A Fork in the Road: An Occupational Hazard?

Normalcy and Motor Control Interventions

The first documented case study in our journals that described occupational therapy interventions for motor control deficits after stroke was in Volume 1, Issue 1, of the Archives of Occupational Therapy in 1922. Occupational therapist Evelyn Lawrence Collins (1922) described being invited by Mrs. Slagle to do home care on the Lower East Side of Manhattan. She described her case as a woman bedridden after a “paralytic stroke” and the woman’s neighbor describing that “she can’t do nothing; she has only got one hand” (p. 36). Collins went on to give a short description of what we now mistakenly call a “contemporary” approach to motor control rehabilitation. Remember, this article was published in 1922. She described engaging the affected hand using a bilateral activity as the means to remediate hand function. The activity of creating three small purses had all the makings of what we have recently rediscovered and proven: Repetitive and purposeful activity has the powerful potential to remediate motor function.

As I continued to review our profession’s literature, I found that the occupational therapy approach to remediating motor control continued to be solidified and consistent across the life course. Occupational therapy interventions for this population were described as bilateral crafts (Collins, 1922); toy making for “uncomplicated paralysis” (Dean, 1922, p. 216); tool use, working looms, making rugs (Bowman, 1923); using a metronome during typing training (Spackman, 1947); engaging lower functioning clients in activity by unweighting the upper limb using a suspension sling (Covalt, Yamshon, & Nowicki, 1949; Spackman, 1947); project making (Suckle & Thompson, 1949); activities that provide graded resistance (Covalt et al., 1949); remedial games (Boeshart & Blau, 1951); an activity-based approach based on choosing selected activities (e.g., adapted games, filing, bilateral activities) determined by impairment level (Press, 1951); toy training (Robinault, 1953); bilateral activities such as sanding and wood working; and, again, using a suspension sling (Hopkins, 1963).

How then can we describe our normalcy? The words that we as an occupational therapy profession have historically used to describe this area of practice have one thing in common: They are primarily words of action. They include practicing, doing, active, activity, repetitive, life related, skill building, and relearning (Brunyate, 1947; Meyer, 1922; Spackman, 1947).

Fork in the Road

In reality, our normalcy and consistency in this area of practice lasted from about 1922 to the late 1950s or early 1960s, as noted earlier. So, just about 40 years. As the world changed dramatically around this time, our language and documented approaches took a dramatic turn as well—a proverbial fork in the road. Remember, we had been concerned that our approaches were commonplace, unsophisticated and, yes, not sexy. Booker (2004) described this point in the plot as a having a fascination for unfamiliar things. We began to get, perhaps, overfocused on sets of techniques that may have looked more sophisticated and important than our normalcy. Instead of being just influenced by others’ approaches, we in fact took an adoption approach and, if you will, a replacement approach. To illustrate, take a look at how our approach to remediating motor control impairments across the life course changed from the third to the fourth edition of Willard and Spackman’s (1963, 1971) Occupational Therapy (Table 1).

As the left column of the table clearly indicates, we were still clearly focused on being the profession that engaged clients in the actual doing and the actual practice. Action words and everyday living were highlighted. Our approach was clear; we were remediating motor control in the context of using everyday activities (Hopkins, 1963). After that, our language and description of occupational therapy abruptly and dramatically changed (Huss, 1971), as indicated in the right column.

In fact, the third edition of Willard and Spackman’s (1963) Occupational Therapy was a transitional volume and confusing at times. This edition was consistent with our sense of normalcy with the exception of an added last and new chapter on neuromuscular integration. This chapter was described as a framework derived from the biological sciences, neurology, physiology, phylogeny, and ontogeny as it related to occupational therapy. It was the initial description in our textbooks of sets of techniques to be applied to our clients and—with one exception, Margaret Rood—exclusively approaches that did not stem from occupational therapy. To summarize and to be a bit facetious, we transitioned from having our clients brush their hair and teeth so that they might relearn motor control and maximize participation to having us, the therapists, brush over muscle–tendon units so that we could facilitate a muscle contraction. We abruptly switched from our patients actively doing (third edition; Willard & Spackman, 1963) to our patients being somewhat passive recipients of our services (fourth edition; Willard & Spackman, 1971).

Our normalcy in this area has been lost over the years. Even in our own textbooks we incorrectly refer to our traditional approaches as total approaches developed by other disciplines such as neurosurgery, physiatry, physical therapy, psychiatry, neurophysiology, and so forth. This was not our tradition. It was never our normalcy. In our current language (American Occupational Therapy Association [AOTA], 2008), these techniques and total approaches would be categorized as preparatory, which relegates activity and occupation to an afterthought.

Following this path led to a dramatic shift away from our core values and occupational therapy principles. We clearly moved away from the actual doing and the actual practice as described by Adolf Meyer in 1922 to a culture in which our primary role was to “do to” our clients. At the same time Mary Reilly (1962) was delivering the most often-quoted sentence in any Slagle lecture to date, which, as you know, contains the key phrase “man through the use of his hands” (p. 1), we started to take the stance that the therapist’s hands are the key to recovery. To make a point, I do not want to be taken the wrong way with regard to the use of our hands. My clinical appointment is in acute neurology, and I am clear on the importance of well-honed hands-on skills for the purposes of safety, task completion, comfort, and reassurance.

Frustration

In the voyage-and-return plot, the next plot point is frustration (Booker, 2004). Did we choose the correct fork? At this point in our profession’s journey, our reliance on the techniques and approaches of our colleagues from other professions has outlasted our own occupational therapy approach by at least a decade—50 years compared with our 40 years of normalcy. The currency and efficacy of these techniques and approaches we have dubbed “traditional” has been called into question for at least 2 decades by scholars and scientists from our field and others, and this questioning continues (Butler & Darrah, 2001; Damiano, 2007; Horak, 1991; Kollen et al., 2009; Mathiowetz & Haugen, 1994).

Confusion over our role may persist when professional blurring, professional envy, and dual-sided encroachment occur. Here is an example of this professional blurring or, perhaps, professional envy. Although the following two studies (like all studies) have limitations, and their methods may vary, the message is, I believe, a powerful one and, yes, a frustrating one. Smallfield and Karges (2009) aimed to classify occupational therapy intervention for stroke survivors on an inpatient rehabilitation unit. They discovered that more sessions were spent on prefunctional activities rather than on functional activities. In fact, almost 66% of sessions were not related to function. They further stated that “occupational therapists use prefunctional activities that aim to improve performance skills and body structures more often than occupation-based activities that incorporate meaningful activities into therapy sessions” (p. 412). How can that be?

In contrast, our colleagues in physical therapy performed a similar study to describe physical therapy interventions for people with stroke undergoing inpatient rehabilitation (Jette et al., 2005). They documented that fewer than 20% of interventions were classified as prefunctional and more than half would be classified as interventions related to areas of occupation using the language in our current practice framework (AOTA, 2008). Granted, most were in the focused category of functional mobility. I hope you can see my concern and point regardless.

In his 1996 Slagle lecture, David Nelson (1997) spoke of his concern that people from other professions are coming late to the table and claiming credit for some of the great ideas of occupational therapy. I agree wholeheartedly. Although I was never a popular kid, I am very proud to be part of a profession that seems to have won the “most-popular” contest. Have you looked around and listened for the past decade? It seems as though so many of our colleagues in other disciplines want to be us. Their current chosen methods (both in practice and in writing) are quickly morphing into our traditional occupational therapy. We know that imitation is the sincerest form of flattery—okay, I am flattered, but more so, frustrated.

It is hard, however, to stand our ground and defend our own practice when the same argument may be made against us. We cannot defend our scope of practice if we do not practice what and how we preach. How can we challenge our colleagues’ use of our modalities if in many cases we are not being seen using them ourselves (reflect back on the findings of Smallfield & Karges, 2009) and if we freely use theirs? I would identify this problem as a dual encroachment related to scope of practice.

In her 2000 Slagle lecture, Margo Holm charged us with a mandate for the new millennium: evidence-based practice, which is consistent with our Centennial Vision (AOTA, 2007). Wow! We have a ton of data to sort through. I mean this in a good way. The past decade has resulted in an explosion of research to help us guide our practice. My colleagues and I just completed a project for AOTA focused on defining effective interventions to improve occupational performance for people with motor deficits after stroke. We reviewed almost 5,000 abstracts, and multiple papers met our strict inclusion criteria. This review was limited to the past several years and included literature both from occupational therapy and from our colleagues in other disciplines as long as a change in occupational performance was noted. For the first time in my career as an occupational therapist, I was overwhelmed by the sheer amount of evidence that was generated. On the basis of this current evidence-based review, if I was going to summarize which interventions are effective in improving occupational performance, I would describe them as practicing, doing, active, activity, repetitive, life related, skill building, and relearning.

Yes, these words should look familiar; earlier, I described that our profession’s professed philosophy and approach is being further validated from a science perspective. This validation is to be celebrated! It is what we had previously been doing for years.

Further descriptions of these approaches include task-oriented approach, task-specific training, repetitive task practice, task-related training, massed practice, high intensity, active, and real-world focused. Occupational therapy is truly an art and science. However—again, frustratingly—these approaches are not being called occupational therapy.

I show some parallels in Figure 1. On the left side are descriptions of specific tasks that come from our own early literature as described earlier, including early editions of our journals and early editions of Willard and Spackman’s Principles of Occupational Therapy, as discussed earlier. On the right side are examples of tasks used in both adult and pediatric rigorous evidence-based protocols that have documented improved occupational performance using a variety of methods: quantitative, qualitative, self-report, significant-other report, and so forth (Gordon, Schneider, Chinnan, & Charles, 2007; Taub et al., 1994). These parallels are not difficult to find if you go back far enough in our literature, but they are pretty far back at this point.

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Figure 1.

Comparison of occupational therapy’s normalcy and current evidence-based practice.

Furthermore, and a further reason to celebrate, many of the techniques and principles we developed and documented as a profession decades ago are now considered cutting edge and, my favorite misnomer, “contemporary.” In the first edition of Principles of Occupational Therapy, Brunyate (1947) discussed treating a child with cerebral palsy, stating that “the child can practice picking up the glass a number of times” (p. 284) and reminding us that “repetitive use will gradually teach control” (p. 276). This concept is one of the most basic motor learning principles used to guide practice today. We now use the seemingly more sophisticated terms of blocked practice and repetitive task practice (Schmidt & Lee, 2011). Clare Spackman (1954) also reminded us that “relearning the desired skills requires practice all day long everyday” (p. 214). Suggested time? Sixteen hours per day! We now called this massed practice, which is a foundation of constraint-induced movement therapy, without doubt effective for a subset of our clients.

Over the years, some of the “traditional”approaches used have shied away from resistive activities. We were early proponents of using resistive activities (Brunyate, 1947; Covalt et al., 1949), consistent with current understanding that weakness after acquired brain injury is a crucial factor to consider to improve occupational performance (Ada, Dorsch, & Canning, 2006).

We have been unweighting severely hemiparetic limbs to promote early use and motor control for decades (Covalt et al., 1949; Spackman, 1947). We did this using deltoid aids and inexpensive counterbalance slings (Urquhart, 1975). Now, seemingly more sophisticated versions of unweighting limbs using expensive robotics are considered contemporary and cutting edge.

On the basis of current research, the efficacy of occupational therapy in motor recovery is based on a triad: early intervention, task-oriented training, and repetition of therapies. New and emerging research continues to demonstrate that the use of this triad, which highlights repetitive practice of real-world activities (our normalcy), not only has the potential to improve motor function and occupational performance, it also has the powerful potential to remodel and reorganize people’s brains. Task-specific training sessions spent “simply” playing games, performing simulated office work, doing housekeeping chores, practicing walking, or practicing how to open and close a door or drawer (our normalcy) has resulted in use-dependent cortical changes. This involvement in everyday activities

As a clinician, this is the icing on the cake; as a researcher and someone who wants occupational therapy to achieve its Centennial Vision (AOTA, 2007)—that is, to be a “powerful, widely recognized, science-driven, and evidence-based profession” (p. 613)—I find it fascinating, exciting and, if I may, sexy as well! Let’s never again call our techniques unsophisticated.

Just to review our journey related to motor control, our early involvement related to motor control training was clear from the inception of the profession. It was only around the 1960s when our professed methods took a dramatic shift in favor of our colleagues' methods (see Figure 2). I will talk about moving forward soon.

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Figure 2.

Timeline related to our involvement in motor control training and cognitive assessment. The top timeline represents occupational therapy’s involvement in the area of motor control. The bottom timeline represents occupational therapy’s involvement in the area of cognitive assessment.

Concerns Regarding Our Normalcy

One major concern is that this style of measurement does not take into account the well-documented dual-task paradigm. A dual-task paradigm is a procedure in research that requires a person to perform two tasks simultaneously to compare performance with single-task conditions. If Task 1 is stepping over obstacles and Task 2 is memorizing a grocery list, one may have a relatively high level of performance when performing the tasks in isolation. When one is then asked to step over obstacles while memorizing, one of three performance changes will most likely be noted: degraded performance in Task 1, in Task 2, or in both tasks.

To fully experience the dual-task paradigm, simply think about all the times you were rushing to work and got behind somebody who was walking and texting. Think about that person’s walking speed. The research is clear. Dual-task measures are more accurate at discriminating cognitive impairment than traditional (single) measures (Holtzer, Burright, & Donovick, 2004). The dual-task research is very controlled to ensure that one is doing only two tasks at once. Again, this is still not everyday life. Life is not controlled. It does not take place in a quiet, well-lit room that is free of distractions. It requires not only dual tasking but multitasking, many times with external time pressures that must also be managed. Even tasks such as dressing that appear so simplistic or, as we have called them, unsophisticated rely on a dynamic interplay of multiple neural networks and cognitive–perceptual processes to be successful (Árnadóttir, 2011). There is nothing simple about it.

The next concern is novelty. I have reviewed survey research to document the cognitive assessments most commonly used by occupational therapists and reviewed the items included to evaluate cognition (Koh, Hoffman, Bennett, & McKenna, 2009; Korner-Bitensky, Barrett-Bernstein, Bibas, & Poulin, 2011; Menon-Nair, Korner-Bitensky, & Ogourtsova, 2007). Item examples include block designs, design drawing or copying, draw a man, butterfly puzzles, gesture copying, pegboard designs, cancellation tasks, memorizing a number string, and making trails. Although novelty testing may be important for our high-level clients with executive dysfunction, it puts many of our clients at a disadvantage. We know this from our own lives and because this paradigm has been in the literature for more than a decade. Performance of novel tasks requires increased attentional control, compromises secondary task performance (i.e., memory), renders one unable to use proceduralized control or “autopilot,” and decreases overall task performance (Beilock, Wierenga, & Carr, 2002).

Finally, in terms of concerns, the concept of ecological validity or variants thereof can be found in the psychology literature dating back to 1943 (Schmuckler, 2001). Ecological validity typically refers to whether one can generalize from observed behavior in testing to natural behavior in the world. I have a more pragmatic definition: So what? What does it really mean if one cannot count backward from 100 by 7s or draw two intersecting pentagons? What does that tell us about occupational performance?

At least two conditions determine whether a tool is ecologically valid (Chaytor & Schmitter-Edgecombe, 2003):

To satisfy the first condition, that is, that the demands of the assessment theoretically resemble everyday demands, we need to move away from block designs, design drawing and copying, draw a man, butterfly puzzles, gesture copying, pegboard designs, cancellation tasks, memorizing a number string, making trails, and so forth and back to what makes us unique—that is, performance-based cognitive assessments using real-world tasks in the correct environmental context. Satisfying the second condition of ecological validity, that is, a statistical relationship with measures of everyday function, will most likely not occur if we continue on our current path. For more than 30 years, scholars and researchers have been concerned about the clear lack of a relationship between this level of cognitive measurement and daily functioning (Bouwens et al., 2008; Burgess et al., 2006; Heaton & Pendleton, 1981), thus highlighting the need for direct observation (both standardized and nonstandardized) of everyday activities: our true normalcy.

True Normalcy

In addition to 30 years of documenting this weak relationship between cognitive testing and real-world functioning, there has been a 30-year dialogue by our colleagues in other professions about what to do about it. Here again is why we should celebrate. We, the profession of occupational therapy, developed some of the first cognitive assessments that used occupation and occupational analysis to document how cognition supported or limited participation in everyday occupations. No more guessing. We should continue to be the leaders in the area of occupation and performance-based assessment. In the area of mental health, 37 years ago Sara Brayman and colleagues developed and published the Comprehensive Occupational Therapy Evaluation (Brayman, Kirby, Misenheimer, & Short, 1976). Many of the behaviors included on this scale were identified by A. Jean Ayres 60 years ago. Almost 30 years ago, Claudia Allen, who delivered the Slagle lecture in 1987, developed the first version of the Routine Task Inventory (Allen, 1985).

The first occupation-based cognitive assessment in the area of neurorehabilitation was developed by an Icelandic master’s-degree student at the University of Southern California in 1985.

Gudrun Árnadóttir was way ahead of her time and almost 30 years ago tried to get us neurotherapists to return to our roots of occupation in this area of practice with the Árnadóttir OT–ADL Neurobehavioral Evaluation, now known as the ADL-focused Occupation-based Neurobehavioral Evaluation (A–ONE; Árnadóttir, 1990, 2011). Soon after that Carolyn Baum, who delivered the Slagle lecture in 1980, and her colleagues developed and published the Kitchen Task Assessment (Baum & Edwards, 1993), which continued to evolve into the Executive Function Performance Test (Baum et al., 2008). In the same time frame, Anne Fisher, who delivered the Slagle lecture in 1998, developed and published the Assessment of Motor and Process Skills (AMPS; Fisher, 1992; Fisher & Jones, 2011) and subsequently the School AMPS (Atchison, Fisher, & Bryze, 1998; Fisher, Bryze, & Atchison, 2000), both measures of occupational performance and performance skills and the gold standard in terms of the sophistication of its psychometric properties (Fisher, 1993).

Frustration

So, we have an almost 40-year history of solving the problem of identified limitations in typical cognitive assessment by creating occupation-based assessments. These tools are completely appropriate to use with our clients throughout the life course who are living with performance deficits secondary to cognitive deficits. However, the next question is, Are we using them in practice? In too many instances, the answer appears to be “no” on the basis of published survey research (Koh et al., 2009; Korner-Bitensky et al., 2011; Menon-Nair et al., 2007) and, I will add, experience. Again, our journey related to this area of practice is colored by an early adoption of the approach to assessment used by our colleagues in other disciplines. Because of this, our journey is also colored by professional blurring and again dual encroachment. I want to read a couple of quotes to you:

None of these quotes are from occupational therapists. They are quotes in the literature from our colleagues in other disciplines. Again, imitation is the sincerest form of flattery. However, I guess our colleagues can say the same about us. Again, I hope you see my concern.

Our colleagues in other disciplines are now developing assessments that use items that clearly represent the authentic use of occupation in an attempt to be a more valid and accurate measure of everyday cognition. Simultaneously, we continue to use (and develop) assessments that can best be described as novel, contrived, and having little to do with occupation and everyday life (Koh et al., 2009; Korner-Bitensky et al., 2011; Menon-Nair et al., 2007).

Here is the current reality. We have already designed, developed, and aggressively tested the psychometric properties of our performance-based cognitive assessments and performance-based assessments in general. We do not need to scramble to create them. We simply need to adopt our own tools and return to our own philosophy, our normalcy. We need to celebrate our decades of work as a profession. Although I referred to some of these tools earlier, there are too many to name in one article. Most are readily available and just awaiting adoption. These tools cover the life course and highlight our unique contribution to this interprofessional area of practice.