meta-ot

Another case of role blurring

2009-05-27T13:40:33+01:00

There are several examples of role blurring with (or due to interaction with) physiotherapists in the British Association of Occupational Therapists' internet discussion forum[1,2,3,4]. Currently, National Health Service physiotherapists seem to be moving away from 'physiotherapy' in musculoskeletal settings towards biopsychosocial treatment. One even suggested scrapping massage as a physiotherapy modality[5]. I believe that physiotherapists are now addressing problems with treatment approaches that would be better addressed by occupational therapists, or perhaps clinical psychologists. This may be detrimental to all of the concerned professions as well as patients, so I wrote a letter to express my opinion[6]. Unfortunately I feel that the editing took some of the weight out of my argument, so the original e-mail is copied below:
"----- Original Message -----
From: Venth
To: frontline [at] csp [dot] org [dot] uk
Sent: Monday, March 30, 2009 9:31 AM
Subject: For the letters page

Dear Sir/Madam

Please do not let the National Health Service destroy our profession.

I am writing in response to various current issues and Julia Squier’s letter in Frontline 18/3/2009 regarding massage and evidence-based practice. It seems to me that there is a bandwagon within healthcare following the belief that “randomised controlled trials are the best way of establishing clinical effect”[1]. Perhaps clinical effectiveness in physiotherapy depends on choosing the best combinations of techniques for individual patients[2], treating whole people rather than reducing them to easily measurable physiological parameters. If so, randomisation will not always be a valid tool for physiotherapy research. I personally believe those that do not recognise massage to be a clinically effective tool may simply not know when or how to use it.

Thirty years from now, if physiotherapists have not reversed the trend towards hands-off biopsychosocial musculoskeletal treatments and generalised exercise classes, what will the public perception of us be? I fear they will gravitate towards osteopaths and chiropractors because they will have no idea what physiotherapy is. There is a big need for psychosocial interventions in primary care today but I do not believe physiotherapy is the best profession to fill that need. Role blurring could be professional suicide. The occupational therapy profession made a similar mistake in the past, which is why they are commonly mistaken for a profession of discharge facilitators today[3]. Perhaps we should learn from their mistake before it is too late.

References:
1. Clemence M. (2009) energy medicine-does it belong in physiotherapy? Available from: http://www.interactivecsp.org.uk/network/viewTopic.cfm?item_id=00C8440EB... Accessed: 8:21 30/3/2009
2. Hunter P.A. (2004) Is physiotherapy any use for back pain? Available from: http://www.bmj.com/cgi/eletters/329/7468/694#75659 Accessed: 8:30 30/3/2009
3. Venth (2008) What is in a name? – Why non-holistic interventions should not be termed ‘occupational therapy’. Available from: http://www.metaot.com/blog/what-a-name-%E2%80%93-why-non-holistic-interv... Accessed: 8:50 30/3/2009

Venthan J. Mailoo BSc (Hons) MCSP CertMgmt"

Are physiotherapists where you work using up their clinical time counselling patients on life satisfaction, lifestyle, stress management, relaxation, pacing and pain psychology? If so, have you ever asked yourself or your therapy services manager why those problems are not being referred to occupational therapists, to free up physiotherapists’ time for the specialised interventions they can offer, that few other professions can?

References:
1. ukblonde (2006) role confusion with physiotherapist. Available from: http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1279&highlight=phys... Accessed: 13:00 27/5/2009
2. Student (2006) In hand therapy are we moving towards a generic role? Available from: http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1512&highlight=phys... Accessed: 13:03 27/5/2009
3. Basic grade (2007)sort them out then. Available from: http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2237&postdays=0&pos... Accessed: 13:11 27/5/2009
4. Rebecca (2009) Amputee withh anoxic brian damage. Available from: http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=3340&highlight=phys... Accessed: 13:14 27/5/2009
5. Squier J. (2009) Consign massage to history. Frontline 15(6):19
6. Mailoo V.J. (2009) Identity crisis. Frontline 15(9):20

Trying to make sense of rheumatological investigations.

2009-05-18T18:46:13+01:00

0. Introduction: I am currently studying autoimmune soft tissue pathologies and unfortunately there is so much overlap between them they all seem to merge into a fuss in my mind. In order to set some concrete divisions I am looking from a medical model approach at antigens and antibodies specific to particular conditions. It is not much practical use to an occupational therapist, but knowing what these tests are used for cannot hurt academically or when interpreting medical notes, and you never know; the knowledge could earn some MDT brownie points. Once again, I am not a biochemist or immunologist so do not take any of this as gospel.

1. Human leukocyte antigen genes:
HLA-DR3 is associated with Sjögren's syndrome
HLA-DR4 is associated with rheumatoid arthritis
HLA-B27 is associated with spondyloarthropathies

2. Antibodies:
Anti-cyclic citrullinated peptide antibodies (anti-CCP): may indicate Rheumatoid arthritis

2.1 Anti-neutrophil cytoplasmic antibodies (ANCA): are markers of vasculitis
Cytoplasmic ANCA: are highly specific for Wegener’s granulomatosis
Peri-nuclear staining ANCA: suggest polyarteritis nodosa, microscopic polyangiitis or Churg-Strauss syndrome.

2.2 Anti-nuclear antibodies:
Anti-double stranded DNA antibodies: may indicate systemic lupus erythematosus or autoimmune hepatitis
2.2.1 Anti-ENA (Extractable nuclear antigen)
· Anti-Sm (Smith) antibodies: indicate systemic lupus erythematosus
· Anti-Ro (SS-A) and Anti-La (SS-B) antibodies: may indicate Sjögren's syndrome, congenital heart block, or cutaneous lupus.
· Anti-centromere antibodies: indicate CREST scleroderma
· Anti Scl-70 (topoisomerase I) antibodies: indicate bad prognosis scleroderma
· Anti-Jo-1 antibodies: may indicate interstitial lung disease, arthralgia and Raynaud’s phenomenon (in polymyositis / dermatomyositis)

Bibliography:
1. Lane S.K., Gravel J.W. (2002) Clinical utility of common serum rheumatologic tests. American Family Physician, 65:1073-80.
2. Marsland D., Kapoor S., Coote A., Haslam P. (2008) Crash Course Rheumatology and Orthopaedics. Mosby: Edinburgh
3. Reichlin M., Harley J.B. (2006) Antibodies to Ro/SSA and La/SSB. Chapter 25 in: Wallace D.J., Hahn B., Dubois E.L. (eds) Dubois' Lupus Erythematosus. 7th edition. Lippincott Williams & Wilkins: Philadelphia. Pp.487-499

yoga and stroke

2009-04-05T03:52:05+01:00

Hello,

As a Masters of Occupational Therapy student, I am undertaking a project exploring benefits and application of Yoga for post stroke clients. There is lot of research supporting the benefits of applying Yoga for various disabilities but there seems to be lack of literature on how to adapt Yoga for post stroke clients. I wish to evoke a discussion on how yoga is being adapted and applied with stroke clients and with what therapeutic gains.

I invite your participation in the discussion about Yoga and stroke at my blogsite, http://strokeofyoga.blogspot.com/. What is likely to emerge out of this is a real-time, practice-based information on the topic. So, please come and share your experiences, ideas, and suggestions about the topic and join in an open & healthy discussion with other like-interest practitioners.

Please share any information along the lines of what type of Yoga is used, how often, how is it adapted, which specific Yogic concepts are used, and how long it takes before the results are seen.

I project to start summarizing the blog site activities by May 15th 2009.

I sincerely appreciate your time and consideration. Your contribution is indispensable to the success of this undertaking and for future growth of knowledge in this area.

Sincerely,

Rashmi Bhatia, OTR/L

Occupational Alienation – a personal perspective

2009-03-23T15:40:22+00:00

Abstract: This blog entry reflects on my personal feelings of occupational alienation and how they were stimulated by the use of occupational alienation and occupational injustice as weapons in a foreign country. It provides examples of politically and internationally generated occupational risk factors. Finally it describes my self-treatment using the limited means I have. Luckily for me, those means are far less limited than those available to people in the country that inspired this blog. THIS BLOG INCLUDES PICTURES FROM WAR, INCLUDING DEATH. YOU MAY THEREFORE WISH TO AVOID READING IT. The pictures in the referenced material are much worse and are likely to shock most people, so think carefully before looking at material from the reference list. Thank you.

Introduction:
The other day I stumbled upon a vulgar article in a year 2000 issue of the Lancet: “Of the 184 men, 38 (21%) said they had been sexually abused during their detention. Three (7%) of the 38 said they had been given electric shocks to their genitals, 26 (68%) had been assaulted on their genitals, and four (9%) had sticks pushed through the anus, usually with chillies rubbed on the stick first. One said he had been forced to masturbate a soldier manually, three had been made to masturbate soldiers orally, and one had been forced with his friends to rape each other in front of soldiers for their “entertainment”…… The injuries were: thickening and tenderness of final 1–2 cm on urethra of a man who described a soldier pushing an object inside his penis; a scar on the base of shaft of penis of a man who said that soldiers had repeatedly slapped a heavy desk drawer shut on it; an irregularly defined defect in the foreskin of a man who said that soldiers had tied some string around his penis and pulled, tearing off a piece of his foreskin; and a cigarette burn on the scrotum of a man who said that soldiers had stubbed cigarettes out on his genitals.”[1] The victimised community described in the article has to date received no tangible protection from the international community, yet, when it raised its own army to protect itself, that action was deemed to be ‘terrorism’ and supporting or even just receiving literature from that army is illegal in Britain today![2] Superficially this appears to be a gross and nonsensical internationally imposed injustice. This blog entry is about my personal perspective of the issue, how it has damaged my psyche and the limited occupational opportunities I am aware that I could use to repair it.

Background:
Personally I do not believe that history is an excuse for current atrocities in any situation but it may provide some understanding of the racial hatred underlying the inhumane acts described above.

Religious stories: According to Hindu scripture the land now known as Sri Lanka was inhabited by a demonic race until it was conquered by an army of demigods incarnated as monkeys, animals and God himself incarnated as Rama[3]. A Buddhist account of Sri Lankan history similarly states that serpentine humanoids, ghosts, and primitive aborigines occupied the land until the sixth century BC when it was colonised by a half-man-half-lion exiled from India, leading 700 exiled criminals of Aryan descent, that later interbred with the family of Buddha to become the Sinhalese race[4, 23]. Indian missionaries progressively converted the Sinhalese people to Buddhism from about 250 BC until they developed into an advanced entirely Buddhist civilisation[4]. According to this account growth of the civilisation was disrupted and great suffering was caused by various Saivite Tamil invasions from 103BC onwards and Indian influences that tried to destroy Buddhism. According to one Sinhalese source, Tamils made up 12.5% of the population[5].

European conquerors: Portuguese invaders that forcefully propagated Catholicism from 1505 further threatened Buddhism. From 1658 Buddhism was threatened by a Protestant schooling and legal system set up by Dutch colonists. The last Buddhist king in Sri Lanka was removed from his throne 2/3/1815 by British conquerors that (it is claimed) systematically oppressed Buddhism while trying to propagate Christianity[4]. They brought with them a Tamil workforce from India, bringing the Tamil population up to 18%[5]. Tamil people were over-represented in professional and administrative jobs until 1948 when the British handed control over to the Sinhalese people[4, 6].

Sinhalese rule: The Sinhalese government denied the citizenship of 30% of the Tamil people[5, 6], pronounced Sinhala the national language and Buddhism the national religion[6]. The Tamil people began non-violent protests against this legislation because many of them could not understand Sinhala. Their protest was broken up by a large mob that sparked off the first anti-Tamil riots in 1956[7]. In 1957 the government signed and agreement (Bandaranaike Chelvanayakam Pact) to allow some Tamil autonomy in the North and East of the country, but the agreement was not honoured because Buddhist monks protested against it claiming it was betrayal of Sinhalese-Buddhist people[8]. A Buddhist monk assassinated the prime minister Solomon Bandaranaike in 1959, to prevent him instigating a system of federal government[6, 13].

The Sinhalese nationalist Janatha Vimukthi Peramuna (JVP) movement tried to take over the country by force in 1971. Their attempted uprising was quashed but they remained as an underground organisation, killing any politicians opposed to their views and the families of armed forces personnel[9]. The military retaliated by abducting and killing people thought to be associated with the JVP, leaving their smouldering burnt bodies in public view[10]. One of the JVPs political spokesmen from that time was Mahinda Rajapakse. Now (at the time of writing this blog entry) he is the president of Sri Lanka[10]. Ironically, the method of control the government once used against him is still in operation today under his government, and it has been estimated that over 40000 people have ‘gone missing’ in Sri Lanka so far[9].

Ethnic cleansing: The anti-Tamil riots of 1956 were followed up by targeted attacks on Tamil people all over the island[7]. Hundreds of Tamil people were murdered and thousands assaulted during another wave of riots in 1958[7]. Tamil homes and businesses were looted and destroyed forcing 25000 refugees to relocate to the north[7].

“The terrible incidents that took place when I was living with my parents in Puttalam in 1958 are still fresh in my mind. Hundreds of innocent Tamil people were massacred. Pregnant Tamil women were put into tar barrels and burnt alive. I am still unable to overcome the trauma of hiding in a haysack after losing my father, getting loaded like cattle with hundreds of others into a lorry, and wandering as a refugee”[22:piii].

During 1977 elections, a political party called the Tamil United Liberation Front was successful in Tamil-dominated geographical areas. Sinhalese nationalists responded with pre-planned, organised anti-Tamil riots[7]. In 1981 the Jaffna Public Library was destroyed during an army-imposed curfew[6]. As the event took place during a forced curfew it is believed that the destruction of the library was either carried out by, or authorised by the government[6].

Following an attack by Tamil militia that killed 13 soldiers on the 23rd of July 1983 a rumour was spread on the 25th of July that the Tamils were going to attack the capital city Colombo[14]. This led to another series of anti-Tamil riots. Surviving victims claim that mobs had been given lists of Tamil people and residences from the electoral register so that they would know who to attack[6, 14]. According to the BBC[6] a government minister was seen in the street directing the mob towards Tamil homes and businesses. Western tourists and journalists that were in the area at the time said that government troops did nothing to stop the riots and in fact, stopped people from putting the fires out[16]. According to witnesses, soldiers re-directed fleeing Tamil people to a mob that killed them and burned their bodies with tyres[14]. Hundreds of Tamil people were killed and hundreds of thousands of refugees fled to India[7]. The South of the country became almost devoid of Tamils, and many of those that remained "forcibly disappeared" over the next 25 years[7]. The allegations of attacks by Sri Lankan forces on Tamil civilians are too numerous for me to critically analyse, but they were summarised by a Sinhalese man here: http://www.youtube.com/watch?v=ZLmwBhUwfac and are catalogued on this web-site: http://www.srilankanatrocities.com/ Examples include children being hung in front of their parents or raped before being killed, and orphanages being bombed by the Sri Lankan air force. Despite these atrocities the British Special Air Service Regiment (SAS) trained Sri Lankan armed forces until 1988[18], and United States Special Forces provided similar services to the Sri Lankan government as late as 1997[19]. On the 2nd of May 2007 it was said in the House of Commons regarding arms exports “£7 million-worth of arms were licensed for delivery to Sri Lanka in the last quarter for which figures are available”[20]. Sri Lanka also receives arms from India, Pakistan and China[21] so it could be argued that ethnic cleansing to remove the Tamil people from Sri Lanka is in fact an international effort.

The rise of Tamil militia: Following the repeated failures of peaceful protests to end racist atrocities against the Tamil people of Sri Lanka several protective Tamil militia groups formed. The most notorious of these, ‘Liberation Tigers of Tamil Eelam’, did not form until 1972[6], and emerged in 1975[11]; 19 years after the ethnic cleansing of Tamils began. Other militia included the Tamil Eelam Liberation Organisation (TELO), the People's Liberation Organisation of Tamil Eelam (PLOT), the Eelam People's Revolutionary Liberation Front (EPRLF), the Eelam Revolutionary Organisation (EROS) and the Eelam National Democratic Liberation Front (ENDLF) [17]. On the 23rd of July 1983 the Tigers attacked a unit of the Sri Lankan army whose soldiers had been accused of raping Tamils[14] and killed 13 soldiers[15]. According to Douglas Wickramaratne[16] the Tigers amputated the soldiers hands and removed their wedding rings. This was the attack (mentioned earlier) that many consider led to the 1983 anti-Tamil riots[15].

Liberation Tigers of Tamil Eelam fall into disrepute: It is believed that following the mass exodus of Tamil refugees from Sri Lanka to India that resulted from the 1983 riots, several militant Tamil groups were armed and trained by India[15]. During subsequent conflict between the various Tamil groups, it is widely believed the Liberation Tigers of Tamil Eelam absorbed or eliminated the other groups by killing their leaders and moderate Tamil politicians[17]. On the 14th of May 1985 the Tigers shot 146 Sinhalese civilians at Anuradhapura to avenge the killing of 70 Tamil civilians at Valvettiturai by the Sri Lankan army[15, 24]. By attacking civilians and alienating Muslim people[24] the Tigers established themselves as a terrorist organisation, leaving the Tamil people with no legitimate force of protection against continuing atrocities by the Sri Lankan armed forces and police. Time-lines of attacks attributed to the tigers can be found here: http://www.reuters.com/article/worldNews/idUSSP33257120080202?pageNumber... or here: http://news.bbc.co.uk/1/hi/world/south_asia/51435.stm According to secondary sources, the Tigers are currently using Tamil civilians as a human shield; shooting those that try to escape, and in one case, even amputating a lower limb to prevent a person from running away[38].

Inability to maintain peace:
The modern history and politics of Sri Lanka are too complex for me to spend any more time on. Too much water has passed under the bridge for analysis in this blog entry. A brief history of government incompetence and conflict between two brutal uncompromising sides can be found here: http://www.uthr.org/Reports/Report4/chapter2.htm The last ceasefire between the Sri Lankan government and the Tigers (agreed in 2002) was violated by both sides. Examples of this include when “alert Naval troops off the sea in Mannar destroyed one more LTTE arms trawler with several LTTE terrorists aboard the vessel”[26, 27] only to suffer a revenge attack the next day, killing 92 Navy personnel[27].

Occupational injustice and alienation suffered by Sinhalese Buddhists:
The survival of Sri Lankan Buddhism has historically been subjected to significant threats. From the time of Portuguese occupation there “are lurid accounts of men thrown into rivers to be eaten by crocodiles, babies spitted on the soldiers’ pikes and held up before the parents, or crushed between millstones before the eyes of their mothers who later were to be tortured to death” [4:p71]. Under Dutch rule “civil rights and inheritance depended on a person’s church affiliation. No person who was not a Christian could hold even a minor office under government, no person who was not a Christian could get married legally or register the birth of a child”[4:pp 75-76]. The under-representation of Sinhalese people (compared to Tamil people) in government and professional jobs under British rule was their final occupational injustice. Perhaps therefore it is not surprising that a fearful and defensive subculture has evolved within Sri Lankan Buddhism, characterised by Buddhist monks believing that Tamil people from India wish to take over the whole of Sri Lanka and pressuring the government to make no concessions to the Tamil people[25]. The belief that India armed and trained Tamil militia in the 1980s adds credibility to this fear.

Occupational alienation of Sri Lankan Tamil people:
Can you imagine Buddhist monks killing ministers of parliament, the police and army coming to your house and raping your family with no fear of punishment, or the British government ordering the assassination of journalists here? Sitting in the comfort of University accommodation in England, it was hard for me to imagine people can be so uncivilised until I saw pictures of atrocities that are probably still ongoing as I type this blog now. How about if the national language of Britain was changed to Sinhala, so that the all the road signs were in Sinhala, the police spoke only Sinhala and when arrested you would be tried in Sinhala? You would not be able to get into University unless you would read, write and speak Sinhala. Can you imagine how life would be? Our inability to imagine the predicament Tamil people in Sri Lanka have suffered for the last 53 years leaves us unable to understand their culture and the ground ripe for their occupational alienation. This alienation has not occurred completely by chance or bad luck; it is continually being engineered as a weapon of war. I have put a few examples that spring to mind below:

Re-writing history: Anybody reading Buddhist accounts of Sri Lankan history could be forgiven for believing that it was a unified Buddhist nation with insignificant non-Buddhist populations. The aboriginal people were only briefly mentioned and given insignificant attention[4]. The Hindu population was described as “sannyasis or yogis who practised asceticism and sometimes lived in cemeteries scantily clad, with bodies covered in ashes, and as the story says, pretending to be saints while at the same time they led sinful lives”[4:p28]. In fact, impartial sources state a Tamil kingdom was established on the island in the 14th century[13] and some Tamil authors claim that the aborigines described in the Buddhist history were Saivite Tamil people[22]. Needless to say, it is those in power that write the official history, and the BBC follows the Sinhalese-Buddhist version[28]. What then happened to the aborigines? Was their continuing existence and culture written out of history, or did they disappear into oblivion? The burning of the Jaffna library was instrumental in destroying evidence of Sri Lankan Tamil history.

Control of the media: I guess that there is a high probability that before you read this blog entry you had heard of ‘Tamil Tiger Terrorists’, but had you ever heard of the anti-Tamil riots of 1956, 1958, 1977 and 1983? Did the media ever tell you that the Tamil people in Sri Lanka endured 19 years of atrocities before finally taking up arms? Did you ever hear of the Chunnakam Market, Othiyamalai, or Mannar massacres in 1984, Valvettithurai, Kumudini Boat, or Killiveddy massacres in 1985, Akkaraipattu massacre in 1986, Prawn Farm massacre (allegedly carried out by police trained by the British SAS[18]) or Jaffna Hospital massacre in 1987, Kalmunai, Eastern University, or Batticaloa massacres in 1990, Kokkadichcholai massacre in 1991, Mylanthanai massacre in 1992, Jaffna Lagoon massacre in 1993, Kumarapuram massacre in 1996, Tampalakamam massacre in 1998, Mirusuvil massacre in 2000, Trincomalee, Allaipiddy, Vankalai, Muttur, or Pottuvil massacres in 2006? Why is this? It is because occupational alienation is key to allowing the extermination of a race to go unnoticed.

When reporting on Sri Lanka the media usually describes atrocities committed by the Tamil Tigers, but rarely on the reasons for their actions. The BBC for example describes the 1985 Anuradhapura massacre as carried out by the Tamil Tigers but makes no mention of the Valvettithurai massacre that provoked it[15], similarly attention has been paid to the Tigers closing the sluice gates of a reservoir[29] ignoring the reasons behind the action[30]. Throughout the history of the conflict the Tigers have been accused of attacks that they themselves denied involvement in. According to one Tamil author, the Tigers denounced the 1985 Anuradhapura massacre as “senseless violence”[31:p119], yet it has been recorded in history as having been perpetrated by them. The victims (or those close to them) of several attacks officially attributed to the Tigers actually believed the perpetrators to be government forces. Douglas Wickramaratneeven for example, broadcast claims that the 1983 anti-Tamil riots were planned and orchestrated by the Tamils[16]. More recent examples of this include rapes routinely blamed on the Tigers before formal investigations[32], the hanging of children in Mannar[33,34] and the killing of 17 workers from the international aid group Action Contre la Faim[35]. According to international press, the Tigers are “preying on tsunami orphans to use as child soldiers” [36] and “using threats and intimidation tactics to extort money” [36] from Tamils living outside Sri Lanka, even ordering them to re-mortgage their houses to fund the war. Impartial sources have reported that the Tigers fund their campaign by human trafficking and smuggling drugs[17]. The Tigers have also been linked to Al Qaeda and other militant Islamic groups[37]. This kind of information serves to alienate the Tigers by putting them securely in the ‘terrorist’ box. As Sri Lankan Tamil people have no other force of protection, alienating the Tigers essentially disarms the Tamil population. The government is denying international journalists access to the war zone[38] preventing the world from hearing exactly who the perpetrators are directly from the victims of the conflict. When journalists were permitted to see a ‘show camp’ where refugees were being held by the army, aid workers asked the journalists not to speak to the inmates for fear that armed guards would later punish them for speaking[38]. Journalists reporting views contrary to government policy are routinely abducted and killed[38].

2002 saw the release of the film ‘In the Name of Buddha’ illustrating the suffering of Tamil people at the hands of the Sri Lankan and Indian armed forces. The film won best foreign film awards at the Beverly Hills and Newport Beach film festivals[39]. If you look for the film now I doubt you will find it anywhere. How can a film just disappear? If you know where I can get a copy, please let me know.

Legislation: Though conveniently written out of Sinhala-Buddhist accounts of Sri Lankan history, the aboriginal people of the island must have been subjected to the same occupational alienation and injustice under the rule of European conquerors as the Sinhalese people were. Those that thrived did so by learning English and/or converting to Christianity. The difference between the Sinhalese people and minority groups in this respect, was that the minority groups continued to suffer after the occupational alienation of Sinhalese people ended in 1948. The Official Language Act No. 33 of 1956 declared Sinhala to be the only official language[12] thus baring Tamil people that could not understand Sinhala from university education[6] and government jobs[9]. Denying 30% of the Tamil population Sri Lankan citizenship was a clear case of occupational alienation.

Occupational Injustice suffered by Sri Lankan Tamil people:
Looking at the ethnic cleansing very crudely and insensitively one could say that denying a group of people life based on their race is an occupational injustice. To a lesser extent, denying them the right to live in certain areas where people of other races are permitted to live is also an occupational injustice. The ethnic cleansing mentioned earlier in this blog entry is therefore a cause of gross occupational injustice. Less extreme examples are restrictions on freedom of movement based on race[40]. The disadvantages created by engineered occupational alienation are a profound source of injustice, but perhaps most damaging of all is the restriction of freedom of speech. There are no international laws to stop the free flow of propaganda from the Sri Lankan government or by Sinhalese groups yet anybody speaking out against the Sri Lankan government or asking for a separate state for Tamils puts himself or herself at risk of being accused of supporting terrorism. In Sri Lanka this often results in abduction and execution. Anything that can be seen as glorification of the Tamil Tigers may be illegal in the United Kingdom[41]. This means that though the Tigers may try to counter defamation with their own media[42], that media is illegal in the United Kingdom. Sri Lanka is currently experiencing conflict between two terrorist organisations; the Tigers and the government. Imposing communication restrictions on just one of these two parties is an occupational injustice.

Regarding armed conflict, the fact the United Nations turned a blind eye while the Sri Lankan military massacred Tamil civilians[43] at a time when the Tamil people’s only armed resistance has internationally been deemed illegal was an occupational injustice. The same applies to the perception that it is was wrong for the Tigers to re-arm during cease-fires while growth of the Sri Lankan armed forces was acceptable. This belief led to the Sri Lankan military attacking Tiger boats during the last cease-fire period, inspiring revenge attacks that were deemed unacceptable by the international community[26, 27].

My personal experience:
Construction of my identity: I was born in England and have always been a British citizen. I first visited Sri Lanka at the age of 4 and was blissfully unaware of the politics or violence. My only memories of that time are the painful boils from mosquito bites, the huge spiders and feeling like I had been abducted when a strange relative took me somewhere without my parents. I remember representatives from the various Tamil militant groups collecting money at social gatherings in England. I even remember putting money in their pots, but that stopped when the various groups started fighting with each other; funding them seemed like a nonsense from that moment on. My parents had kept me isolated from British society up until that time. I am not sure whether that was to protect me, or the future of their culture. They also sent me to a Tamil school on Saturdays that I resented because I wanted a 5-day working week just like everybody else. I remember hearing bad news about Sri Lanka every so often. There were stories of the army sealing bus doors closed and burning everybody inside alive with petrol. Those stories would take a twist much later in my life.

My next visit to Sri Lanka was when I was about 11. The first things I noticed were the dogs and cows that took themselves for walks down the streets, huge flying cockroaches and the big ants, closely followed by the indoor gecko. Then I noticed there were no attractive girls in Sri Lanka. I did not find Asian girls attractive because they reminded me of my sisters, and having grown up surrounded by white girls I only found them attractive. That was enough to convince me I wanted nothing to do with Sri Lanka despite the nice weather, fruits and beaches. I spent the rest of my childhood living in dread of arranged marriage. After a brief stay in the south we went to the North that at the time was occupied by an Indian Peace Keeping Force. There were army checkpoints everywhere fortified with sandbags and armed with machine guns. A curfew was in place from 19:00hrs to 7:00hrs every day, and anybody that went outside during those times was shot by the Indian army. The back garden of my grandmothers’ house was full of military paraphernalia. There were 7.62 cases and separated machinegun link everywhere. I remember linking cases together to make a belt and packing it in my suitcase to bring home. My mother unpacked it and threw it away without telling me, to avoid any trouble at the military checkpoints when we left. Fragments of various munitions such as mortars and rocket-propelled grenades were also strewn all over the garden and one tree trunk had a hole right through it. I was warned to avoid touching any of it because my cousin had managed to blow his thumb off by doing so. My cousin’s house was half burnt out with only a few intact rooms remaining.

My uncle told me the people had welcomed the Indian army with flowers when they arrived, thinking they would offer protection from the Sri Lankan army and police. One of my relatives had previously been suspended by his big toes and had chilli powder rubbed into his eyes while Sri Lankan forces personnel beat him. Peace did not last though. According to a Tiger propaganda web-site the Indian prime minister signed a peace agreement with the Sri Lankan prime minister regarding the future of the Tamil people, without including Tamil groups in the process[44]. This resulted in conflict between the Tigers and the Indian army. The Tigers had been fighting the Indian army for a while before we arrived. While I was eating breakfast one morning the Tigers attacked a military checkpoint on my grandmother’s street. There was an explosion and gunfire, but everybody just calmly continued eating their breakfast as if it was a daily event. Later, one of my relatives told me that violence in Jaffna was like rain in England, and that the community had become so desensitised to it that they previously continued with their daily shopping while being bombed by the Sri Lankan air force. One day the Tigers showed up with a baby elephant during festivities at the Temple behind my grandmother’s house. A short while later the Indian army showed up and the Tigers disappeared. One of my cousins had joined the Tigers but left and went back home. My father took me to visit one of his friends whose only son had been killed in action as a Tiger. He seemed to have a very calm resigned sadness about him. I remember him giving me sugar cane. My thumb-deficient cousin told me he wanted to be a Tiger. I wanted to be a Tiger too. From my experience of being there, I feel that at the time the people favoured the Tigers. That is not surprising, as it was believed that the Indian Army was responsible for the 1987 Jaffna Hospital massacre. I also heard talk of rapes, though nobody was going to speak to me directly about that as an 11 year old boy. At the time I naively ignored what I heard because my father had brainwashed me into believing that Hindus only used sex for procreation and for no other reason. I therefore doubted that Indian or Sri Lankan soldiers would rape Tamil women. The worst thing I saw Indian soldiers doing was beating up a man with their sub-machine gun butts by the roadside and the worst thing I saw the Tigers doing was tying a woman to a tree and cutting all her hair off. In my juvenile naivety the conflict simply added excitement to my holiday. I remember back in England hearing on television news (I believe it was the BBC) that British colonists introduced the Tamil population to Sri Lanka as a workforce for tea plantations. My mother was infuriated that history had been re-written and she went straight to the telephone and called the BBC to tell them Tamil people had lived in Sri Lanka for thousands of years. The account presented by the BBC has since improved, but it still reflects the Sinhalese-Buddhist view neglecting the Tamil history[28].

Occupational alienation due to racial stereotypes: A few years later and wiser I became disillusioned by the fact Sri Lankan Tamil people were killing each other. I had heard British people likening the Tigers to the Irish Republican Army many times. I also had Sinhalese friends so I wanted nothing to do with the Tigers. The books ‘Bravo Two Zero’ and ‘Who Dares Wins’ inspired me and I decided I wanted to work for the British SAS instead. It was a fantasy that I did not think would ever become real. Much later, during my first year at University a girl I liked that had been flirting with me for several months told me that nothing could happen between us because I was from a different culture. This experience hurt me quite badly and I found myself looking at all of the Asian stereotypes portrayed in the media, wondering whether people associated them with me. I was not proud to be Tamil because by then I was ashamed of the brutality of the Tigers and the disgraceful behaviour of some Tamils in London[45]. I started to notice racist graffiti that I had previously been oblivious to and remembered previous incidents of racism that I had previously been unaffected by. Other than some overt racial harassment I had experienced during a summer job, the most prominent memory I had was skinheads throwing stones at my brother and trying to terrorise my family. The police came to our house but I do not remember them actually doing anything about it. I systematically removed all traces of my ancestry from my persona. I took up Buddhism because I considered it less dogmatic than Hinduism and more applicable to life. I even stayed in a Theravada Buddhist monastery for a week to see what life would be like if I became a monk. The Abbot told me he was ashamed of Sri Lankan Buddhist monks and that they should give up their vows before entering politics but I did not really understand what he was talking about. I began a military career with the Royal Engineers (TA). I heard rumours that the SAS had operated in Sri Lanka but I ignored them. My military identity was a trump card for me whenever I faced racism or people questioned my national identity due to the colour of my skin. After a two-month holiday in Canada and America I flew back from John F. Kennedy Airport on the day of an international air travel security scare related to liquid explosives. I remember the border guard between Canada and the United States being very hostile towards me until I whipped out my MOD90 card identifying me as a British Army officer. Suddenly his attitude changed entirely. It was as though I was part of a club. I managed to work for some of the country’s most elite units. It was then; at the peak of my career that one of my seniors said to me “Are you Tamil? You know the Tamil Tigers? They are the most brutal terrorists in the world. You know they sealed civilians in a bus and burnt them alive?” At this point I wondered how naive the British government and elite British soldiers were to think of this as a one-sided conflict, but thought it best to bite my lip to avoid jeopardising my hard-earned career. I remained indifferent to the troubles in Sri Lanka until very recent times. I have heard the odd story, such as a relative being found dead in a well and my cousins being orphaned, but I am ashamed to say I feel desensitised and heartless regarding such things. A huge tree was recently stolen from my mother’s garden during an army-imposed curfew, leading my mother to believe the army stole it, but this is a minor problem. Tigers come to my home about once a year asking for money. When I tell them I am not interested they just leave politely. I have seen a lot of racism from Sinhalese people on the internet[46] but similarly have seen Tamil people being racist towards Sinhalese people[31]. It was exposure to information about babies being killed by artillery[47] that drew my attention to Sri Lanka over the last few weeks. Another Tamil student I met at University seemed more concerned with the cricket. He told me that even though the violence is particularly heated now, he does not believe it will ever end and has therefore accepted it as a normal part of life. I am not so hardened. I made the mistake of looking at pictures from towns shelled by the Sri Lankan army and saw one baby with a partial traumatic hindquarter amputation and another partially decapitated[48]. After that I was no longer able to ignore the situation and started looking into it.

Deliberately engineered occupational alienation: News reports stating that the Tigers are extorting money from Tamil people in Britain[41] do not match my experience so I phoned an uncle that runs a shop yesterday and asked him if the Tigers have ever threatened him. He also told me that they occasionally visit and ask for money, but leave him alone when he refuses. As the Tigers are illegal in this country I doubt they present an overt infrastructure, so it would not be possible to check that people making threats are real Tigers, or have them disciplined by their seniors. I spoke to a cousin in Southern Sri Lanka on MSN messenger recently and he told me that the Tigers have ruined the country. He told me that when he lived in a Tiger controlled area he was not permitted to watch movies. “Do not give the Tigers any money” he said. I asked a couple of personal questions to authenticate his identity, but he could not remember the answers. His communication was abrupt. He said he had to study for an exam, and then he logged off, so I did not get any useful information out of him. One of my friends was a Tiger at the age of 12 but subsequently ran away. I asked him if he believed the Tigers would use civilians as a human shield and he told me that the only Tamil people they terrorised were those considered to be traitors. He said he went to the Tigers voluntarily after seeing members of his family killed and was given military training but was not permitted to fight because he was too young. Everybody I speak to agrees that the Tigers are brutal, but first hand accounts of people I speak to do not match the reputation portrayed by the media. Propaganda linking the Tigers to Islamic terrorist groups is not consistent with propaganda saying the Tigers terrorise Sri Lankan Muslims. It may be one or the other, but I cannot understand how both of these allegations could be true. I personally believe they were fabricated to help place the Tigers in the ‘terrorist’ box. Finally, on the 6th of March 2009 I received an e-mail saying “This is the destiny of the innocent Tamil civilians who tried to escape into government controlled areas. If caught they will be burned alive!!!!!!!!!!!!!! Extreme brutality of LTTE…… Burning their own people A L I V E !!!!!1……” It appeared to have been sent from a Anuradha Wijesekera (6/3/2009) to a Shanika Ranasinghe to a Chris Desilva to a Dulsri Ranjan Weerasinghe who was kind enough to forward it to me. Strangely I had seen the exact same pictures before on a web-site claiming to show the effects of Sri Lankan Army shelling on Tamil civilians[48]. The HTML alternate text of the pictures in the e-mail was “Tamil%20Genocide%20”, which funnily enough was the exact same alternate text that was on the web-site. The injuries in the pictures were not consistent with small arms fire or burning alive. Bodies were completely mangled and heads or limbs had been blown off suggesting heavy weaponry. I had just witnessed somebody trying to re-write history to discredit the Tigers. When I replied to the e-mail with my quires I received the response “These are NOT my pictures They are being circulated/forwarded on the WEB”. I believe the Tigers are a terrorist organisation, but now that I have seen how easily people are duped, I wonder how much of their reputation is actually deserved, and how much should be attributed to the Sri Lankan armed forces. Some time ago, my father was admitted to Northwick Park Hospital with respiratory problems. I remember one of my uncles who is a doctor standing at the entrance to the hospital during visiting time. He was staring at a sign that said ‘Welcome’ in several languages. Tamil was amongst those languages. He pointed to it and said: “Look, we have more freedom to use our language in this country than we do in our own!” When I asked him what he meant, he told me that Sri Lankan signs were written in Sinhalese only. Reflecting on this I feel glad to live in a country where racial equality is valued.

My investigation of the problems: It was while researching the subject I found news reports of 108 out of 950 Sri Lankan soldiers on a United Nations mission to Haiti being returned to unit due to rape, child abuse and sexual offences[49] and allegations of mass rape made against the Indian Army in Manipur[50]. Now the allegations I heard before seem completely plausible. I also learned that the police unit accused of the 1987 Prawn Farm Massacre were actually trained by the British SAS[18]. Though Tiger propaganda is illegal, ridiculously false information still streams from Tamil sources[51]. Looking at a less extreme video I could hear a lot of screaming and see many people running around creating an appearance of chaos, but there were relatively few obvious casualties[52]. This led me in my heartless frame of mind to wonder whether people were playing up to the camera. It seems clear to me that two terrorist groups plague Sri Lanka at the moment. Due to mass propaganda it is difficult to determine which is the lesser of the two evils. To do this I looked at an impartial source:

"The overwhelming majority of Sri Lankan clients seen by the Medical Foundation in the past year were Tamil, with just three giving their ethnicity as Sinhalese. This accords with findings by Amnesty International and Human Rights Watch (HRW) who in recent country-specific reports have highlighted the Sri Lankan government’s strategy of targeting members of the Tamil community………Where religion was specified, 61 clients declared themselves as Hindu, 14 were Catholic, and five were Muslim…………Several women who were detained by security forces or paramilitary groups while seeking to find their husbands were raped by the very authorities they had sought help from…….Out of 115 where the perpetrator was named, in 79 cases the perpetrators were the Sri Lankan Army, with the Sri Lankan navy named in a further 14. The Karuna group was named in 11 cases, and the LTTE implicated in 15."[53:p4-5]

Karuna is an agent of the Sri Lankan government wanted for war crimes[54]. That means according the above sample only 13% were victims of the Tigers; the rest being victims of government forces. This sample may not of course be representative of the country. Perhaps the Tigers kill more of their victims leaving less to seek help for recovery from torture. Perhaps Sinhalese victims are less likely to flee the country to seek help due to greater social support from the Sinhalese majority. Any number of factors could have influenced these statistics. We will only ever get a true picture of what is going on in Sri Lanka if the survivors of atrocities are given full protection from the Sri Lankan government and the Tigers to enable them to testify without fear.

How this experience affected me:
During my military training I was shown pictures of dead people that had been hit by various weapons. This was to enable other soldiers to gather intelligence about enemy weaponry from corpses and to psychologically prepare me as a medic for treating battlefield casualties. At the time, other soldiers in the same position surrounded me, so I felt undisturbed. Seeing mutilated babies a few weeks ago had a much more profound affect on me. I was unable to sleep and unable to concentrate on work. This was because the images I was seeing were happening in real time; they were not from a past that I could not change. I knew that as I sat blissfully studying at University, the killing was ongoing. I am aware that killing like this is happening all the time in various places from Dharfur to the Congo, but I believe I was born Tamil for a reason and therefore have more responsibility to do something about this particular problem. I felt fortunate that my parents had fled the country long ago to give me a better life, but I also felt like a deserter that had turned my back on my people. My military background made this harder for me to deal with, because if I had never had military training it would have been easier to rationalise that there was nothing that I could do. Up until this point I had not really identified with Tamil people since my teens. Solid knowledge of British involvement in arming and training the Sri Lankan military changed my opinion about British Army careers. I can no longer ignore the fact that British armed forces have secretly taken part in unethical military campaigns since at least the 1970s, and no longer feel any pride about the British army. I feel unable to recommend careers in the British military to people and will actively discourage Tamil people from joining. The problem with that is that my involvement in the British armed forces was a key component of my British identity. Now I am clearly aware that even by paying taxes I may effectively be contributing blood money to foreign military campaigns. Events in Sri Lanka have therefore diminished my sense of British identity. On Sunday I visited another Buddhist monastery of the Theravada tradition. I was unable to look at the monks the same way. I wondered what their political beliefs were, and whether they would advocate the genocide of Tamil people. I may never be able to look at Buddhism the same way again. If this is not occupational alienation, I am not sure what is.

Personal solutions: What could I do? My first animalistic impulses when seeing the pictures were despair, anger and a bloodlust for revenge, but I am a yoga teacher, and therefore believe one is unfit to go into battle unless one has compassion for ones enemies. Acts of revenge would simply add to the problem and reinforce the international image of Tamil people as terrorists. This ‘terrorist’ label is being used to disarm oppressed people and render them completely helpless. Out of sheer desperation, several people had burnt themselves to death in India to protest. I remembered that Buddhist monks had created a lasting impression by doing this to protest about religious oppression by Catholics in Vietnam[55], but the Indian self-immolations were hardly noticed in Britain. I figured that doing that in London would effectively draw people’s attention to current Sri Lankan events. Murugathasan Varnakulasingham had the same idea and did it in front of the United Nations building in Switzerland[56]. Sadly I fear his sacrifice had little effect on the awareness of the European public. Only earlier today a medical student at the University where I study told me that she is looking forward to her holiday in Sri Lanka this Easter. She sent me this link: http://www.mermaidhotelnclub.com/ It looks like paradise.

I figured the only thing I could do was raise public awareness. I posted several links about Sri Lanka on Facebook, but a couple of friends told me they would rather not know anything about it. Then, feeling helpless I wrote an expressive poem for my own benefit. It seems to me that it has been suggested on MetaOT that clinical trials are needed for evidence-based practice[57] but I do not need a clinical trial to tell me that writing the poem was therapeutic for me. Perhaps this illustrates how the meaning of occupation is a very personal and individual thing, and clinical trials are not always the best source of evidence for efficacy or lack thereof. Finally I hope that writing this blog entry will enable me to feel like I have done my part to stop the suffering of Tamil people in Sri Lanka. I hope I can now get on with studying for my degree without any feelings of guilt.

Possible solutions to the actual problem:
It is clear to me that the Tigers are too brutal to rule the Tamil people, but anybody that thinks they will be safer under the Sri Lankan government must in my opinion be ignoring history and current events. The fact that the Sri Lankan government is prepared to shell Tamil civilians in order to occupy land, suggests to me that the government values the land more than it values the people. You cannot free people from terrorists by killing the people. The government is therefore not fit to rule the Tamil people. I believe the international community should never have interfered as it did; disadvantaging the Tigers by declaring them an illegal terrorist organisation and blocking their sources of funding. The international ‘war on terror’ created the power imbalance that brought about the current desperate situation. I therefore believe that the powers that disarmed the Tamil people now have a moral responsibility to protect them from the state terrorism that they armed themselves against.

I wish Tamil and Sinhalese people could live in peace in Sri Lanka, but in reality I think that could only happen if Tamil people accepted their status as second-class citizens. The people in the North and East should therefore be permitted to choose their own government without intimidation from the Sri Lankan armed forces or the Tigers. I doubt this will happen without intervention from larger powers. Tigers, armed forces personnel and government officials should be charged and tried for war crimes whenever adequate evidence can be found. When considering such crimes, steps should be taken to avoid occupational alienation due to cultural differences. Is it realistic to expect people that have been the victims of inhumane, violent oppression for generations to value the Geneva Convention on the battlefield? British army cadets start training at the age of 12[58]. Are they child soldiers? If British children had been attacked and terrorised for several generations and their lives were continually at risk, would arming them still seem an alien concept? How about if Britain had an apprenticeship system of education as there was in traditional Hindu societies, instead of a national curriculum[59]? At what age would it be acceptable for warriors to start training then? Hindu Tamils are not told that they will go to heaven and be greeted by 100 virgins for suicide bombing. Their acts of suicide bombing, just like the acts of self-immolation, reflect desperate feelings of helplessness. I feel disappointed by the Tigers’ deviation from dharma, but I lose my own temper whenever my flatmates use my ketchup without asking me first, or take my food out of the fridge to make more space for their own, so I do not believe it is realistic to expect the Tigers to behave in a civilised manner without first considering their personal histories. Unless the United Nations protects survivors from the Sri Lankan government and Tigers to enable them to testify, it is unlikely we will ever find out what is really going on in Sri Lanka.

Even if the Tigers are completely wiped out, it is unlikely that armed Tamil resistance will cease until the abuse of Tamil people ceases. Seeing pictures of current atrocities by the Sri Lankan government initially inspired me to take revenge. I quickly overcame that destructive feeling because I am a yoga teacher. Only a small proportion of the Tamil people that see or experience those atrocities will be yoga teachers. The Sri Lankan armed forces and paramilitaries are probably the biggest recruiters for the Tigers. A robust mental healthcare system will therefore be necessary to rehabilitate traumatised people away from the viscous circle of violence.

When there was an apartheid system in South Africa, other nations placed sanctions on the country and refused to compete with South Africans in sport. I do not remember the South African government using artillery and cluster bombs to kill black South African people. It seems strange to me that Sri Lankan sportsman can play while Sri Lankan Tamils are being massacred[60]. As you are reading this blog, please consider that any money you spend on Sri Lankan produce could be blood-money, as you will be fuelling the economy of a country hell-bent on genocide. That includes flying with the Sri Lankan airline or going to Sri Lanka for your holidays. Finally, I noted earlier in this blog that occupational alienation is being used as a weapon. It may also be the cure. Buddhist leaders from around the world should openly condemn the war mongering of the Sri Lankan Buddhist clergy, and they should consider going to Sri Lanka to speak of dharma. None of these things are likely to happen without international intervention, so thank you for reading this blog.

To avoid alienating British Tamil people, the current British government should consider reviewing its foreign policy regarding Sri Lanka, and it light of current events in Sri Lanka the British government should formally express regret about previous involvement in arming and training the Sri Lankan armed forces. If the government does not do this, it is likely that Tamil people will be discouraged from serving with the British armed forces in future.

Conclusions:
Occupational alienation and injustice have been used as weapons against Sri Lankan Tamil people since Sri Lanka gained independence in 1948. This blog entry provides a stark example of how occupational risk factors are politically generated. The occupational therapy profession may have to work cohesively at political levels to address such risk factors.

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41. Al Jazeera (?date?) LTTE terrorising UK Tamils. Available from: http://www.youtube.com/watch?v=cstpE1-lhzk Accessed: 17:07 17/3/2009
42. Journeymanpictures (2008) Truth Tigers – Sri Lanka. Available from: http://www.youtube.com/watch?v=1zlxyvWOkfk Accessed: 17:11 17/3/2009
43. Bone J. (2009) UN Security Council fight for Sri Lanka. Available from: http://www.timesonline.co.uk/tol/news/world/asia/article5817983.ece Accessed: 18:36 17/3/2009
44. EelamWeb (undated) The Indo-Sri Lanka Accord. Available from: http://www.eelamweb.com/history/document/indo_lanka/ Accessed: 19:36 17/3/2009
45. Majumdar D. (2007) Tamil gangs tackled from 'within'. Available from: http://news.bbc.co.uk/1/hi/england/london/6380817.stm Accessed: 22:23 17/3/2009
46. byebyeeelam (2008) Prabhakaran speaks to LTTE special forces wanni. Available from: http://www.youtube.com/watch?v=spDpIhusIHk Accessed: 23:04 17/3/2009
47. US Senate Hearing on Sri Lanka Government Genocide (2009) Available from: http://www.youtube.com/watch?v=u10r-9FJg4A Accessed: 23:25 17/3/2009
48. Tamil National Ne... 's Public Gallery (2009) Available from: http://www.facebook.com/ext/share.php?sid=54208203929&h=3rNwi&u=9M5tb Accessed: 23:30 17/3/2009
49. B12N (2009) he Great Sri Lankan army. Look what there are doing under peace keeping mission. 108/950. Available from: http://www.youtube.com/watch?v=NkubYPeRxWQ Accessed: 23:44 17/3/2009
50. Hussain S.Z. (2004) Women Rage Against 'Rape' in Northeast India. Available from: http://www.commondreams.org/headlines04/0719-03.htm Accessed: 23:53 17/3/2009
51. TamilNet (2008) Breaking news: LTTE air craft not shot down. Available from: http://www.tamilnet.tv/index.php/tamil-eelam-ltte-air-plane-shot-down-sl... Accessed: 8:15 18/3/2009
52. Warning-VIEWER DISCRETION ADVISED-25 Jan 2009 Shelling of Visuvamadhu by SL Army Available from: http://www.youtube.com/watch?v=7y0_e1fhKaM Accessed: 17:32 26/2/2009
53. Medical Foundation for the Care of Victims of Torture (2007) Torture once again rampant in the Sri Lanka conflict. Medical Foundation for the Care of Victims of Torture: London
54. Foster P. (2008) No justice in Sri Lanka. Available from: http://blogs.telegraph.co.uk/peter_foster/blog/2008/05/12/no_justice_in_... Accessed: 9:10 17/3/2009
55. Browne M. (undated) Burning Monk - The Self-Immolation [1963] Available from: http://www.worldsfamousphotos.com/burning-monk-the-self-immolation-1963.... Accessed: 17:27 18/3/2009
56. BBC (2009) Tamil suicide protester mourned. Available from: http://news.bbc.co.uk/1/hi/uk/7930382.stm Accessed: 17:20 18/3/2009
57. Bronnie (2008) Just some brief comments. Available from: http://www.metaot.com/blog/reiki-facilitate-spiritual-emergence-personal... Accessed: 17:35 18/3/2009
58. Army Cadet Force (2007) Want to get involved? Available from: http://www.armycadets.com/home/ Accessed: 18:11 18/3/2009
59. Mailoo V.J. (2007) The Ayurvedic Model of Human Occupation. Available from: http://www.jstage.jst.go.jp/article/asiajot/6/1/1/_pdf Accessed: 18:24 18/3/2009
60. BBC (2009) Hunt for Lahore cricket attackers. Available from: http://news.bbc.co.uk/1/hi/world/south_asia/7921430.stm Accessed: 18:35 18/3/2009

Hip muscle mnemonics

2009-03-23T13:06:28+00:00

These are some mnemonics that some friends and I made up or found when we were revising for an anatomy exam. They really helped us learn the muscles of the hip. Hope you find them useful.

Extensors

Genetically Modified Ham
Gluteus Maximus
Hamstrings

Adductors

Three little ducks Peck Grass
Adductor Longus, Brevis & Magnus
Pectineus
Gracilis

Abductors

Two Sores on two small bottoms
Tensor Faciae Latae
Sartorius
Gluteus Medius & Minimus

Medial Rotators

Two small Tense Infected bottoms
Gluteus Medeus & Minimus
Tensor Fasciae Latae
Iliacus

Drunkenness is stupid

2009-03-05T00:25:40+00:00

1. Introduction:
Some years ago while I was working as a health care assistant in operating theatres a student nurse from Ireland consumed alcohol excessively during her 21st birthday party. The next day she attended the accident and emergency department but was sent away diagnosed with a hangover. Normal doses of self-administered paracetamol overloaded her liver due to her dehydrated state and she subsequently underwent a liver transplant. Unfortunately she then had a stroke and died in the intensive care unit. Her 18 year old sister who was also a student nurse went back to Ireland in a state of distress. My last shift in theatres before I departed to University ended with an alcoholic man bleeding to death. I still remember the distinctive smell of blood which at first could not be seen. The surgeon tried to look for the source of his bleed with an endoscope, but there was so much blood that his view was obscured. As his blood pressure dropped we put him in a head-down tilt. That was when I first saw the blood as it gushed out of his mouth looking like chopped liver. I was at his waist level when we turned him on his side to clear his airway and I found myself covered with blood as he was bleeding from his rectum too.

I soon forgot these experiences while at University, where I myself resorted to getting drunk to escape the huge mismatch between my achievements and what I knew to be my potential. It was an easy way to escape the feelings generated by being underestimated and disrespected. With the luxury of hindsight I know I was foolish for risking a good life for a few moments of escapism. I chose to moderate my alcohol consumption after a couple of near misses. I woke up one morning face-down in my own vomit, with no memory of having been sick. I must have vomited while unconscious, and if I had been lying on my back, perhaps I would have died of asphyxiation. Shortly after I started my current University course there was news of a man being beaten to death in the city[1]. I wonder whether alcohol played any part in the killing. I know a student nurse here that has been to hospital twice so far in a state of intoxication though we are still only first year students. The first time, it was due to unconsciousness after a drunken person sat on her head and the second it was due to the intoxication itself. I also know a lesbian woman that flirts with men when she is drunk and a student occupational therapist that wanted to sleep with me while she was intoxicated but changed her mind when she was sober (this has also happened to me once before with a student occupational therapist that is now qualified). During my first year of training, a fellow student occupational therapist jumped fully clothed into the river Thames on a winters night because in a drunken state she decided she wanted to get away from her date. She is lucky to be alive. Only yesterday one of my flatmates suffered bereavement. His friend had been missing for a few days[2]. A Facebook memorial states he “lost his life all because of a few to many drinks”[3]. As I type this there are several drunk people in my flat, seemingly oblivious to the suffering of our absent flatmate and the cause of his unfortunate loss. Condoms were left out for people to make use of and in their state of drunken stupor they opened the packets and threw the condoms on the floor needlessly wasting British taxpayers' money during a time of recession. Those condoms were worth more than I can afford. My humility is being tested to its limits and I find myself judging those around me. I believe life is too short and valuable to lose moments in intoxicated stupor. I now see my disregard for life as an undergraduate and the behaviour of those around me as a symptom of social disease; an occupational disease with potential occupational cures.

2. Why do people get drunk?
Adolescent alcohol abuse has been linked to negative thinking, anxiety sensitivity, impulsivity and sensation seeking[4]. Looking around me now it is easy to find examples of these traits. Negative thinking accurately describes my state of mind as an undergraduate when I chose to get drunk. At the time I globally attributed negativity to life in general. Anxiety sensitivity may be the reason some people feel unable to socialize unless they are drunk. A key occupation underlying this is dancing; many people have told me that they feel unable to go clubbing unless they are under the influence of alcohol. The animalistic behaviour exhibited by drunken people can be intolerable for sober people, creating occupational alienation[5]. Unfortunately clubbing seems to be a keystone in British youth culture and if people feel unable to dance without alcohol, alcohol consumption may be a determinant of social inclusion. While studying occupational therapy I regularly socialized with several Irish female occupational therapy students and one Irish female student social worker. They advised me that the best way to get a girlfriend was to snog drunk girls, because according to them, girls feel too shy to show sexual or intimate emotions while sober. I told them that I did not feel right about taking advantage of girls with diminished mental capacity due to alcohol intoxication. They told me the best solution to this was to get drunk too because apparently it is acceptable to take advantage of intoxicated girls as long as you are drunk yourself at the time. This attitude occupationally alienates non-drinkers with respect to sexual and perhaps romantic relationships. Nowadays my working solution is to let drunk women snog me but then carry out a mental capacity assessment before letting them do anything more. This strategy saved the student occupational therapist mentioned in section 1 from potentially regrettable sexual activity.

From observation I believe impulsivity and sensation seeking are most common precursors of drunkenness amongst my peers. I live with cheerleaders for whom drunkenness seems to be a normal and regular part of life. Some of my friends in high-powered jobs, living lifestyles I can only dream of with a health service income, get drunk every Thursday night with their work colleagues. At the last doctors’ mess party I went to I saw medical students that were unable to walk unsupported and probably had little idea of where they were going. I have seen one medical student lose the ability to sit on a chair or speak on two separate occasions. This particular person revealed to me that he has a problem with anxiety, but rightly or wrongly, I suspect these high achievers to exhibit less negative thinking and anxiety sensitivity than less advantaged subsets of society. This leads me to believe sensation seeking may be the dominant motivation. Sensation seeking may be a symptom of occupational imbalance. Modern British society seems to be characterized by some people living off the state and enjoying family life[6] while others work too hard just to maintain what they consider to be survivable lives.

" Binge Drinking. I hate the fact the government are trying to tell all of us how much we should drink. They say we should all limit ourselves to 10 units on a night out, F*** that I say, that's a measley 5 pints, if I want to have a good sesh, I'll have a f****n good sesh, if I want to be chucking my guts up in the middle of Reform st then I'll do that, if I want to get totally legless then I'll get totally legless. I don't need them c**** in government telling me what I can or cannot drink. I work a 50 hour week, so don't tell me that I shouldn't go out & let my 'hair' down that one night a week."[7]

3. How much is unhealthy?
According to the British Department of Health, women should consume no more than 3 units of alcohol per day, while men should consume no more than 4 units per day[8]. Last week my next-door neighbour boasted about drinking more than 40 units in one night. Binge drinking is classed as 6 or more units per day or 35 units per week for women and 8 or more units per day or 50 units per week for men[8].

4. Is it a disease?
Drunkenness seems to be a cultural part of the society I live in. I think of it as a disease, but it might be wrong of me to actively look to treat it, as by doing so I would be imposing my cultural values on other people, for whom drinking pathological amounts of beer while watching rugby or stupefying volumes of spirits on a night out with the girls is a defining characteristic of their culture. If pubs and clubs stopped serving alcohol in the United Kingdom how would the majority of young people socialise? The rest of this blog entry is therefore just a theoretical, academic and speculative exercise applying my own cultural values. According to Ayurvedic theory fermented products such as alcohol express the nature of inertia, predisposing people to laziness, selfishness and ignorance whereas stimulating foods such as spices and meat predispose people to anxiety or passionate, impulsive behaviour[8]. Anxiety and feelings of insecurity are generated by material consciousness while sensation craving is generated by bodily consciousness[8]. Drunkenness may therefore be a maladaptive compensation strategy for occupational deprivation of the material or bodily centres of consciousness. In the society I live in I see material consciousness deprived due to consumerist culture generating a high cost of living, and bodily consciousness deprived due to chronic occupational imbalance between work and leisure or family life due to the high cost of living. To maintain occupational balance I would ideally like to practise 2 hours of meditation and 1 hour of yoga postures every day. Working 9 to 5, commuting for 1 hour, spending 2 hours per day on self-care and domestic tasks, sleeping for 8 hours and then practising yoga would only leave me 1 hour for family and social life. Few people I know have that luxury. Student nurses I know here are working 12 hour days on clinical placement and as a medical student my back-log of study seems ever-increasing.

How did this situation come to be? I blame uncompensated feminism and collective insanity. Working has reduced the occupational injustice suffered by women but subjected them to the same occupational imbalances traditionally suffered by men, creating a norm characterised by both partners in heterosexual relationships working full time[9]. I wish society had evolved to allow both partners to work part-time (instead of one working while the other stays at home), thus maintaining healthy family life. I do not believe both partners working full-time has increased quality of life at all because the cost of living has simply increased on a par. This brings me to the point of collective insanity. Could house prices currently be so high if people were unwilling to spend their lives in slavery to mortgages? What would happen if people simply stopped buying and opted for freedom from slavery to materialism, or preferentially migrated to countries with more sensible economies and less materialistic lifestyles? The final straw is sexual repression. Why are sexual words considered to be swear words? Why did I feel the need to censor the sexual words in an above quote? Why do many people have to get drunk before they can express romantic or sexual feelings? In short, the society I live in predisposes people to occupational imbalance characterised by feelings of insecurity, pleasure deprivation and sexual inhibition that leads to maladaptive sensation seeking. It is a society ripe for drunkenness.

5. Solutions:
5.1. Education: In the words of one Students’ Union Welfare Officer candidate:

“I think people are smart enough to decide how much they are going to drink, I cannot control the amount people drink and I don't want to . I hope people will keep it under control and are in control enough to decide when they ahve had enough...”[10]

I guess she has never been to Accident & Emergency on a Friday or Saturday night. The public in general seem to be aware of risks associated with alcohol consumption. In 2007 7 out of 10 people surveyed by the Department of Health thought a reduction of alcohol consumption reduction would make Britain healthier and 78% of people perceived alcohol to be more damaging to health than illegal drugs[11]. Despite this, few people monitor their own alcohol consumption[11] so education may not be effective for reducing drunkenness, except for with people that already wish to reduce their alcohol consumption[12].

5.2. Cognitive Behavioural Interventions: If knowledge of the risks does not inspire reduced alcohol consumption, the next logical step might be cognitive behavioural interventions. Primary determinants of future drunkenness are thought to be one’s intention to get drunk, perceived control of drunkenness, positive or negative evaluation of the state of being drunk and one’s perception of other people’s opinions of one’s drunkenness[13]. The last component of this may be socially determined and therefore difficult to change in some environments, such as Universities where drunken antics are often applauded. I find perceived control of drunkenness easy to challenge amongst my peers but it is difficult to shake their positive evaluation of drunkenness as a state of being. Amongst University students anticipated regret is the biggest determinant of intention[13]. People seem to perceive greater risks to others than themselves[11]. Students may therefore be balancing the potential regret of a decimated social life (motivating them to drink) against the potential regret of a hangover, rather than the potential regret of serious and lasting health problems. Manipulating the consequences of drunkenness may therefore be an effective intervention. Increasing alcohol prices would increase the negative financial consequences of excessive drinking and tougher law enforcement against alcohol related antisocial behaviour might act as a deterrent[11]. My neighbour that boasted about drinking more than 40 units in one night said he only drinks that much because alcohol is so cheap. Brief motivational interventions are known to increase readiness to change, but this does not correlate with decreased alcohol consumption[14]. Cognitive behavioural interventions alone may therefore be inadequate to reduce drunkenness.

5.3. Occupational Therapy: As an occupational therapist I am biased towards the belief that occupational therapy could play a huge role in reducing drunkenness. The occupational risk factors identified so far in this blog are occupational imbalance and occupational deprivation with respect to leisure and pleasure and occupational alienation with respect to social, romantic and sex life. I wonder if abolishing these risk factors would effectively reduce drunkenness. Various established conventional occupational therapy models could be used to approach this, but I prefer to reflect with one that is culturally appropriate to me. Applying Ayurvedic principles I look at this from 2 angles. One is the three modes of material nature: essence, activity and intertia[8]. The other is 7 domains of consciousness known as chakras[8].

5.3.1. The three natures: Alcohol abuse is associated with other high-risk behaviours such as drug abuse, risky sexual practices and violence. According to Ayurveda, alcohol has the nature of inertia (tamas) and would therefore be expected to make people withdraw, become depressed and go to sleep[8]. Perhaps the behaviours associated with alcohol abuse are concurrent symptoms of an underlying occupational disease, rather than problems caused by the alcohol abuse itself. I see people excessively exposed to the nature of activity (rajas) by work-pressures, caffeine, excessively flavoured foods, music, sexual imagery, other media and association with other over-stimulated people. Expression of this nature is often not socially acceptable. Alcohol provides a maladaptive coping mechanism for this in two ways. Firstly, alcohol is used as an excuse for behaviour (such as violence or sexual assertiveness) that would normally be deemed inappropriate. The second student occupational therapist that tried to sleep with me for example, told me at the time that her behaviour was acceptable because she was drunk but she thought it was creepy that I was sober. Secondly the nature of alcohol (tamas) counterbalances the nature of over-stimulation (rajas). Yogis traditionally deal with this by cutting over-stimulating products out of their diets, meditating (relaxing) to maintain occupational balance and associating with other yogis to avoid occupational alienation. As a medical student on a university campus the yogis I come across seem to have much more time on their hands then I do and the socials they arrange are usually too time consuming for me. Despite this, I can use the internet to find other people that disapprove of drunkenness:
http://www.facebook.com/group.php?gid=47813614445
http://www.facebook.com/group.php?gid=52491475539

5.3.2. Seven domains of consciousness: Earlier in this blog entry, links were made between drunkenness, anxiety and sensation seeking. Anxiety is believed to be seated in material consciousness (1st chakra). My bereaved flatmate told me that he would like to avoid getting drunk but feels unable to talk to new people unless he has been drinking. He admitted that alcohol is a temporary solution to low confidence. Occupational therapy could play significant role in coaching people for confidence in communication and interpersonal interactions thus displacing the maladaptive strategy of alcohol abuse. I believe this would best be done prophylactically with people of school age, rather than reactively once drinking culture has been ingrained as a social norm. Though anxiety can be chemically mediated by the action of corticosteroids on the brain, I believe it is usually associated with attachment of one kind or another. The beliefs that one needs a house, a car, a romantic relationship, popularity, or to have children can all lead to anxiety. Alcohol consumption, other “health-damaging behaviours and violence, for example, may be survival strategies in the face of multiple problems, anger and despair related to occupational insecurity, poverty, debt, poor housing, exclusion and other indicators of low status”[15: p.iii]. It is questionable whether any of these things are needed. Inequity may be a stronger predictor of poor health than poverty[15] and if so, people’s perceptions of their relative wealth may be a bigger determinant of their health than their actual wealth.

“In terms of happiness and peace of mind, we were much better off as a world society in former times when every family had some land and a cow and easily got all their eatables by planting in the spring and harvesting in the fall.” (Sankarshan Das Adhikari 2009)

The “relentless pursuit of economic growth is not environmentally sustainable. What is now becoming clear is that current economic and fiscal strategies for growth may also be undermining family and community relationships: economic growth at the cost of social recession”[15:p.iv]. Detachment is the yogic way of maintaining healthy material consciousness and escaping consumerist slavery.

Sensation seeking impulses are believed to come from the bodily centre of consciousness (2nd chakra). This is thought to be the source of the human sex drive. It has even been suggested that risk taking and self harming behaviours are motivated by a need to display hardiness indicative of genetic superiority, thus increasing sexual attraction[16]. Unfortunately in British society it seems the human body[17, 18] let alone sexuality is taboo and even some healthcare professionals fear to approach the subject[19]. When sexual expression is repressed bodily consciousness will express itself in other ways. Sensation seeking may be a product of this. Sensation seeking itself can be repressed through processes of reasoning[4] but emotional repression can itself have negative health consequences[20]. Research on sunbathing has shown that when risk-taking is associated with perceived increased sexual attraction behavioural changes based on knowledge of health risks are unlikely[21]. Extrapolating this to alcohol consumption in young people, if drinking is seen as an essential aid to socialising (as with my bereaved friend), socialising is seen as necessary for meeting sexual partners and drunkenness is seen as an essential justification for initial sexual activity (as with the student occupational therapist mentioned earlier) it is unlikely that people will avoid drunkenness at the cost of their sex-lives. An Ayurvedic solution would be to challenge and break sexual taboos in society. Occupational therapists have a role to play in this. I believe as long as words like ‘penis’ or ‘vagina’ are seen as less acceptable for everyday communication than ‘cup’ or ‘fork’, and occupational therapists find sexuality more difficult to approach with their patients than washing and dressing or eating, maladaptive responses to sexual repression, such as binge drinking will continue to be left inadequately treated.

6. Limitations:
This blog entry may seem a little off the wall. That is because it is based on my personal, unqualified opinion. I am aware that therapists working with people that misuse substances read MetaOT blogs. I hope they will be kind enough to enlighten me with their feedback.

7. Conclusion:
Until people are empowered to escape consumerist slavery to restore healthy occupational balance, interact socially with confidence and high self-esteem and engage in healthy, pleasurable leisure occupations and sexual occupations without fear or taboo, I believe drunkenness will be a persistent problem in society. Occupational therapy could play a huge proactive role in reducing this.

References:
1. Grice E. (2008) The killing that shamed Norwich. Available from: http://www.telegraph.co.uk/news/3130972/The-killing-that-shamed-Norwich.... accessed: 23:46 4/3/2009
2. BBC News (2009) Beach search for missing teenager. Available from: http://news.bbc.co.uk/1/hi/england/suffolk/7918520.stm accessed: 00.01 5/3/2009
3. Julings W.R. (2009) Memorial Of Daniel Hannant. Available from: http://www.facebook.com/profile.php?id=516941128&ref=ts#/group.php?gid=5... accessed: 00:07 5/3/2009
4. Conrod P.J., Castellanos N., Mackie C. (2008) Personality-targeted interventions delay the growth of adolescent drinking and binge drinking. Journal of Child Psychology and Psychiatry 49(2): 181–190
5. Mailoo V. (2008) Respond clearly to unwanted sexual advances from spineless cocks. Available from: http://www.facebook.com/home.php#/note.php?note_id=40739021130&id=514766... Accessed: 14:17 29/3/2009
6. thisisnottingham.co.uk (2009) Column: Bravo for uber-chav comment. Available from: http://www.thisisnottingham.co.uk/newscolumnist/Column-Bravo-uber-chav-c... Accessed: 14:26 29/3/2009
7. Hill M. (2008) Activities. Available from: http://www.facebook.com/home.php#/profile.php?id=556052978&v=info&viewas... Accessed: 14:33 29/3/2009
8. Mailoo V.J. (2007) The Ayurvedic Model of Human Occupation. Asian Journal of Occupational Therapy 6: 1-13 Available from: http://www.jstage.jst.go.jp/article/asiajot/6/1/1/_pdf Accessed: 18:13 26/3/2009
9. Venth (2007) Gender role blurring: has it reduced or increased occupational risk? Available from: http://www.metaot.com/blogs/venth-3 Accessed: 12:17 30/3/2009
10: Dennis A.A. (2009) Sensible drinking. Available from: http://www.facebook.com/group.php?sid=ef54568e80abfce05e307a55a04ed15b&g... Accessed: 12:32 30/3/2009
11. Department of Health, Home Office, Department for Education and Skills, Department for Culture, Media and Sport (2007) Safe. Sensible. Social. The next steps in the National Alcohol Strategy. Department of Health: London
12. Mulvihill C., Taylor L., Waller S, Naidoo B., Thom B. (2005) Prevention and reduction of alcohol misuse. Health Development Agency. Available from: http://www.nice.org.uk/niceMedia/documents/alcoholEB2ndedition.pdf Accessed: 16:53 30/3/2009
13. Cooke R., Sniehotta F., Benjamin Schuz B. (2007) Predicting binge-drinking behaviour using an extended TBP: examining the impact of anticipated regret and descriptive norms. Alcohol & Alcoholism 42(2): 84–91
14. Borsari B., Murphy J.G., Carey K.B. (2009) Readiness to change in brief motivational interventions: A requisite condition for drinking reductions? Addictive Behaviors. 34 :232–235
15. Friedli L. (2009) Mental health, resilience and inequalities. World Health Organization: Copenhagen
16. Sosis R., Kress H.C., Boster J.S. (2007) Scars for war: evaluating alternative signaling explanations for cross-cultural variance in ritual costs. Evolution and Human Behavior 28:234– 247
17. telegraph.co.uk (2008) Cambridge University magazine prints topless page three picture of student. Available from: http://www.telegraph.co.uk/news/3491536/Cambridge-University-magazine-pr... Accessed: 19:13 31/3/2009
18. telegraph.co.uk (2009) Teacher facing action over thong photos. Available from: http://www.telegraph.co.uk/news/uknews/5081931/Teacher-facing-action-ove... Accessed 19:15 31/3/2009
19. Various (2007) intercourse & OT. Available from: http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1682&postdays=0&pos... Accessed: 20:46 31/3/2009
20. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11): 503-510
21. Health Education Authority (1997) Attitudes to sunbathing and the risks of skin cancer. Health Education Authority: London

Is dorsi-flexion ‘flexion’ or ‘extension’?

2009-02-17T14:53:55+00:00

I have been a little bemused of late by Heylings et al[1] which uses the term ‘extension’ instead of dorsi-flexion to describe movement that brings the top of the foot towards the shin. Other sources say that dorsi-flexion is associated with hip and knee flexion in the total flexor pattern, while plantar-flexion is associated with hip and knee extension in the total extensor pattern[2, 3] seen in neurologically impaired people. It therefore makes no sense to me to call dorsi-flexion 'extension'. If anything I would call planta-flexion 'extension' and dorsi-flexion 'flexion'. What do you think? I started a poll here: http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=3230 for members of the British Association of Occupational Therapists. Please consider leaving your opinion as a comment below too. Thank you.

1. Heylings D.J.A., Spence R.A.J., Kelly B.E. (2007) Integrated Anatomy. Churchill Livingstone: Edinburgh
2. Bobath K. (1980) A Neurophysiological Basis for the Treatment of Cerebral Palsy. Mac Keith Press: Lavenham
3. Basmajian J. (2004) Biofeedback in physical medicine and rehabilitation. In: DeLisa J.A., Gans B.M., Walsh N.E., Bockenek W.L., Frontera W.R., Gerber L.H., Geiringer S.R., Pease W.S., Robinson L.R., Smith J. (eds) Physical Medicine and Rehabilitation: Principles and Practice. 4th edition. Lippincott Williams & Wilkins: Philadelphia. 271-284

Control of movement

2009-02-16T12:04:49+00:00

0. Introduction:
My problem-based learning objective for this week is to summarize how voluntary movement is controlled. Unfortunately, voluntary movement depends on the integration of several non-voluntary mechanisms so the material I had to cover seemed pretty complex to me. I thought I might as well share my work here instead of wasting it, but I am no neuro-physiologist so please do not expect any rocket science.

1. Sensation:
In order to move in a controlled manner it is first necessary to be aware of one’s position in space. There are various sensory mechanisms in place for this.

1.1. Vision: the importance of vision for position awareness only becomes clear in the absence of visual and tactile cues. Examples of this are being deep under water (divers are trained to blow and follow bubbles in emergencies when they are unable to tell the difference between up and down) or being buried in snow (clearing an air pocket and spitting into it will show you the direction of gravity). The physiology of sight will not be addressed here but points to note are that binocular vision helps us judge distance and visual data is received by the lateral geniculate nucleus of the thalamus and then relayed to the visual cortex of the brain for processing.[1]

1.2. Vestibular system (in the inner ear):[1]
· semicircular canals detect angular acceleration: fluid from the canals flows through a widening (ampulla) which contains a gelatinous mass (cupula) embedded with cilia from sensory cells.
· utricles (fluid-filled chamber between the semicircular cannals and saccule) detect horizontal (if a person is standing) linear acceleration: cilia covered with a gelatinous substance impregnated with heavy calcium carbonate crystals (otoliths).
· saccules (fluid-filled chamber between the utricle and cochlea) detect vertical (if a person is standing) linear acceleration: cilia covered with a gelatinous substance impregnated with heavy calcium carbonate crystals (otoliths).

1.3. Mechanoreceptors (touch):[1] if you sit on the edge of your chair so that one buttock is on the chair while the other is hanging off the side, the lack of pressure on one buttock is the reason you are aware that you are in danger of falling off the chair.

1.4. Nociceptors (pain):[1] If you bear weight excessively through one of your ischial tuberosities, pain may inspire you to shift your weight to the other one.

1.5. Proprioceptors (body position):
· Muscle Spindles (stretch):[1] muscle spindles contain sensors for a) how far and b) how quickly muscles are being stretched.
· Golgi Tendon Organs (tension):[1] detect tension (force) at musculotendonous junctions.
· Joint mechanoreceptors: fire during specific ranges of movement (in feline models[2])

2. Motor response to stimuli:
Sensory information is processed at and responses are generated at various functional levels of the nervous system.

2.1. Reflexes: are the simplest level of movement control. Examples of this include:
· Muscles contracting automatically when their muscle spindles are stretched.[3] Examples of this include the knee jerk and ankle jerk tests. These are the simplest reflexes because they involve only one synapse (monosynaptic). All other reflexes are polysynaptic[1].
· Muscles relaxing automatically when their golgi tendon organs detect tension of a magnitude that might damage the muscle.[3]
Simple reflexes are mediated in the spinal cord by the reflex arc. This basically involves a sensory neuron running to the spinal cord and either connecting to a motor neurone (monosynaptic reflex) or to inter-neurones that either stimulate or inhibit motor neurones (polysynaptic). The motor neurones connect to muscle fibers where they stimulate contraction.
Why are reflexes important for voluntary movement? Reflexes play a role in co-ordination of movement. Examples of this include:
· When muscle spindles are stimulated the antagonist muscles are automatically inhibited. This is why clonus (shaking) does not occur when the knee jerk or ankle jerk reflex are tested.
· When muscle spindles are stimulated synergistic muscles may be activated.

2.2. Central pattern generators
Simple movement patterns such as gross flexion or extension are generated from the spinal cord. Interplay between these patterns at the spinal level can produce complex movements without regulation from the brain:
· The crossed extensor reflex occurs when nociceptors in one foot are sufficiently stimulated. The motor response generated is flexion of the threatened lower limb with extension of the opposite lower limb. This reflex is partially responsible for enabling a person to lift a painful foot while standing on the other leg.[1]
The term ‘central pattern generators’ is used to describe how complex systems within the spinal cord can generate rhythmical patterns of movement such as those required for walking without regulation from the brain [4]. Impulses from the brain selectively promote or inhibit these movement patterns to produce controlled movement.

2.3. Roles of the brain:
Looking at the functions of different brain parts and applying the theory of evolution, we may assume that the human brain evolved anatomically upwards and outwards; the brainstem generally regulates physiological functions necessary for viability, the midbrain is involved with gross processing of sensory information and gross responses, while the cerebrum is responsible for higher awareness and reasoning.

2.3.1. Sub-cortical influences on movement:
Sensory information is mostly relayed from the spinal cord to the thalamus (touch via the anterior spinothalamic tract [10], pain and temperature via the lateral spinothalamic tract [10]) and from there to other appropriate areas of the brain:

2.3.1.1. Brainstem: The brainstem contains the pons, medulla and midbrain. The brainstem coordinates neck and eye movements via the medial longitudinal fasiculus and tectospinal tracts[12]. The reticular formation in the brainstem regulates the muscle tone necessary for posture via the reticulospinal tract[9]. The red nucleus in the midbrain is thought to influence gross flexion and extension via the rubrospinal tract[13] and the vestibular nuclei stimulate increased extensor activity via the vestibulospinal tract[14]. If you attempted to walk using your spinal central pattern generators alone you would fall over as soon as you stepped on an uneven surface. You would also fall over if you exhibited a crossed extensor reflex (see section 2.2.) without postural compensations regulated by your brainstem. Similarly sitting with just one buttock on your chair while the other hangs over the edge, you would fall off your chair unless the muscle tone in the unsupported side of your trunk increased automatically. The brainstem therefore regulates postural control under the influence of the cerebellum and cerebrum.

2.3.1.2. The basal ganglia: are a group of sub-cortical nuclei involved in the initiation and inhibition of movement through their influence on the brainstem and spinal cord[8]. Disorders of the basal ganglia are anecdotally associated with uncontrolled movements (such as tics[5]) collectively known as dyskinesias[6]. A lack of dopamine supply to the basal ganglia is responsible for the difficulties with starting and stopping movements that people with Parksinson’s disease experience[6].

2.3.1.3. The cerebellum: is an area posterior to the brainstem. It plays a role in refinement of movement using sensory feedback[1]. Proprioceptive information is relayed to the cerebellum via the spinocerebellar tracts[11]. Smooth grading of movement depends on the sequential recruitment of motor units within muscle to match the amount of force required [1]. Damage to the cerebellum leads a condition known as ataxia, characterised by poor balance and loss of accuracy of movement[7]. The cerebellum does not connect directly to the spinal cord but influences movement via connections to the brainstem nuclei.
· I once prepared myself for an army course that involved running long planks 20-30 feet high by walking on the top beam of a set of swings in a playground. Even though the beam was less than 10 feet high and I could easily walk along such a beam if it was on the floor, my lower limbs shook uncontrollably due to my fear of heights. Perhaps this shaking was because I was trying to use my motor cerebral cortex to do a job much better suited to my brainstem and cerebellum (trying to consciously control balance). My theory is totally unsubstantiated, but if it is true, it contribute to the increased falls risk associated with fear of falling.

2.3.2. Cortical influences on movement:
The outer-most part of the brain is called the cerebral cortex. This is thought to be the home of our conscious awareness of movement. Parts of the cortex are specifically for our awareness of sensation and others are for conscious control of movement. The cortex communicates with the spinal cord via upper motor neurons collectively termed the anterior and lateral corticospinal tracts[1]. It also communicates with brainstem nuclei via the corticobulbar tract to control movements of the head and neck[1].

3. Limitations
Some of the data gathered for this work was from animal studies and may have limited validity for humans. Assumptions about neurological function have mostly been made by studying function when parts of the nervous system have been removed or impaired either experimentally or by pathology. As the functional relationships between different neuro-anatomical structures are complex, functional deficits noted once a structure has been removed may not accurately mark all of the functions of the removed structure. One could therefore argue that much of the text above is based on assumption!

References
1.Vander A.J., Sherman J.H., Luciano D.S. (1994) Human Physiology. 6th edition. McGraw Hill: New York.
2. Cohen L.A. (1955) Activity of knee joint proprioceptors recorded from the posterior articular nerve. Yale Journal Of Biology And Medicine. 28(6): 225-232
3. Tortora G.J., Derrickson B. (2007) Principles of Anatomy and Physiology. 11th edition. John Wiley & Sons: Hoboken
4. Lacquaniti F., Grasso R., Zago M. (1999) Motor Patterns in Walking. News In Physiological Science 14: 168-174
5. Saba P.S., Dastur K., Reza Raji M.R., Keshavan M.S., Katerji M.K. (1998) Obsessive-compulsive disorder, Tourette’s syndrome, and basal ganglia pathology on MRI Journal Of Neuropsychiatry 10(1): 116
6. Moyer J.T., Danish S.F. (2007) Stimulation-induced dyskinesias inform basal ganglia models and the mechanisms of deep brain stimulation. The Journal of Neuroscience, 27(8):1799 –1800
7. Hartree N. (2008) Cerebellar Ataxia. http://www.patient.co.uk/showdoc/40001724/ accessed 14:53 15/2/2008
8. Takakusaki K., Saitoh K., Harada H., Kashiwayanagi M. (2004) Role of basal ganglia–brainstem pathways in the control of motor behaviors. Neuroscience Research 50: 137–151
9. Magoun H.W. (1950) Caudal and cephalic influences of the brain stem reticular formation. Physiological Reviews. 30(4):459-474
10. Takahashi S., Yamada T., Ishii K., Saito H., Tanji H., Kobayashi T., Soma Y., Sakamoto K. (1992) MRI of anterior spinal artery syndrome of the cervical spinal cord. Neuroradiology 35:25-29
11. Poppele R.E.,·Rankin A., Eian J. (2003) Dorsal spinocerebellar tract neurons respond to contralateral limb stepping. Experimental Brain Research. 149:361–370
12. Hendelman W.J. (2000) Atlas of Functional Neuroanatomy. CRC Press Inc: Klagenfurt
13. McDougal D., Lieshout D.V., Harting J. (2006) Red Nucleus ("The Ruber") http://www.neuroanatomy.wisc.edu/virtualbrain/BrainStem/22Ruber.html accessed 20:27 15/2/2008
14. McDougal D., Lieshout D.V., Harting J. (2006) Vestibular Nuclei And Abducens Nucleus http://www.neuroanatomy.wisc.edu/virtualbrain/BrainStem/13VNAN.html accessed 20:46 15/2/2008

What does pain tell us?

2009-02-02T11:38:28+00:00

1. Introduction:
My problem-based learning objective for this week is to find out how to differentiate between different types of pain. How are we supposed to do that? My general experience of occupational therapists is that if a patient complains of pain they go and get a doctor or nurse. As occupational therapists are trained in anatomy and physiology it would be great to see occupational therapists investigating pain themselves (at least on a superficial level) before reporting to other multidisciplinary team members. Hence I thought it might be worth sharing my work this week, which is intended for first-year students.

2. History taking:
The first step is taking a history. Medical students are trained to “use the acronym SOCRATES to remember site, onset, character, radiation, alleviating factors (some people use 'A' for associated symptoms), time course, exacerbating factors, and severity”[1]. As a student physiotherapist I was taught to take a history and then use the acronym SIN to remember severity, irritability and nature. What do these things tell us?

2.1. Site: Of course it helps to know where a patient experiences pain. Matching this to your knowledge of pathology may give you an idea of the patient’s condition. In the case of arthritis for example, asymmetrical inflammation is more indicative of osteo-arthritis than rheumatoid arthritis. Pain does not always directly tell us where a problem is though. I personally have had pain in the sacro-iliac region that on examination proved to be a dysfunction of the upper lumbar spine, upper limb pain due to problems with my lower cervical and upper thoracic spine and rib pain that stemmed from my lower thoracic spine. Pain referred from the spine is common but it can happen in other areas too. A soldier once presented to me with intermittent knee pain that on examination turned out to be from a stress fracture in his neck of femur. Due to the potentially misleading nature of pain, it is helpful to understand dermatomes and referred visceral pain. A dermatome is “the cutaneous area supplied by one spinal nerve”[2:p363]. Unfortunately there are huge inconsistencies in the accounts different anatomy texts supply regarding dermatomes[2]. I have therefore only included areas I found consistent in the diagram below.

Figure 1:

Visceral pain is pain from internal organs. It can refer to other body parts. A good example of this is angina referring to the left upper limb. The diagram below has been adapted from my physiotherapy student notes. Unfortunately I have not been able to find any reliable reference for it, so it cannot be relied on as a source.

Figure 2:

2.2. Onset: The nature of onset can give us some indication of the cause of pain. Sudden onset at the time of trauma or gradual onset after trauma can be indicative of injury. If there is a history of trauma, the mechanism of injury can tell us which structures are likely to be injured. Gradual onset with no history of trauma may indicate pathology or occupationally related overuse injury. It is therefore useful to know exactly what the patient was doing when they first noticed the pain, and whether they were doing anything unusual in the previous 24 hours[6]. A good understanding of pathology may be required for this fragment of information to be useful e.g.:

· If a person develops calf pain during a period of bed-rest, after an operation or during a long economy-class flight, this history could lead you to suspect deep vein thrombosis.

2.3. Character: The way patients describe pain may give us an indication of where it comes from.

Table 1: Pain descriptions and related structures[6]

Pain	Structure
Cramping, dull, aching	Muscle
Sharp, shooting	Nerve root
Sharp, lightning-like	Nerve
Burning, pressure-like, stinging, aching	Sympathetic nerve
Deep, nagging, dull	Bone
Sharp, severe	Fracture
Throbbing, diffuse	Vascular

The list in table 1 is not exhaustive. Pain is a subjective phenomenon so perhaps it will never be possible for one person to understand another’s pain.

2.4. Radiation: Radiation of pain from one body part to another or parasthesia (pins and needles) may suggest nerve involvement[5]. This does not necessarily mean a nerve itself is injured; another damaged structure such as a slipped intervertebral disc or muscle in spasm may be impinging it. Alternatively, radiation may indicate a visceral source such as indicated in figure 2.

2.5. Irritability (exacerbating and alleviating factors): Exacerbating and alleviating factors can be a good indicator of the source of pain, but only if knowledge of anatomy, physiology and pathology are applied to this information e.g.:

· Pain when limbs are elevated that eases when they are kept low, or calf pain that builds up gradually with walking and eases with rest may indicate ischaemia due to atherosclerosis. In the absence of these factors it could be due to injury, infection or thrombosis.
· Chest pain after eating that is worse when leaning forwards or lying down suggests gastric acid reflux or hiatus hernia. In the absence of these factors it could be musculo-skeletal or from other visceral sources (as shown in figure 2).

2.6. Time course: It is useful to know how long a person has had pain, whether it is getting better or worse with time and whether it follows a regular 24-hour pattern e.g.:
· Pain and stiffness first thing in the morning that eases with movement can be an indication of chronic inflammation[6] such as found in osteo-arthritis[7], or oedema, whereas pain that gets worse while a person is at work, or is worse after work but is eased by rest may suggest mechanical, ergonomic or overuse problems, or that a person does not enjoy his or her work.
· Intervertebral discs swell up while people sleep and are gradually compressed while people are active. This can have implications for back pain and nerve root compression.

2.7. Severity: I have heard several accounts of soldiers that were able to continue fighting or running while seriously wounded and on the other end of the spectrum I have met people that cried during drainage of small foot blisters. Occasionally people have presented to me with pain behaviour leading me to believe they were seriously injured, but on examination the actual injuries were relatively minor. The severity of pain can fluctuate according to how much a person is distracted. I therefore believe it would be inhumane to compare one person’s pain to another’s. Regularly asking about severity can give you an idea of whether a person’s pain getting better or worse over time. As a student physiotherapist I was taught to do this with a modified Likert scale: “On a scale of 0-10 where 0 is no pain and 10 is the most excruciating pain a human could ever feel, what number would you give your pain now?” It is worth noting that a person’s perception of number 10 will vary as they experience increasing pain.

Table 2. Putting the subjective assessment together using chest pain as an example[20].

Pain History	Possible source
Superficial, exacerbated by movement and heavy touch	Muscular
Localised rib pain exacerbated by inspiration or touch	Rib fracture
Localised to one or more costochondral joints (occasionally radiating to general chest pain)	Costochondritis
Pain or paraesthesia in a dermatomal distribution	Neuralgia
Retrosternal, exacerbated by lying flat or bending forward	Oesophagus
Sharp, stabbing, well localised pain limiting inspiration. Not exacerbated by touch.	Pleurisy, pulmonary embolism, pericarditis
Severe central chest pain	Ischaemic heart disease, pericarditis, pneumothorax, dissecting aortic aneurysm

3. Physical Examination:
3.1. Appearance and feel:[6] Looking at a person may reveal the source of their pain to you. You may for example see swelling, bruising or signs of poor circulation such altered skin colour or missing hair. Even if you cannot see the injury, abnormal posture or movement can give you an indication of the injured structure. If the suspected structures are superficial you can then palpate them to see if they are tender on light or heavy touch. Some body parts are usually tender, so if a person has an injury on one side of his or her body it helps to compare the injured side to the non-injured side. It is also important to check that the pain produced by examination is the same pain the patient is complaining of rather than some other unrelated pain. If pain is reproduced by palpation of the bone, military physiotherapists (in my experience) use tuning forks or ultrasound to vibrate the bone. If vibration reproduces pain they suspect a fracture.

· A parachutist once came to me with groin pain following a heavy landing one month earlier. He was seen by a paramedic and doctor at the scene. At the time his pain was too generalised and vague for them to determine the cause so he was treated with anti-inflammatory medication for groin strain. On examination, active movements and end range passive movements of his hip hurt, but on palpation pain was only reproduced by palpation of the inferior ramus of pubis. I referred him back to the doctor and a bone scan revealed a fracture.

3.2. Passive movements:[6] If you suspect musculoskeletal pain you can distinguish between injuries of muscle and other structures by testing passive movements (when you move the patient’s body parts for them) and static muscle contractions (tensing a muscle without moving). When testing passive movements patients will naturally try to help you by moving actively. If they do so, the movements will feel light. It is essential to make sure the patient is as relaxed as possible and the movements should feel heavy. If passive movements reproduce pain it may be due to stretching a muscle (either at the end of its range or if it is in spasm), nerve, ligament, tendon, joint capsule or skin. Pain at the end of range of movement with a soft end-feel is likely to be due to stretching or compression of soft tissues or joint effusion. Pain at the end of range of movement with a hard end-feel is likely to be due to bone on bone compression. Pain with stiffness through the whole range of movement is likely to be due to joint inflammation or muscle spasm. Pain through range with no stiffness may due to acute joint inflammation or nerve irritation. The characteristics of pain response as previously described can help you determine which structures are affected. Sharp pains tend to indicate new injuries whereas dull aches indicate chronic or healing injuries.

3.3. Static muscle testing:[6] Static muscle contractions do not in theory stress non-contractile structures. If pain is reproduced by tensing a muscle without moving it is likely that the tensed muscle or its tendon is injured. It is worth noting though that muscle contractions will increase joint compression even if a limb is not moving. As bursae sit under tendons, static muscle testing can compress a bursa and give positive signs for bursitis.

3.4. Active movements:[6] If repeated active movements ease an ache, this may suggest chronic inflammation or tissue shortening. If they worsen a sharp pain this is more likely to be acute inflammation.

3.5. Tests that a physiotherapist or doctor may use:

3.5.1. Isolating and stressing individual anatomical structures:[6] Applying anatomical and biomechanical knowledge a doctor or physiotherapist may isolate individual muscles, ligaments or articulating surfaces and apply stress to them to see if they hurt. If a visceral source is suspected a doctor will examine the abdomen. Similarly, physiotherapists and doctors will examine the chest. My current module of study is locomotion so I will not address these now.

3.5.2. Biomechanical assessment:[6] If there is no history of trauma and pain onset was gradual a physiotherapist may look at muscle and bone lengths and joint positions to see whether the painful structures were injured over time due to a mechanical disadvantage.

3.5.3. Nerve pain: If stretching over several joints exacerbates pain, this suggests that unless several structures have been injured the pain may be coming from a nerve. This can be tested by stretching a nerve over several joints consecutively to see if pain increases. A commonly known example of this is the straight leg raise.
· To experience a nerve stretch for yourself lie on your back and raise a straight leg as high as you can until the pulling sensation on the back of your leg stops you. Then keeping your leg still, put your chin on your chest or dorsi-flex your foot. If either of these movements increase the pulling sensation you are experiencing a nerve stretch.
Testing of sensation, muscle power and reflexes can help reveal nerve injuries. Decreased reflexes suggest peripheral nerve injury whereas exaggerated reflexes suggest central neurological impairments.

3.5.4. Circulation: A doctor may palpate pulses to check circulation and lymph nodes to check for infection. Swollen lymph nodes suggest an immune reaction that may be in response to infection.

4. Investigations that doctors may use: Pain that is not affected by movement, weight bearing or structural testing may indicate pathology such a malignancy or infection. If the cause of pain is in doubt following history taking and examination investigations may be undertaken, but these will not be much use unless applied to the full clinical picture.

4.1. Checking medication for side-effects: “Arthralgia is a known side-effect of the following; ACE inhibitors, proton pump inhibitors, quinolones, gonadorelin analogues and tibolones.”[8] http://www.wrongdiagnosis.com/ lists 218 drugs that can cause muscle aches as a side effect. This source may not be accurate, so a doctor may check a patient’s drug history against the side effects listed in the British National Formulary.

4.2. Blood tests: Full blood count (low haemoglobin may indicate chronic disease, elevated white blood cells indicate infection, eosinophilia indicates and allergic reaction)[9]
4.2.1. For inflammatory pathology:[8]
· Plasma viscosity, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are used as markers of inflammation (but can be normal in 60-70% of patients with inflammatory pathology).
· Rheumatoid factor (positive in 33% of patients with inflammatory pathology)
· Anti-cyclic citrullinated peptide (anti-CCP) for differential diagnosis between rheumatoid arthritis (positive) and polymyalgia rheumatica (negative).[10]
· Interleukin-6 for polymyalgia rheumatica.
· Serum uric acid (SUA) or plasma urate for gout.[11]
4.2.2. For blood clots: D-dimer[13]which if positive, indicates the presence of an abnormally high level of cross-linked fibrin degradation products due to significant blood clot formation and breakdown somewhere in the body.[18]

4.3. Imaging: Plain x-rays or bone scans may reveal bone pathology or loss of intervertebral disc space. Diagnositc ultrasound, computerised tomography (CT) or Magnetic resonance imaging (MRI) can be used to reveal pathology in other tissues.

4.4. Biopsy or aspiration: Synovial fluid can be analysed for crystals, white blood cell count, blood and fat. Crystals suggest crystalline arthritis, elevated white blood cells suggest inflammatory or septic arthritis and fat or blood may suggest a fracture or tumor.[12] Soft tissue biopsies can be used to check for suspected malignancy or other pathology.

5. When all else fails:
When no cause can be found (such as in fibromyalgia[14]) it is possible that pain is psychosocially mediated, as according to NICE[19:p16] "at least two-thirds of depressed people who see their GP present with physical or somatic symptoms rather than psychological symptoms, making recognition harder." An inflammatory mediator known as substance-P can be released by the central nervous system and peripheral sensory nerves in response to stress[15]. Case study evidence suggests that occupational and lifestyle changes can alter somatic symptoms but this remains to be tested by clinical trials[16].
· When I working as a basic grade occupational therapist in orthopaedics, physiotherapists told me that a patient was unable to move in bed without crying hysterically due to lower limb pain. Medical investigations revealed no pathology, but examination of her social history revealed that she was a refugee with a troubled past, and her husband was being treated with psychotherapy due to their past trauma. Applying the principles from John Eaton’s book on Reverse Therapy[17] the lady was able to transfer independently from bed to commode after two treatment sessions.

6. Summary:
I consulted a general practitioner when writing this blog and he told me that when he was taught medicine, 90% of diagnosis was in history taking. Just by remembering the acronym SOCRATES and looking at active and passive movements, occupational therapists may be able to get a good idea of where pain is coming from before reporting to other multidisciplinary team members. Having said that, if a patient requires prompt analgesia or is likely to need emergency medical or surgical treatment, it may be unethical to delay referral to doctors or nurses in order to take a history.

References:
1. Hayes T (2003) 10 green bottles. http://student.bmj.com/issues/03/04/life/122.php accessed 13:33 31/1/2009
2. Lee M.W.L., McPhee R.W., Stringer M.D. (2008) An Evidence-Based Approach To Human Dermatomes. Clinical Anatomy 21:363–373
3. Snell R.S. (1981) Clinical Anatomy 2nd edition. Little, Brown and Company: Boston.
4. Drake R.L., Vogl W., MitchellA.W.M. (2005) Gray’s Anatomy for Students. Churchill Livingsone: Philadelphia.
5. Saunders D.R., Thompson A.J. (2008) Pain from the digestive organs. http://www.uwgi.org/gut/pain_03.asp accessed 19:58 31/1/2008
6. Magee D.J. (1992) Orthopedic Physical Assessment 2nd edition. W.B. Saunders Company: Philadelphia.
7. Bellamy N., Sothern, J Campbell J., W W Buchanan W.W. (2002) Rhythmic variations in pain, stiffness, and manual dexterity in hand osteoarthritis Annals of the Rheumatic Diseases;61:1075-1080
8. Willacy H. (2008) Aching Joints - Assessment, Investigations and Management in Primary Care. http://www.patient.co.uk/showdoc/40024540/ accessed 19.25 1/2/2009
9. EMIS and PIP (2006) Full Blood Count and Blood Smear. http://www.patient.co.uk/showdoc/27000454/
10. Willacy H. (2007) Polymyalgia rheumatica (PMR). http://www.patient.co.uk/showdoc/40001184/ accessed 20.16 1/2/2009
11. Clinical Knowledge Summaries (2007) Gout - Making a diagnosis. http://www.cks.library.nhs.uk/gout/making_a_diagnosis/diagnosing_gout/history#-302321 accessed 21:20 1/2/2009
12. Siva C, Velazquez C, Mody A, Brasington R. (2003) Diagnosing acute monoarthritis in adults: a practical approach for the family physician. American Family Physician. 68(1) http://www.aafp.org/afp/20030701/83.html accessed 21:33 1/2/2009
13. EMIS and PIP (2006) Deep Vein Thrombosis (DVT). http://www.patient.co.uk/showdoc/23068982/ accessed 10:44 2/2/2009
14. EMIS and PiP (2008) Fibromyalgia. http://www.patient.co.uk/showdoc/27000172/ accessed 12:43 2/2/2009
15. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11): 503-510
16. Various (2005-2007) Testimonials http://www.reverse-therapy.com/Testimonials/default.asp
17. Eaton J. (2006) M.E., Chronic Fatigue Syndrome & Fibromyalgia. The Reverse Therapy Approach. Authors Online: Hertford
18. Lab tests online uk (2007)D-dimer http://www.labtestsonline.org.uk/understanding/analytes/d-dimer/test.html accessed 16:52 29/1/2009
19. NICE (2007) Depression (amended) Management of depression in primary and secondary care: http://www.nice.org.uk/nicemedia/pdf/CG23NICEguidelineamended.pdf accessed 11:39 3/2/2009
20. Parker S., Middleton P.G. (1993) Assessment. In: Webber B.A., Pryor J.A. (eds)Physiotherapy for Respiratory and Cardiac Problems.Churchill Livingstone: Edinburgh. 3-22

Multidisciplinary roles for mobility rehabilitation

2009-01-26T23:51:01+00:00

1. Introduction:
One of my problem-based learning objectives this week is to explain the multidisciplinary team roles for mobility rehabilitation. Mobility is classified in chapter 4 of the World Health Organisation International Classification of Functioning, Disability and Health[1]. To answer this question thoroughly I should ask each relevant professional association for statements on the issue, or carry out a very broad literature review. Due to time constraints however (I only have 3 days) I thought a logical way to approach this question would be to browse the listed body functions and see how different professions treat impairments of these functions. This blog entry is intended to give first year students a vague idea of the things non-medical multidisciplinary team members might do. Looking at it simply, to move, we need functional bones, joints and muscles. Adequate nutrition is required to build bone and muscle. The latter requires fuel, oxygen and electrolytes delivered by the circulatory system in order to function. Assuming intact sensation and absorption, my analysis is summarised in the table below.

2. Before you begin:
Before attempting mobility rehabilitation it is important to check with medical and nursing staff that a patient is medically fit enough to rehabilitate. Necessary interventions may include:[13, 14]
· reduction of poly-pharmacy
· stabilization of heart rate, rhythm and blood pressure
· stabilization of blood sugar
· treatment of infection or injury
· adequate analgesia (at the right times for rehabilitation or independent function)

Table 1. Multidisciplinary roles for mobility rehabilitation [1, 2, 3, 4, 5, 6, 7, 8, 9]

Performance components	Structures	Profession	Possible interventions
Volition: MENTAL FUNCTIONS: Optimism, b1266 Confidence, b1301 Motivation	STRUCTURES OF THE NERVOUS SYSTEM	Clinical psychologists, cognitive behavioural therapists, occupational therapists	Cognitive behavioural, functional rehabilitation or compensation interventions to address identified impairments.
	STRUCTURES OF THE NERVOUS SYSTEM	Dietitians	Correction of malnutrition
Rigidity: Stability of joint functions	STRUCTURES RELATED TO MOVEMENT (bones, cartilage and ligaments)	Orthotists (or physiotherapists)	Orthotics to correct bone/joint position
		Orthotists (or occupational therapists)	Splints to limit movement
		Physiotherapists	Exercise to stimulate bone density and correct orientation of bone tissue.
		Occupational therapists	Specialist seating for maintenance of body position
		Prosthetists	Artificial limbs
		Dietitians	Diet adjustment for calcium and vitamin D
Flexibility: Mobility of joint functions	STRUCTURES RELATED TO MOVEMENT (joints and muscles)	Physiotherapists	Muscle lengthening, break-down of scar tissue, ligament stretching, mobilisation of individual joints or nerves.
		Prosthetists	Articulated artificial limbs
		Dietitians	Diet adjustment for adequate protein intake
Power and reaction-time: b798 Neuromusculoskeletal and movement-related	STRUCTURES OF THE NERVOUS SYSTEM, STRUCTURES RELATED TO MOVEMENT (nerves and muscles)	Physiotherapists	Rehabilitation of normal movement and balance reactions, training to increase muscle power and endurance.
		Dietitians	Diet modification for electrolyte balance and protein intake (for muscle mass) or calorie control (to reduce body mass) if necessary.
Fuel: b410-b429 Functions of the cardiovascular system	s410 Structure of cardiovascular system	Dietitians	Diet adjustment for adequate calorific intake and reduced cardiovascular risk.
Oxygen: Functions of the cardiovascular system, b440-b449 Functions of the respiratory system	Structure of cardiovascular system, s430 Structure of respiratory system	Physiotherapists	Positioning, exercises and adjuncts to optimise respiratory function. Exercise to improve muscle cell oxygen uptake and open muscle capillary beds thereby reducing peripheral resistance and cardiac loading.
		Occupational Therapists	Pacing or equipment to compensate for reduced exercise tolerance.
		Dietitians	Diet adjustment to reduce cardiovascular risk and optimise respiratory function.

3. Pain:
When pain limits mobility physiotherapists and occupational therapists may use physical or psychosocial interventions respectively. During my career so far I have only seen clinical psychologists working in physical settings on two occasions. As psychological factors greatly influence pain perception I believe that psychologists and occupational therapists could play much bigger roles in all physical healthcare settings. Pain is a complex subject in itself so I will not attempt to address it here other than this brief mention.

4. Mobility aids:[10]
If performance components cannot be restored, or during the period while they are being restored, mobility aids can be used to compensate for impairments. In my experience occupational therapists tend to use the word ‘mobility’ to refer to movement from one location to another and consider ‘transfers’ as a separate area of assessment. As a physiotherapist I used to consider transfers as part of mobility; thinking of ‘bed mobility’ for example rather than ‘bed transfers’. With the exceptions of generic working and accident and emergency departments, in the United Kingdom physiotherapists tend to issue walking aids while occupational therapists issue aids for transfers, wheelchairs or similar outdoor mobility aids and prescribe housing adaptations to compensate for physical impairments. Some brief examples are given below:

People with poor bed mobility can be issued with electrically powered, position-adjustable beds or simple grab rails. Occupational therapists can raise the heights of beds or other furniture to make it easier for people to get on and off.

Similarly, adjustments can be made to toilets and bathrooms, ranging from simple frames to powered lifts.

Walking aids range from a simple stick, through elbow crutches to frames. Frames with four legs are used for people that are unable to bear weight through one of their lower limbs. Gutter frames (like the one pictured to the left below) provide elbow weight-bearing surfaces for people that are unable to bear weight adequately through their hands or wrists. People that can bear weight through both lower limbs may be issued with frames with two legs and two wheels. Use of these walking aids is not limited to people with musculo-skeletal or balance problems. People with poor exercise tolerance due for example to chronic obstructive pulmonary disease can lean on walking aids to reduce the demands placed on their postural muscles. Devices with wheels and no legs are generally not considered safe walking aids unless they have brakes. Such walkers (as pictured to the right) have been designed for use when shopping.

People able to mobilise short distances but unable to access the community due to mobility impairments may benefit from scooters and those that are unable to walk may benefit from indoor or outdoor powered on non-powered wheelchairs. These items can be purchased privately but their statutory services allocation is strictly controlled due to financial constraints. It may therefore be wise to refer patients to your local occupational therapy service before raising any ideas or expectations regarding this type of equipment.

5. Housing adaptations:
If people’s mobility is permanently impaired, occupational therapists may consider housing adaptations to enable them to continue living independently at home. Examples of this include wheelchair ramps (where the door steps once were), removal of doorframes to (allow wheelchair access) and stair lifts (for people that can walk) or through-floor lifts similar to but smaller than those found in shopping centres (for indoor wheelchair users). People in wheelchairs may also require cupboards and kitchen work surfaces lowered.

6. Sensory and perceptual impairments:
So far I have presented a reductionist approach to reduced mobility; neglecting how sensory and perceptual impairments can affect function. Vestibular, proprioceptive or perceptual impairments can interfere with balance and co-ordination of movement. If for example you were now unable to feel any pressure on your left buttock, you might be led to believe you were going to fall to the left off your chair. Examples of this include stroke, severe migraine or labrinthitis. People showing no evidence of sensation or proprioception usually have a poor prognosis for rehabilitation. Some things that physiotherapists might do include:

· Feedback exercises to restore normal body awareness and balance[11]
· Exercises to resolve balance problems of vestibular origin[12]

From my experience I believe occupational therapists in the United Kingdom are more likely to work on functional exercises to restore normal perception and re-sensitise skin. Correction of visual impairment alone has not been proven to reduce falls risk, but it can be an effective part of multifaceted treatment.[13]

7. Falls interventions:
Intrinsic risk factors for falls include[14]:

· balance, gait or mobility problems, degenerative joint disease, motor disorders
· taking four or more concurrent medications
· visual impairment
· depression or impaired cognition
· postural hypotension

Extrinsic risk factors for falls include:[14]

· badly fitting footwear or clothing
· trip hazards such as loose carpets, rugs or paving
· poor lighting, particularly on stairs
· steep stairs
· having to over-reach for lights or windows.

According to the National Service Framework for Older People[14] specialist falls intervention should be offered to people with fragility fractures, older people that attend Accident and Emergency Departments or use emergency ambulances due to falls, those with two or more intrinsic risk factors, those who have had frequent unexplained falls, fall in hospital, nursing or residential care homes, have unsafe housing conditions, or very afraid of falling.

Physiotherapists can reduce falls risk for specifically targeted older people at high risk[15] with individually tailored exercise programs by:[14]

· providing balance training
· strengthening the muscles around the hip, knee and ankle
· increasing the flexibility of the trunk and lower limbs
· providing appropriate mobility equipment
· teaching people to get up safely after falling
· providing information

Occupational therapists can reduce falls risk by assessing functional actitivites in patients’ own environments and facilitating risk reduction though:

· task modification
· removal of environmental hazards
· provision of safety equipment such as stair rails and grab rails
· liasing with local authorities regarding paving and street lighting
· providing means for at-risk people to summon help if they fall
· teaching people to get up safely after falling
· providing information

8. Maintaining general health:
Steps to maintain general health such as smoking cessation, moderation of alcohol consumption, exercise, sun exposure and a healthy diet may prevent secondary deteriorations of mobility. Occupational therapists may consider lifestyle re-design or life narrative re-structuring in addition to compensations to ensure continuing quality of life and sense of well-being when mobility cannot be recovered.

9. In conclusion:
Superficially it may appear that mobility rehabilitation simply consists of referring patients to physiotherapy and progressing them through a series of walking aids. Hopefully this blog entry has revealed that mobility impairments may be a little more complicated than that. It has very superficially touched on things various professions might do, but it is in no way comprehensive or authoritative. When I was a physiotherapist I had no idea about occupational therapy equipment and so did not think to refer patients to occupational therapy. As an occupational therapist I found on one occasion that the senior physiotherapists I was working with had no idea that I could help them with a patient that had idiopathic mobility loss until after I showed them what occupational therapy can achieve. After analyzing patients’ functional deficits down to the impairment level, I believe it would be better to consult with other professions directly on a case by case basis, than to make assumptions about what a profession can do, in order to achieve the full potential of multidisciplinary working.

References:
1. World Health Organisation (2001) International Classification of Functioning, Disability and Health (ICF) http://www.who.int/classifications/icfbrowser
2. http://www.nhscareers.nhs.uk (undated) Psychologist http://www.nhscareers.nhs.uk/details/Default.aspx?Id=446 accessed: 16:11 26/1/2009
3. NHS choices (undated) Cognitive behavioural therapy http://www.nhs.uk/Conditions/Cognitive-behavioural-therapy/Pages/Introduction.aspx?url=Pages/what-is-it.aspx accessed 16:16 26/1/2009
4. Crepeau E.B., Cohn E.S., Schell B.A.B. (2003) Willard & Spackman’s Occupational Therapy. 10th edition. Lippincott Williams & Wilkins: Philadelphia
5. Mitchell S.L., Creed G., Thow M., Hunter A., Chapman J. (1999) Physiotherapy guidelines for the management of osteoporosis http://www.csp.org.uk/uploads/documents/OSTEOgl.pdf
6. http://www.nhscareers.nhs.uk (undated) Prosthetist and orthotist http://www.nhscareers.nhs.uk/details/Default.aspx?Id=286 accessed 16:31 26/1/2009
7. http://www.nhscareers.nhs.uk (undated) Dietitian http://www.nhscareers.nhs.uk/details/Default.aspx?Id=285 accessed 16:39 26/1/2009
8. Venth (2007) Gain with no pain; just a little strain – physical conditioning for people with cardio-pulmonary impairments. http://www.metaot.com/blog/gain-no-pain-just-little-strain-%E2%80%93-physical-conditioning-people-cardio-pulmonary-impairments. Accessed 18:44 26/1/2009
9. McKeever T.M., Scrivener S., Broadfield E., Jones Z, Britton J., Lewis S.A. (2002) Prospective Study of Diet and Decline in Lung Function in a General Population. American Journal of Respiratory and Critical Care Medicine 165:1299-1303
10. http://www.keepable.co.uk/ accessed 9:31 27/1/2008
11. The Bobath Centre (undated) TheBobathApproach http://www.bobath.org.uk/TheBobathApproach.html accessed 9:34 27/1/2009
12. Corna S, Nardone A, Prestinari A, Galante M, Grasso M, Schieppati M. (2003) Comparison of Cawthorne-Cooksey exercises and sinusoidal support surface translations to improve balance in patients with unilateral vestibular deficit. Arch Phys Med Rehabil 84:1173–84.
13. NICE (2004) Clinical Guideline 21: The assessment and prevention of falls in older people. NICE: London
14. Department of Health (2001) National Service Framework – for Older People. Department of Health: London
15. Feder G., Colin Cryer C., Donovan S., Carter Y. (2000) Guidelines for the prevention of falls in people over 65. BMJ;321:1007-1011

My thought for the day....

2008-12-13T15:03:56+00:00

Speech and language therapists help people communicate and swallow. Dietitians help them choose what to swallow. Physiotherapists help them hold position or move with reduced pain. Doctors and nurses keep people alive and reduce suffering, but being alive, moving, speaking and eating does not always equate to having a (satisfying) 'life'. Who is it that helps people save their own 'lives' by integrating all of these efforts then? That would be the occupational therapists :0)

Below is something I wrote for a group of medical students about the use of therapy services for older people. My knowledge of speech and language therapy is limited, so it may have a physiotherapy and occupational therapy bias, but I thought I might as well post it here in case it is of use to anybody:

The World Health Organisation (2001) identified the activities listed below, as well as ‘environmental factors’ (http://www.who.int/classifications/icfbrowser/) as determinants of health.

“LEARNING AND APPLYING KNOWLEDGE
GENERAL TASKS AND DEMANDS
COMMUNICATION
MOBILITY
SELF-CARE
DOMESTIC LIFE
INTERPERSONAL INTERACTIONS AND RELATIONSHIPS
MAJOR LIFE AREAS
COMMUNITY, SOCIAL AND CIVIC LIFE” (http://www.who.int/classifications/icfbrowser/)

Inability to perform any of these activities is likely to cause health inequality. Therapy services are therefore used to address such deficits:

Speech and Language Therapy (SALT): 1-3, 5-9 (through emphasis on 3 and swallowing)
Physiotherapy: 2-9 (through emphasis on 4)
Occupational Therapy (OT): 1-9

Failure to address these issues is likely to precipitate long-term health inequality and therefore repeated attendance of Primary or Secondary Care.

	Indications	Likely intervention	Possible consequences of not referring
SALT	Choking, repeated unexplained chest infections.	Swallow assessment and re-training. Thickened fluids or tube feeding.	Aspiration and repeated chest infections with the risk of subsequent death.
SALT	Communication problems	Sensory, motor and cognitive assessment and re-training or compensations.	Loss of autonomy and client centred practice. Social isolation. Mental illness with secondary physical illness.
Physiotherapy	Decreased air entry (to lungs) or retained respiratory secretions	Positioning and breathing exercises. Mechanical adjuncts such as bagging, positive airway pressure or suction.	Chest infections with subsequent death.
	Constipation or painful trapped wind.	Mobilisation	Pain, or impaction that may require theatre time.
	Musculoskeletal pain.	Exercise and postural correction. Mechanical or electrical intervention.	Loss of function with physical de-conditioning and increased risk of mental health problems. Unnecessary surgery (e.g. carpal tunnel release for neck problems)
	Decreased mobility (including for stroke)	Exercise, walking aids, re-education of normal movement.	Loss of function and physical de-conditioning leading to increased risk of respiratory problems, pressure sores, constipation or postural hypotension. Loss of autonomy. Social isolation.
	Falls or balance problems with no treatable medical cause	Vestibular and proprioceptive assessment and rehabilitation. Walking aids. Balance re-training.	Repeated trauma and hospital admissions. Risk of serious injury.
Occupational Therapy	Problems with any of the domains of “ACTIVITIES AND PARTICIPATION” specified by the World Health Organisation (2001: http://www.who.int/classifications/icfbrowser/)	Physical, cognitive, environmental and social assessment followed by rehabilitation, adaptations and compensations (e.g. re-training of self-care, equipment provision, housing adaptations, lifestyle re-design).	Loss of autonomy. Social isolation. Increased risk of mental and physical health problems requiring Primary and Secondary Care intervention.

Reference:
1. World Health Organisation (2001) International Classification of Functioning, Disability and Health (ICF) http://www.who.int/classifications/icfbrowser

Reiki to facilitate spiritual emergence: a personal journey.

2008-06-28T18:43:38+01:00

0. Abstract:
Reiki is a healing energy technique of uncertain origin. It may not be applicable to occupational therapy, but the process of learning reiki may be of use to occupational therapists for facilitating spiritual emergence and personal development. This blog entry describes my personal journey as a physiotherapist learning reiki, and how the experience led me to re-train as an occupational therapist. The benefits I experienced included increased empathy and interpersonal skills, more ethical living, a deeper respect for occupational therapy, improved physical and mental health, a feeling of connection to the universe and restored faith in God.

1. What is reiki?
Reiki is a technique for channelling energy from the universe into a person, object or event through placement of the hands. Some believe it was developed in the early 1900s[1]. Others believe that it was revealed from meditation on ancient Sanskrit sutras[2]. A woman named Hawayo Takata is credited with introducing reiki to the West[2]. According to her, reiki was invented by a Christian boys’ school headmaster named Usui Mikao[3], but according to cynics this story may have been contrived to facilitate the marketing of reiki to Christian people in the West[2]. Others believe that Usui was a Tendai Mikkyo Buddhist, influenced by Shintoism and Shugendo[4]. Unfortunately until recent times reiki teachings were conveyed only by word of mouth. It is therefore likely that the techniques and story have been modified several times by people to suit their own needs and religious or political interests. It may therefore not be possible to determine where reiki actually came from.

2. Before I experienced reiki:
As a junior physiotherapist I was scientifically minded to the point of being sceptical about many physiotherapy modalities. I had seen enough inequity and injustice to turn me to atheism. I worked weekends for Britain’s nuclear, biological, chemical regiment, to prove my British identity and express aggression in a socially acceptable way. I consumed tubs of ice cream or family-sized cheesecakes on a daily basis and accompanied colleagues to the pub across the road every day after work to relax myself with stout. A couple of male colleagues and myself used to have regular letching competitions during which we would each try to find the most attractive woman to look at. Unbeknown to me, a chance meeting was about to start a chain of events that would change all of this.

3. My initial experience of reiki:
A woman I met socially told me about reiki and offered me a demonstration. She moved her hands over me without touching me, and as she did so I felt waves of energy pulsating through my body. To my amazement, she told me things she intuitively knew about my military injuries. I thought this would be a great skill to have as a physiotherapist, so I asked for her teacher’s contact details and booked myself onto the first available lesson.

4. The first attunement:
The first lesson took just one day. The reiki teacher spoke of angels and how reiki would change our lives. I thought she was away with the fairies. She told the students that reiki was taught through a series of attunements, each of which would be followed by a detoxification period during which we could feel ill as our bodies became accustomed to a higher energy flow. After a brief ritual she blew into my hands. From that moment my palms were tingling and warm for no apparent rational reason. We spent the rest of the day practising reiki on each other and most of the students were able to find each other’s illnesses and injuries by feeling the energy alone.

On returning to work, I wondered whether I had imagined the whole thing, but as soon as I walked onto a ward my palms started tingling. Practising on patients was out of the question, but one of the senior physiotherapists had a migraine and allowed me to try reiki on her. She said it worked, but I found it very difficult to believe. Similar incidents would soon occur with several other clinicians, but I remained unconvinced. Events did not fit with my understanding of science and I wondered if my colleagues were teasing me when they said the reiki worked. At the pub after work my hands felt repelled by an unseen force around a pint of stout and a strong sense of intuition told me not to put chocolate cake in my mouth.

5. The detoxification:
Over the next month I re-experienced childhood knee pains, digestive problems, asthma and had a terrible cold. According to the reiki teacher these things were significant messages about problems with my life. This theory was just another aspect of reiki that I was not prepared to believe. With time however I came to accept that my childhood abdominal problems were due to a lack of power and social status. My asthma and heartburn were due to inhibition of my love, and my perpetual colds were due to poor awareness of my own intuition[5]. I would come to understand this theory as somatic metaphor. It brought me awareness of the huge untapped potential for occupational therapy. I just needed scientific evidence to triangulate the belief. I was still unsure whether reiki was real or just a figment of my imagination.

6. Learning to use reiki:
I learned to use reiki through experience. The results did not cease to amaze me. Feeling people’s energy provided me with indications of what their psychosocial problems were according to the theory of somatic metaphor. Lifestyle change proved to be far more effective for resolving chronic energy problems than the reiki treatment itself.

7. Progressive attunements:
I went to my second attunement with an occupational therapy manager I knew. The attunement was to an energy called seichem. We were taught a psychic surgery technique that involved liaison with celestial beings. I did not believe in such things, but went through the motions and was shocked to feel an unseen being placing unseen objects in my hand. Several experiences during the surgery did not fit with my understanding of science and I thought I was imagining them until the occupational therapy manager described the exact same events in a way that she could not have known that I had experienced them. My rational mind searched for explanations. Had we been drugged or hypnotised? Was this some form of mass hysteria? As I progressed through four other attunements over the next nine months my paranormal experiences became progressively more vivid. After my final attunement I went on to teach several doctors and a student nurse. Conducting attunements myself was an overwhelming experience. I perceived brilliant light radiating out from inside my body and saw angelic beings for the first time.

8. Progressive breakdown of my reality:
I became aware of sensations that other beings were around me at various times during the day. At first I could not see them but could feel their presence. I became sensitive to other people’s feelings to the extent that my emotional state varied to match that of people in my proximity. Over time I would learn to distinguish between other people’s emotions and my own. I remember going to my pigeonhole at work one morning and wondering whether I had developed schizophrenia. I was experiencing what Collins[6] recently described as spiritual emergency. As my training progressed, my psychosocial problems manifested metaphorically as visible and tangible demons. My intuition told me the meaning of each demon, and what I had to change about my life to leave it behind. The natures and significance of each demon were personal and will therefore not be described in this blog. For my masters’ attunements I was taught how to teach reiki and attune other people. During this lesson I discovered that reiki teachers (from the Tera-Mai lineage) do not actually attune their students, but call on celestial beings that do it. I was unable to believe in such beings until I started teaching reiki myself, and experienced direct contact with them. At this point, the logic I had based my atheism on no longer seemed valid.

9. Ethical problems:
A senior occupational therapist once told me that Jesus is the only source of spiritual healing and therefore reiki must be a trick of Satan. During a lunchtime discussion one day, fellow physiotherapists ridiculed the concept of healing energy and expressed that the idea of occupational choices profoundly influencing health was ludicrous. I was not aware of any published data to support evidence-based practice. The Royal College of Nursing once approved a reiki course for the continuing professional development of nurses, but subsequently withdrew their approval due to their interpretation of a House of Lords report on complimentary therapies[7]. For these reasons, I have never been able to use reiki with National Health Service patients. Some time later, I was presented with two subjects that seemed to have serious energy problems. One had an energy imbalance down one entire side of his body and the other seemed completely deplete of energy. Neither had any awareness of having health problems. I therefore said that there was no evidence that what I was feeling meant anything and it should not be a cause for alarm. After this event I stopped practising reiki because I thought it could worry people unnecessarily. Within a year I was shocked to find that the first subject had a hemiplegic stroke and the second had died of cancer. Diagnosis had been made too late for life-saving treatment. I had a few sleepless nights after receiving this news, before deciding not to start practising reiki again, except for with spiritual aspirants that requested it specifically to facilitate spiritual emergence. I believe that great care should be taken when selecting reiki students, to ensure that they have the emotional resilience to endure spiritual emergencies without developing mental health problems.

10. How reiki changed me:
Reiki inspired several changes in my life. Much to the bemusement of my friends, I gave up alcohol and letching at women. Specific decision-making is often informed by reiki. A memorable example of this was an attractive woman flirting with me and kissing me after a formal army dinner. I felt a very strong force pushing me away from her as though an invisible person had put his palm on the side of my head and was extending his arm. At the time I thought her guardian angel was protecting her from my amorous intentions. I therefore concluded my behaviour was immoral and I left her alone. Later that night I noticed her tendency for attention-seeking and somebody that knew her well told me she was pregnant. Perhaps I was the one that was being protected. On a wider scale, I was unsure of the ethics of the invasion of Afghanistan, but previously ignored this because I enjoyed soldiering so much. As a manifest demon, this dilemma was impossible to ignore, so I transferred to the Medical Corps to ensure that I would never be ordered to kill. My new sensitivity also convinced me to leave unethical jobs in Council Housing and National Health Service management. My experiential knowledge of somatic metaphor convinced me of the importance of occupational therapy[8]. If demons could be real I reasoned that God could too. This inspired me to read the Bible, Koran and various other religious texts that have restored my faith in God and helped me built rapports with patients of each book’s respective faith. The fact that lifestyle change is more effective for restoring energy balance than reiki itself is an indication to me that occupational therapy has the potential to make reiki obsolete. Reiki inspired me to analyse evidence of occupational influences on health[9, 10] and ultimately re-train to be an occupational therapist.

11. Possible implications:
The paranormal experiences resulting from reiki led me to wonder about the functions of hallucinations and whether or not these are always pathological. Perhaps people should only be considered ill if their hallucinations adversely affect their happiness or social functioning. Shamanism is common to several cultures, and though Western science currently tells us to disregard it, there may be a hidden science underlying it. Some occupational therapists have argued that “there is still a need to understand better the impact that spirituality has on health and wellbeing”[11]. Perhaps reiki training is a suitable method for occupational therapists to gain experiential knowledge of this. In some cases, responding to or interacting with hallucinations might change an individual’s life for the better, while ignoring them or medically suppressing them could prove detrimental. An example of this has been documented in the British Medical Journal. A woman was alerted to her brain tumour by a voice telling her a) that she had one, and b) which hospital in her locality had a suitable magnetic resonance imaging (MRI) unit. Responding to the voice she managed to convince her general practitioner that she needed a MRI scan, and was therefore successfully diagnosed and treated[12]. If medical treatment had been focused on suppressing this lady’s auditory hallucinations, the brain tumour would not have been diagnosed as early.

12. Summary:
Modern reiki is a healing energy technique of uncertain origin. I do not believe it is a suitable modality for occupational therapy. It has however been offered by non-occupational therapy staff in National Health Service Hospitals[13] and could be a great personal development tool for occupational therapists that wish to accelerate their own spiritual emergence, or would like to experience a different perspective on how occupation can influence health. The evidence for this is intra-personal. This blog entry only briefly touches on my experiences of reiki, and I only trained with one of many reiki lineages. Further reading is therefore recommended. As scientists I expect graduate occupational therapists to have a healthy cynicism about reiki. I suggest that anybody that doubts reiki or the existence of a spiritual plane should take the six reiki and seichem attunements up to masters’ level to inform their judgment before making up their minds.

13. Recommended reading:
Brown F. (1992) Living Reiki: Takata’s teachings. Mendocino: Liferhythm
Paul N.L. (2005) Reiki for Dummies. Hoboken: Wiley
Stiene B., Stiene F. (2005) The Japanese Art of Reiki. Ropley: O Books

14. References:
1. Stevenson M. (2003) Brief introduction to Reiki. British Journal of Therapy and Rehabilitation 10(1):34
2. Shealy C.N. (1999) The Complete Illustrated Encyclopedia of Alternative Healing Therapies. Shaftesbury: Element Books
3. Brown F. (1992) Living Reiki: Takata’s teachings. Mendocino: Liferhythm
4. Stiene B., Stiene F. (2005) The Japanese Art of Reiki. Ropley: O Books
5. Mailoo V., Wickham J., Bannigan K. (2006) OT and the tantric frame of reference. Therapy Weekly 33(3): 8-10
6. Collins M. (2007) Spiritual emergency and occupational identity: a transpersonal perspective. British Journal of Occupational Therapy, 70(12):504-512
7. Manson C. (2003) A brief introduction to Reiki. British Journal of Therapy and Rehabilitation 9(9):368
8. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. Available at: http://www.metaot.com/blogs/%5Buser%5D-6 Accessed on 24.3.2008
9. Mailoo V.J., Williams C.J. (2004) Psychoneuroimmunology: a theoretical basis for occupational therapy in oncology? International Journal of Therapy & Rehabilitation 11(1):7-12.
10. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11):503-510
11. College of Occupational Therapists Ethics Committee (2001) Addressing spiritual needs. British Journal of Occupational Therapy 64(2):107
12. Azuonye I.O. (1997) A difficult case: diagnosis made by hallucinatory voices. British Medical Journal, 315:1685-86
13. Mehrfar M. (2006) Patient Healing comments. Available at: http://www.cancertherapies.org.uk/patient.php?PHPSESSID=ca4dc83f058d6a7f... Accessed on 28.6.2008

Technology as a tool in OT

2008-06-23T21:34:45+01:00

I am incredibly excited at the prospect of research in to the use of the Wii to assist stroke survivors in re-learning movement. What a great example of our need as therapists to move with the times and exploit modern technology to engage clients in meaningful, therapeutic activities. I can just visualise Mrs Jones extending her shoulder back, flexing her hip and knee and going in for that killer ‘virtual’ strike!!!!!

Examples of it’s potential rehabilitative qualities include ‘77-year old Jerry Pope, a former semi-pro tennis player. Following his stroke in June, he’s been using the Wii Tennis activity of Wii Sports and swings of the Wii Remote to help regain movement in his hands and feet, along with his balance’

He claims the Wii “is extremely motivational and gives you the illusion that you’re progressing even if you’re not, putting you in a better frame of mind”.

An opinion piece by Verdonk and Ryan ( 2008 ) asserts that occupational therapists ‘can, and should, capitilise on the opportunities offered by mainstream technology’ within everyday meaningful occupations as potential therapy tools and for use in practice environments. They suggest that technology ‘offers therapists new types of handiwork and enabling devices’ and that both occupational therapists and occupational therapy departments ’should reflect these changes and consider exchanging therapeutic cones for computer and video games consoles’.

The use of computer games in therapy appear to multi-faceted. Not only (in my opinion) are they more enjoyable and stimulating than for example the use of the therapeutic cone, their multiplayer options can be used to encourage group therapy sessions. As suggested by Verdonck and Ryan ( 2008 ) ‘competition can be an intrinsic motivator or it can be a pain distracter and increase tolerance for occupational therapy sessions’. Who knows, perhaps the next PlayStation will be able to cure cancer?

Another example of the implications of technology within the field of occupational therapy lies with the use of information and communication technology. Verdonck and Ryan ( 2008 ) demonstrate an interpretation of the Canadian Model of Occupational Performance to mainstream technology using the internet. They state that the internet ‘can be considered a virtual environment in which the person can engage in occupation’. An example is: Self care through the use of online shopping; Leisure through the use of music downloads; and Productivity through the use of buying and selling online. It is clear that the internet plays a huge role in not only improving the quality of life for those who may have limited access to their communities but also plays a huge part in facilitating functional independence. With a potentially more technologically savvy older population, is it likely that hospital assessments may eventually incorporate the persons ability to use the internet as a factor in their safe discharge home?

Please see my blog: otlondon.wordpress.com

ref:
http://www.dailymail.co.uk/health/article-486525/Wii-games-help-stroke-v...
Verdonk and Ryan (June 2008)Mainstream Technology as an Occupational Therapy Tool: Technophobe or Technogeek? BJOT

The Dressing Loop in Accident and Emergency

2008-06-18T16:33:19+01:00

Hi,

I'm an OT based in Accident and Emergency. I've recently become aware of the 'dressing loop, Rapid Functional Assessment tool', available from Nottingham Rehab Supplies. I'm interested to explore it's use as a screening tool and/or part of the assessment toolbox in A+E.

I've had a look at the dressing loop and think it's got potential for this field but it has been developed primarily with neuro patients in mind. Due to the four hour targets for patient care governing A&E we have very little time to complete functional assessments - and often cannot carry out PADL assessment due to a lack of suitable clothing.

Does anyone else use a dressing loop in a rapid (predominantly physical) setting? If so then how do you find it? Have you adapted the recommended assessment form that’s supplied along with the loop?

All feedback gratefully received!

Thanks Kate

What is in a name? – Why non-holistic interventions should not be termed ‘occupational therapy’.

2008-04-10T11:37:18+01:00

1. Introduction: Have you ever seen a Ferrari Panda or Fiat Testarossa? What about a Lexus Yaris or Toyota Soarer? What about a Nicole Farhi FCUK T-shirt? If you do, please send me a photograph because I never have. This phenomenon has also occurred with Ralph Lauren and Chaps. Companies are using different names to market products in distinct quality brackets. There is a very good reason for this. What do you think a Fiat Panda would do for the image of Ferrari if it was branded ‘Ferrari’? Ferrari would lose out to other super-car producers that were more sensible with maintenance of their brand images. The occupational therapy profession could learn this valuable lesson from industry. This blog entry is a very brief reflection on that thought.

2. Relevance to occupational therapy: Here are a couple of examples of non-holistic service being delivered in the guise of ‘occupational therapy’:

“I work in acute orthopaedics. I have been told due to budgetary constraints my role is only to ensure safe discharge from hospital. I have previously been criticised for improper use of resources when I dealt with quality of life issues.” [1]

“….one of their team leaders told me community occupational therapists only work on equipment and adaptations and cannot provide rehabilitation.” [2]

How do you think this kind of practice is affecting the professional and public images of the occupational therapy profession?

3. The consequences: I recently heard that in one acute setting, physiotherapy has been funded for cardiac rehabilitation but occupational therapy has not. Could this be because the funding authorities have no idea what occupational therapy is, due to the various confusing images we have collectively portrayed while working in reductionist ways? [3] Here is another example of where our profession seems to have lost out due to failure to project a clear image of its remit and potential:

“The Primary Care Mental Health Team told me that they no longer have any occupational therapists on their staff. The woman I spoke to said that even when they did have occupational therapists, they did not provide an occupational therapy service, but worked generically. She actually said "we provide mental health-care; not occupational therapy". I asked her how it was possible to provide mental health-care without occupational therapy, but this question just went over her head.” [2]

Our profession is losing out to other competing professions due to failure to maintain a strong professional image.

4. Conclusion: Perhaps we should change our job titles when not practising holistically. This would prevent non-holistic practice (due to constraints set by public service management) from tainting the image of our profession. Discharge facilitators should simply be called 'discharge facilitators' and the social services team leader who thinks “community occupational therapists only work on equipment and adaptations and cannot provide rehabilitation” [2] should consider re-naming her team ‘the ergonomic adaptation team’ or something similar without the words ‘occupational therapy’ included.

5. References:
1. Basic grade (2008) Somebody please help me. http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2289
2. Venth (2008) reality check. http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2237&postdays=0&pos...
3. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. http://www.metaot.com/blogs/%5Buser%5D-6

meta-ot

Another case of role blurring

Trying to make sense of rheumatological investigations.

yoga and stroke

Occupational Alienation – a personal perspective

Hip muscle mnemonics

Drunkenness is stupid

Is dorsi-flexion ‘flexion’ or ‘extension’?

Control of movement

What does pain tell us?

Pain

Structure

Pain History

Possible source

Multidisciplinary roles for mobility rehabilitation

My thought for the day....

Indications

Likely intervention

SALT

Physiotherapy

Reiki to facilitate spiritual emergence: a personal journey.

Technology as a tool in OT

The Dressing Loop in Accident and Emergency

What is in a name? – Why non-holistic interventions should not be termed ‘occupational therapy’.