Australian Lefty on Politics, Governance, Science and Info Management

More good news, and rationale for visiting OT services

Posted by Dave Bath on 2009-04-20

My extra "pretend-OT/torturer" work has born enough fruit to see my daughter teary-eyed (in a good way), her orthopod stunned, and prompts thoughts about funding "visiting OTs" similar to "visiting nurses" as a good investment.

Over the last few weekends since the car accident I’ve been doing extensive work on my daughter’s arm, manipulating and designing exercises, which luckily my daughter has accepted despite the pain (mainly through nasty "pins and needles" because she trusts my instincts (it’s a long time since I studied anatomy and tissue repair mechanisms).

Her surgeon puts the extent her recovery in her lower arm so far to this work, which has included providing instant aural feedback to my daughter by using one of my grandson’s toy keyboards (some details below which I hope might help others).

This suggests to me that while the visiting nurses (they’ve been changing her dressings every day) are essential to minimize costs, the availability of visiting occupational therapists could do much to not only decrease the suffering of lack-of-function after injury, there would be a significant "business benefit" to government by decreasing the total financial outlays.

My daughter had been classified for Centrelink as needing 2 years on disability payments, by which time there would have been "significant improvement" (not "recovery"), but while her humerus is still misaligned and with a 1cm gap in the middle, she has gone from almost no feeling and movement from the elbow down, to having problems (apart from painful paraesthesia and obvious issues with her upper arm) mainly with extension of wrist and fingers, abduction of thumb, and co-ordination of the flexion she has regained.

The "here are a few exercises for the next few weeks" was all the hospital OT’s could possibly do, but this doesn’t allow for adaptation of the manipulations and exercises in response to improvements, including twitches in particular muscles which would then get more attention.  There was no training of my daughter’s partner in how to manipulate, give appropriate resistance to various movements… etc, etc, etc.

Could people get better results with a better handout sheet of exercises, that said "if you get this change, add in the next exercise?  I think so.  Would this cost much to institute?  No.

Would a few minutes with partners, explaining how to give resistance to movements, how to manipulate bones relative to another (including the "invisible" ones like metacarpal and carpalbones) accelerate improvement?  I think so.  Cost much?  No.

Would a visiting OT, every couple of days during the early critical stages of recovery be useful, so they could assess and modify exercises accordingly, accelerate recovery?  I think so.  Would this decrease costs because time needing disability payments was reduced?  I think so.  Cost effective?  Probably.

Without a program of visiting OTs, taxpayers have the choice of funding more disability payments for longer, or, where patients can’t use public transport (which would cause re-injuries) and don’t have private transport, fund in-patient care.

Mind you, giving standard visiting nurses the groundwork in OT, and allowing this to form part of their duties would be another alternative, although still providing "visiting OT services".  (If I could nut out some things, then surely those experienced visiting nurses could do something similar.)

Perhaps there is not enough thinking by politicians on the relationship between funding of services early in recovery, where hospitals and ancillary services are encouraged to rush and skimp to meet case-mix targets, and the total long term costs via social welfare payments (and the misery of less-than-otherwise function).

The same relationship exists between the extent of mental health services and Centrelink payments, not to mention workforce productivity.

Just as the "phone hotline nurses" give great value, and one of the few good initiatives by the Howard regime, perhaps it is time for the federal ALP government to crack the whip over the states about funding for visiting nurses with a bit of extra training in physio and OT.

Notes/See Also:

  • Previous notes about my daughter’s accident and related matters: "Keyboards: one handed and four-limbed" (2009-04-16), "Up a bit… and solar-powered lights needed" (2009-04-14), "Down…" (2009-04-07)
  • Use of toy keyboard:  
    Toy keyboards (the tiny battery-powered ones suitable for toddlers) might be useful because they give immediate aural feedback, encourage independent finger movement, and are light enough for someone else to hold them at just the correct angle so that shoulder/elbow/carpal movement isn’t required, the (non-thumb) fingers can all reach the keys, and extensors aren’t necessary (the springyness of the keys can bounce the fingers back). 
    • Different patterns (and attempts at syncopation and even timings) are more interesting, and encourage persistence.
    • If you imagine the fingers labelled 2 through 5, the following are the sorts of patterns I’d introduce: 2-3-4-5,   5-4-3-2,   2-3-4-5-4-3-2-3-4-5…,   2-4-3-5-…5-3-2-4  
    • Placing the fingers so that it will sound ok can make a difference, e.g. little finger on a C – although the more musically sophisticated might like to work in A-min going from G through C.  If you have good wrist support, sticking to the black notes can sound nice – as well as demanding control if you want to avoid falling into the gaps.
    • A polyphonic (even two-notes-at-a-time) keyboard can give better feedback, as you can tell whether a finger has got "stuck".
    • If you can change tones (e.g. a tinkle sound and an organ sound), start with the fast attack and decay (piano tinkle) first, so you can concentrate on pressing the key rather than worry about release.
    • Toddler keyboards have keys close together, so an adult can use adjacent notes first without trouble, but later, use a 1-note gap between fingers.  They also require very little strength.
    • When there are twinges in finger extensors, I’ll hold the keyboard behind her hand, so she presses the keys with her knuckles rather than finger pads.
  • Other:
    • I’d giver her resistance against my own fingers, and comment on any strength improvement (which has very useful, because she couldn’t feel much).  This feedback including working thumb flexion in a “shaking hands” position… she could see the dint my thumb was making and get an idea of how well she was doing.
    • When movement was very weak, I’d have my hands around her fingers, feel the movement, and amplify it… which gave feedback to her eyes, as well as positive feedback to the muscle fibres and nerves that were starting to work.
    • It was important to define a useful pain threshold, especially for the pins and needles that would get much worse with any movement – even passive.  I reminded her of the pain of some of the piano exercises (5-4-3 5-4-3 … 3-4-5) that build fitness and independence of the little, ring, and impudent fingers, and said "when your arm hurts as much as it did the first time you tried two octaves up and down, then that’s probably the right amount… because you know that is what is required to make the difference  I don’t know what I would have talked about otherwise that would have seemed reasonable to the "victim" on the pain/gain axis.

2 Responses to “More good news, and rationale for visiting OT services”

  1. Lyn said

    She’s lucky to have you Dave. I don’t know whether I could do it. A scraped knee is one thing. A mangled limb is another thing altogether.

  2. Dave Bath said

    Ta. It is kindof a bonus of being a process/principles person rather than declarative memory – if I understand the basics, I can extend to new situations. (When I did my Medical Sergeant’s course, while I did NOTHING according to the book, and was theoretically a dismal failure (0%), the brass wanted to give me whatever the army calls a H1, because everything I did would have worked, but because of THE RULES, all they could give me was a pass.)

    Of course, I didn’t try anything unless I was 4-sigma-sure it would do no harm.

    And I’m sure that all the visiting nurses have the ability to work safely from general principles… all the ones I’ve met have been experienced and cluey. If I had policy control, the “OT Principles” training of the visiting nurses is how I’d implement these services…. and of course include funding for their time doing the work!

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