function resulting not from damage to the nervous system itself, but rather from learned suppres-sion of movement in an extremity that has been affected by the CVA. Learned nonuse is a behavioral phenomenon

that results from constant negative feedback. When a person with hemipa-resis tries to use an affected extremity and experiences failure at task per-formance, a “downward spiral” often occurs, in which the person knowingly and progressively begins to suppress use of the affected limb. This downward spiral continues to grow based on a number of factors associated with lack of practice and failure when attempting to use the extremity, which ultimately can lead to a near complete loss of upper extremity use.3

The continued suppression of motor activity in the affected limb becomes reinforced by the brain. However, learned nonuse resulting from CVA does not necessarily need to become perma-nent. The behavioral aspect of learned nonuse is just that: learned. With proper retraining, practice, and motivation, learned nonuse can be overcome.3 After insult to the central nervous system, the brain can oftentimes be repro-grammed.4 This is particularly true for persons who have gross functional use remaining in the affected upper extrem-ity after neurological insult.

CONSTRAINT-INDUCED MOVEMENT THERAPyConstraint-induced movement ther-apy (CIMT) is a type of rehabilitation therapy that addresses motor perfor-mance deficits and learned nonuse occurring after neurological insult by providing intense training of the arm

affected by CVA.5 The unaffected arm is constrained for a set number of hours a day, to “force” use of the affected arm, leading to improvements in function of the affected upper extremity. During treatment, the client is expected to use his or her affected upper extremity to perform tasks, while the unaffected arm is placed in a constraint.4

Traditional CIMT involves an intense 2-week training protocol during which the participant’s nonaffected limb is constrained during therapy sessions (which are 6 hours in duration), and 90% of his or her waking hours out-side of therapy sessions, including weekends. During therapy, fine motor tasks, gross motor tasks, and ADLs are performed on a one-on-one basis. Unfortunately, the large number of hours of direct therapist–client interac-tion required with traditional CIMT can make it difficult to obtain third-party reimbursement for this form of inter-vention.4 A week of CIMT therapy at two major centers in the United States costs between $3,000 and $3,500; this does not include the cost of transpor-tation, housing, and meals for each participant. Thus, traditional CIMT is not a therapy regimen that many people have the resources to participate in.6

In response to these barriers, mod-ified constraint-induced movement therapy protocols have been developed. Modified constraint-induced move-ment therapy (mCIMT) can include a number of different protocols, but it

A research project found home-based constraint-induced movement

therapy (CIMT), for increasing the use of upper extremities,

to be as effective at home and often more convenient than

at a clinic or other facility.

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Improving Upper Extremity FunctionThrough a Home-Based Modified Constraint-Induced Movement Therapy Program

15OT PRACTICE • OCTOBER 8, 2012

frequently involves intense therapy for at least 5 days per week, for at least 3 hours a day, over a minimum of 4 weeks, for a total of 60 hours of therapy time distributed over 20 sessions.7 The mCIMT approach decreases time spent in the clinic and increases accessibility of this form of therapy for patients.8 Both CIMT and mCIMT have been found to be effective in increasing the use of upper extremities in patients who have experienced a stroke.9

HOME-BASED REHABILITATION PROGRAMS Prior research has demonstrated that home-based rehabilitation programs can be effective in improving strength, balance, endurance, bimanual hand use, and functional ability of clients who have experienced CVAs. Home-based rehabilitation programs do not involve intense one-on-one intervention with a therapist, which can make them an economically feasible approach to reha-bilitation. Participants in home-based programs do not have to frequently

travel to and from the clinic for therapy, adding to the ease of accessibility.10 Additionally, treatment programs involving home- and community-based rehabilitation programs are becoming a more popular approach to rehabilitation as third-party payers are moving toward decreasing coverage for inpatient reha-bilitation services.11

Limited research has examined outcomes associated with home-based rehabilitation programs, particularly for persons with upper-extremity limita-tions post-CVA. One of the most recent studies, a meta-analysis completed by Coupar et al., reviewed randomized controlled trials comparing home-based therapy interventions focusing on upper-extremity limitations post-CVA to placebo, no intervention, or usual care.11 The results of the review indicated that the home-based programs were no more or less effective than the clinic-based programs (although the authors noted that there was a lack of good-quality evidence upon which to make recom-mendations regarding the effectiveness

of home-based versus placebo, no intervention, or usual care services). The authors emphasized that additional research focusing on the effects of home-based rehabilitation programs for persons with upper-extremity impair-ments post-CVA is necessary.

It seems that for some clients, a home-based approach to mCIMT may be more realistic than traditional CIMT. Putting an mCIMT program in the participant’s control (including times of constraint wear, and identification of treatment activities that are most meaningful) may make the program more convenient and appealing.12 Furthermore, home-based mCIMT pro-grams would not likely require the large amount of face-to-face clinic time that traditional CIMT programs do, there-fore increasing accessibility for persons with limited financial resources and/or those with difficulty attending regular clinic-based therapy.

After an extensive review of research on mCIMT, the authors concluded that a home-based form of mCIMT, though its use has not been explored in depth, could potentially be beneficial to per-sons who experience a CVA. The proven effectiveness of mCIMT, combined with the cost-effectiveness of performing therapy in the home, could be beneficial and convenient for clients and thera-pists alike.

HOME-BASED MCIMT PROGRAMThe authors conducted a research study in the summer of 2011 that examined the effects of an 8-week home-based mCIMT program on upper-extremity function. The study was approved by the ethics board at the researchers’ university. Participants were recruited through advertisements in the local newspaper. The authors also provided information regarding the

Facing page: A participant learns to don the constraint.

This page: During sessions in the clinic, subjects participated in repetitive task practice. At home, participants engaged in more purposeful activities.

21OT PRACTICE • OCTOBER 8, 2012

The 2012 elections are almost here and, as AOTA members prepare to select the candidates they will support, the American Occupational Therapy Political

Action Committee (AOTPAC) is sharing its list of supported candidates for the 2012 federal elections at www.aota.org/aotpac-support.

AOTPAC wants all occupational ther-apy practitioners to vote in the November 6 elections, regardless of which candi-dates they choose. Meaningful policy and legislation requires a bipartisan approach, and that is why AOTPAC supports candi-dates from both parties who support the occupational therapy profession.

“Voting is an exercise of our power in choosing legislators who represent our interests,” says AOTPAC Chairperson Gail Fisher, MPA, OTR/L. “Some people take voting for granted, and so many people don’t vote, but really it is a privilege to be able to select our own representatives and feel that we have a personal stake in what they do.”

AOTPAC supports candidates in many states, including Tammy Duckworth, who is a big fan of occupational therapy. Duck-worth was one of the first women to fly combat missions in Iraq, but she lost both of her legs and part of the use of her right arm in a helicopter crash. Duckworth spoke at AOTA’s Annual Conference & Expo in 2012, praising army occupational therapy for assisting in her recovery. Duckworth is running for Illinois’ 8th dis-trict in the U.S. House of Representatives.

“Tammy Duckworth is a huge propo-nent of occupational therapy,” says Fisher. “Certainly having legislators like her who totally understand what we do—we won’t have to explain it—means they will fight for other people’s right to access our services when they need it.”

AOTPAC is a vital link to making sure congressional candidates who support occupational therapy are elected. A political action committee (PAC) is the legally sanctioned vehicle through which organizations such as AOTA can engage in

otherwise prohibited political action and work to influence the outcome of federal elections. AOTPAC is a voluntary, non-profit, and unincorporated committee of members of AOTA. For 35 years, AOTPAC has furthered the legislative aims of AOTA by influencing and supporting candidates.

“AOTA is in charge of educating leg-islators. AOTPAC is in charge of making contributions to legislators,” says Fisher. “The two work very closely together.”

AOTPAC follows strict criteria when selecting candidates to support, includ-ing analyzing congressional support for occupational therapy legislative issues. AOTPAC supports candidates for the U.S. House of Representatives and U.S. Senate, and it supports AOTA members running for public office. AOTPAC does not endorse presidential candidates.

When AOTPAC is successful in helping congressional candidates who support occupational therapy get elected, it allows the profession to be at the table for discussions about health care reform, the Medicare outpatient therapy cap, funding for research, and other issues that affect the practice of occupational therapy. AOTPAC has made political contributions to candidates for election in almost every state in both House and Senate elections, enabling AOTA to broaden its contacts in Congress.

By becoming politically aware and contributing to AOTPAC, occupational

therapy practitioners can ensure some influence in the decisions that affect their professional lives so directly. The money raised by AOTPAC is through direct AOTA member contributions. Without member contributions, AOTPAC would not have the high profile needed to sup-port occupational therapy in the political process.

No matter the amount of the contribution, the support that occupational therapy practitioners give AOTPAC will help its ongoing efforts on behalf of the profession. As an added incentive, members who contribute $1,000 or more to AOTPAC by November 1 will be eligible for a drawing to win a trip to Washington to attend the presidential inaugural events with Fisher and AOTA policy staff. Members who contribute $365 or more by November 1 will be eligible for a drawing to win a trip to Wash-ington to attend the Congressional Swearing In Day activities. More information may be found at www.aota.org/aotpac-contest.

In addition to voting and supporting AOTPAC, occupational therapy practition-ers can also volunteer their time. “You can go beyond voting and spend an afternoon working for a candidate,” says Fisher. “Work on the campaign, support them financially, or go to a town hall meeting the candidate is holding.”

Fisher hopes to use the excitement of the upcoming elections to help AOTPAC have many more successful years. “I feel that AOTPAC is much more visible than it used to be,” says Fisher. “Former Chair-person Amy Lamb has done a tremendous job in bringing us to this point. I want to keep it going.” n

Stephanie yamkovenko is AOTA’s staff writer.

Going Beyond the VoteSupport AOTPAC Today!Stephanie yamkovenko

By becoming politically aware and contributing to AOTPAC, occupational therapy practitioners can ensure some influence in the decisions that affect their professional lives so directly.

26

C A L E N D A R

OCTOBER 8, 2012 • WWW.AOTA.ORG

Order #WA1010, AOTA Members: $25, Nonmem-bers: $36. http://store.aota.org/view/?SKU=WA1010

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2010 Autism Webcast SetPresented by experts in the field. These fully nar-rated PowerPoint™ presentations provide learning from prominent experts and designed to enhance knowledge and skills. With value pricing, purchas-ing the entire webcast series provides a specialty conference from home or work computer. These webcasts do not require a course exam. Earn up to 13.5 contact hours. Full Set Order #WA1000K. AOTA Members: $175, Nonmembers: $250. http://store.aota.org/view/?SKU=WA1000K

MENTAl hEAlThSelf-Paced Clinical Course Mental Health Promotion, Prevention, and In-tervention With Children and Youth: A Guiding Framework for Occupational Therapy, edited by Susan Bazyk. Framework on the role of OT in mental health interventions for children that can be applied in all pediatric practice settings. Earn 2 AOTA CEUs (25 NBCOT PDUs/20 contact hours). Order #3030, AOTA Members: $259, Nonmembers: $359. http://store.aota.org/view/?SKU=3030

Self-Paced Clinical CourseOccupational Therapy in Mental Health: Consid-erations for Advanced Practice, edited by Marian Kavanagh Scheinholtz. Comprehensive discussion of recent advances and trends in mental health practice, including theories, standards of practice, and evidence as they apply to OT with content from federal and non-government entities. Earn 2 AOTA CEUs (25 NBCOT PDUs/20 contact hours). Order #3027, AOTA Members: $259, Nonmembers: $359. http://store.aota.org/view/?SKU=3027

PRODUCTIvE AGINGSelf-Paced Clinical CourseStrategies to Advance Gerontology Excellence: Promoting Best Practice in Occupational Therapy, edited by Susan Coppola, Sharon J. Elliott, and Pamela E. Toto. Core best practice methodology with older adults, approaches to and prevention of occupational problems, health conditions that af-fect participation, and practice in cross-cutting and emerging areas. Earn 3 AOTA CEUs (37.5 NBCOT PDUs/30 contact hours). Order #3024, AOTA Mem-bers: $245, Nonmembers: $345. http://store.aota.org/view/?SKU=3024

Self-Paced Clinical CourseLow Vision: Occupational Therapy Evaluation and Intervention With Older Adults, Revised Edi-tion. 2008, edited by Mary Warren. Support for professional competency through AOTA Specialty Certification in Low Vision Rehabilitation (SCLV) with information on evaluation and lessons related to psychosocial issues and low vision, eye conditions that cause low vision in adults, and basic optics and optical devices. Earn 2 AOTA CEUs (25 NBCOT PDUs/20 contact hours). Order #3025, AOTA Mem-bers: $259, Nonmembers: $359. http://store.aota.org/view/?SKU=3025

CEonCD™An Occupation-Based Approach in Postacute Care to Support Productive Aging, by Denise Chisholm, Cathy Dolhi, and Jodi L. Schreiber.

Occupation-based practice with a focus on post-acute care practice settings for older adults and strategies for integrating occupation throughout the OT process to maximize clinical application. Earn .6 AOTA CEU (7.5 NBCOT PDUs/6 contact hours). Order #4875, AOTA Members: $210, Nonmembers: $299. http://store.aota.org/view/?SKU=4875

CEonCD™Skilled Nursing Facilities 101, by Christine Kroll and Nancy Richman. Importance of documentation, re-quirements for different payers, significance of manag-ing productivity, understanding billing considerations, and maintaining ethical practice standards. Earn .3 AOTA CEU (3.75 MBCOT PDUs/3 contact hours). Order #4843, AOTA Members: $108, Nonmembers: $154. http://store.aota.org/view/?SKU=4843

CEonCD™Seating and Positioning for Productive Aging: An Occupation-Based Approach, by Felicia Chew and Vickie Pierman. Manual wheelchair mobil-ity through review of seating and positioning from evaluation to outcome with a concentration on inter-ventions applicable to a variety of settings. Earn .4 AOTA CEU (5 NBCOT PDUs/4 contact hours). Order #4831, AOTA Members: $97, Nonmembers: $138. http://store.aota.org/view/?SKU=4831

Online CourseFalls Module I—Falls Among Community-Dwell-ing Older Adults: Overview, Evaluation, and Assessments, by Elizabeth W. Peterson and Ro-berta Newton. First module in 3-part series on fall prevention to support OTs in providing evidence-based fall prevention services to older adults at risk for falling or that seek preventive services with sec-tions on prevalence, consequences, and evaluation of fall risk. Earn .6 AOTA CEU (7.5 NBCOT PDUs/6 contact hours). Order #OL34, AOTA Members: $210, Nonmembers: $299. http://store.aota.org/view/?SKU =OL34

Online Course Falls Module II—Falls Among Older Adults in the Hospital Setting: Overview, Assessment, and Strategies to Reduce Fall Risk, by Roberta Newton and Elizabeth W. Peterson. Second module in 3-part series on fall prevention with over-view of falls that occur in the hospital setting and identification of older adults at risk, factors that contribute to fall risks, and assessment strategies. Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). Order #OL35, AOTA Members: $68, Non-members: $97. http://store.aota.org/view/?SKU= OL35

Online CourseFalls Module III: Preventing Falls Among Commu-nity-Dwelling Older Adults—Intervention Strate-gies for Occupational Therapy Practitioners, by Elizabeth W. Peterson and Elena Wong Espiritu. Third module in 3-part series on fall prevention with evidence-based intervention strategies to reduce falls among community-dwelling older adults that include both older adults who are well and those who are living with chronic diseases. Earn .45 AOTA CEU (5.63 NBCOT PDUs/4.5 contact hours). Order #OL36, AOTA Members: $158, Nonmembers: $225. http://store.aota.org/view/?SKU=OL36

Online CourseDriving and Community Mobility for Older Adults: Occupational Therapy Roles, Revised, by Susan L. Pierce and Elin Schold Davis. Expanded con-tent and updated links on research, tools, and re-sources to help advance knowledge about instru-mental activity of daily living (IADL) of driving and community mobility. Earn .6 AOTA CEU (7.5 NBCOT PDUs/6 contact hours). Order #OL33, AOTA Mem-bers: $180, Nonmembers: $255. http://store.aota.org/view/?SKU=OL33

REhABIlITATION, DISABIlITY, & PARTICIPATION

Self-Paced Clinical CourseDysphagia Care and Related Feeding Concerns for Adults, 2nd Edition, edited by Wendy Avery. Up-to-date resource in dysphagia care written from an occupational therapy perspective for OTs at entry and intermediate skill levels. Earn 1.5 AOTA CEUs (18.75 NBCOT PDUs/15 contact hours. Order #3028. AOTA Members: $199, Nonmembers: $299. http://store.aota.org/view/?SKU=3028

Self-Paced Clinical CourseThe Hand: An Interactive Study for Therapists, by Judy C. Colditz. Written coursework with interac-tive, computer-based learning to present the ana-tomical basis and clinical presentation of problems in the hand and forearm and preparation for Hand Therapy Certification Exam. Earn 1.6 CEUs (20 NB-COT PDUs/16 contact hours). Order #3017, AOTA Members: $182, Nonmembers: $252. http://store.aota.org/view/?SKU=3017

CEonCD™Occupation-Focused Intervention Strategies for Clients With Fibromyalgia and Fatiguing Condi-tions, by Rénee R. Taylor. Evidence-based strate-gies for managing fibromyalgia and other fatiguing conditions, such as chronic fatigue syndrome, with interdisciplinary treatment approaches and collabo-ration with other professionals. Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). Order #4839, AOTA Members: $68, Nonmembers: $97. http://store.aota.org/view/?SKU=4839

CEonCD™Pain, Fear, and Avoidance: Therapeutic Use of Self With Difficult Occupational Therapy Popu-lations, by Reneé R. Taylor. Examines strategies for managing client pain, fear, and avoidance in OT practice with six distinct modes of interacting based on the author’s conceptual practice model. Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). Order #4836, AOTA Members: $68, Nonmembers: $97. http://store.aota.org/view/?SKU=4836

CEonCD™Hand Rehabilitation: A Client-Centered and Occupation-Based Approach, by Debbie Amini. Occupation-based intervention to enhance hand re-habilitation protocols without sacrificing productivity or detracting from the concurrent client factor focus. Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). Order #4832, AOTA Members: $68, Nonmem-bers: $97. http://store.aota.org/view/?SKU=4832

“We envision that occupational therapy is a

powerful, widely recognized, science-driven, and evidence-

based profession with a globally connected and

diverse workforce meeting society’s occupational needs.”

• • •Join us on the road to the

Centennial Vision at www.aota.org

29OT PRACTICE • OCTOBER 8, 2012

E M P L O Y M E N T O P P O R T U N I T I E SFaculty

OT PRACTICEIssue: September 24th and October 8th issue - deadline TODAYSize: 4/9 page sq = 4.687 x 5.937”

Assistant ProfessorDepartment of Rehabilitation Sciences

Master of Occupational Therapy ProgramCollege of Health Sciences

POSITION DESCRIPTION: This position is a tenure-track, nine-month academic yearappointment with the possibility of summer teaching. Faculty duties include teaching graduateoccupational therapy courses; advising graduate students; mentoring master's and doctoralstudents; engaging scholarly research and publication, including external grant proposals; andparticipation in service opportunities within the department, college, university and profession.The anticipated appointment date is Fall 2013. Preferred candidates will have practice and/orteaching expertise in the areas of mental health or adult physical/neurological dysfunction.

THE PROGRAM: For more information about the program, see the Occupational Therapyprogram website at http://chs.utep.edu/ot/REQUIRED QUALIFICATIONS: Candidates must (1) have an earned doctorate degree inoccupational therapy, (2) be eligible for Texas licensure, (3) be an active member of the AmericanOccupational Therapy Association, and (4) have a minimum of 5 years of experience inoccupational therapy practice. Candidates are expected to (5) demonstrate a commitment to, orpotential for, teaching excellence at the university level, (6) be able to use technology ininstruction, and (7) demonstrate a potential for or record of scholarly research and publication,including development of grant proposals and attracting external funding. (8) Finally, candidateswill demonstrate the ability to work effectively with faculty, staff and students from diverse ethnic,cultural, and socioeconomic backgrounds. Preferred candidates will also show a record of activeparticipation or leadership roles in the profession of occupational therapy or relevant organizations.

APPLICATION PROCEDURE: Applicants should submit: (1) a cover letter; (2) a curriculumvitae; and (3) the names, addresses, phone numbers, and e-mails of three professional references.Candidates will be notified before references are contacted. Applications will be reviewedimmediately and received until the position is filled. Applicants are encouraged to apply byNovember 30, 2012. For more information and to apply, please contact:

Dr. Stephanie CapshawOT Search Committee ChairUniversity of Texas at El Paso

College of Health SciencesDepartment of Rehabilitiation Sciences

Ocupational Therapy Program500 W. University Ave.

El Paso, TX 79968Tel. 915-747-7269, email: scapshaw@utep.edu

The University of Texas at El Paso is an Equal Opportunity/Affirmative Action Employer.The University does not discriminate on the basis of race, color, national origin, sex,

religion, age, disability, genetic information, veteran status, or sexual orientation in employment or the provision of services.

UNIVERSITY OF TEXAS AT EL PASO

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The University of Tennessee Health Science Center is conducting a nationwide search for Chair of the Department of Occupational Therapy. The Search Committee invites letters of nomination, applications (letter of interest, resume/CV, and references), or expressions of interest to be submitted to the search firm assisting the University. For a complete position description, refer to Current Opportunities on www.parkersearch.com.

Gary L. Daugherty, Senior Vice President | Ryan Crawford, Principalgdaugherty@parkersearch.com | rcrawford@parkersearch.com

Phone: 770-804-1996 x 110 Fax: 770-804-1917

The University of Tennessee is an EEO/AA/Title VI/Title IX/Section 504/ADA/ADEA institution.

Faculty

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Chair, Department of Occupational Therapy

Faculty

Midwestern UniversityOccupational Therapy Program

Downers, Grove, ILOpen Faculty Position:

Assistant Professor

The Occupational Therapy Program has im-mediate opportunities to join an established

occupational therapy professional master’s degree program. The spacious 105-acre, wooded, Down-ers Grove, IL campus is located just 45 minutes west of downtown Chicago.Applications are invited for a full-time, tenure track faculty position. Successful applicants must possess (1) an earned doctorate (or ABD) in oc-cupational therapy or a related field; (2) eligibility for licensure as an occupational therapist in Il-linois; (3) at least 5 years of clinical experience; and (4) instructional experience in a college or university academic program. Experience in pedi-atrics, geriatrics, or adult rehabilitation is needed. A record of scholarly productivity or potential to develop an active research program and pro-fessional service will enhance the candidate’s ap-plication. Preference will be given to candidates with a doctoral degree; teaching experience in an academic program; and whose background, expe-rience and interests complement those of current faculty members.A faculty member in the Occupational Therapy Program has responsibilities in teaching, schol-arship, and service. Teaching responsibilities include conducting class sessions and designing learning activities that will lead to student mas-tery and success in their professional and personal development. This role also encompasses the general areas of academic advising and student development. Scholarship responsibilities include pursuing on an ongoing basis the continuance of scholarly growth, engaging in scholarly/creative activity, and disseminating the results through critical peer review. Service responsibilities in-clude participating actively in program, college, and university committees; assisting with the stu-dent recruitment and admissions process; profes-sional role-modeling; and participating actively in the professional activities of state and national occupational therapy organizations.Midwestern University is an independent in-stitution of higher education committed to the education of health care professionals. The salary and benefits are competitive. Rank and salary are commensurate with qualifications and experi-ence. Interested applicants should apply online at www.midwestern.edu and send a letter of applica-tion, curriculum vitae, and the names and contact information of three professional references to the Chair of the OT Program Faculty Search Com-mittee:

Mark Kovic, OTD, OTR/LChair, OT Program Search Committee,

Occupational Therapy Program555 31st Street,

Downers Grove, IL 60515mkovic@midwestern.edu F-6173

November 30–December 1, 2012baltimore, marylaND

earn Up to 13 contact Hours (1.3 aota ceUs/13 Nbcot PDUs)

register now at www.aota.org/confandevents/stroke

aota SPecialty coNFereNce

adults With Stroke

A stroke can take meaning out of life, but occupational therapy can restore it.An estimated 5.4 million people in America live with the disabling effects of stroke and that number is bound to increase in the years to come. Occupational therapy must take the lead in stroke rehabilitation for survivors, families and caregivers, so join us this fall at Adults With Stroke and take advantage of top-level continuing education!

PR-213

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