Kathy Kuipers

Factors influencing occupational therapists' clinical decision-making for clients with upper limb performance dysfunction following brain injury

Occupational therapists make clinical decisions to help clients with upper limb performance dysfunction following brain injury to achieve their goals. Although occupational therapy services have traditionally been separated for paediatric and adult populations, it has been proposed that a common process can be used to make clinical decisions for children and adults with upper limb performance dysfunction following brain injury. This study compared the factors that influenced the clinical decisions of experienced occupational therapists who worked with either children or adults with upper limb performance dysfunction after brain injury to determine if the clinical decision-making process was common for all clients with brain injury. Eleven occupational therapists with experience in working with clients with brain injury participated in two focus groups. Six had experience in working with children and five in working with adults. The discussions were audiotaped, transcribed and analysed using NUD*IST Version 4 data management software. The intrinsic or client-related factors identified as influencing clinical decision making were the clients condition, personal attributes and occupational performance needs. The extrinsic factors were related both to the therapist (knowledge of ‘feel’, experience, treatment preferences, confidence and personal convictions and beliefs) and to the environment (context of service provision and organisational culture and constraints). The consistency in the factors identified across different caseloads appeared to indicate that a common protocol would be suitable for guiding clinical decision making for both children and adults with varying patterns and intensity of upper limb performance dysfunction. Further research is needed to determine the clinical usefulness of such a protocol and the consistency of client outcomes following its use.

Individualised resting hand splints for adults with acquired brain injury: a randomized, single blinded, single case design.

AIM To evaluate the effect of individualized resting mitt splints on hypertonicity (spasticity and tissue stiffness) and passive range of motion (PROM). METHODS A randomized, single blinded, single case design. Ten adults with acquired brain injury were randomized to control (no-splint) and experimental (splint) groups. The experimental group received an individualized (wrist position, wearing schedule) thermoplastic resting mitt splint. Measures included wrist and finger PROM, muscle stiffness (Modified Ashworth Scale), and spasticity (Modified Tardieu Scale) which were taken at five time points. RESULTS Between-group analyses indicated a statistically significant effect on PROM at the wrist (d = 2.14, CI₉₅ = 0.57, 3.72, p < 0.05) and clinically important effects on finger PROM, and wrist and finger spasticity and stiffness. Within-group analyses indicated that splint-wear resulted in positive clinical effects ranging from zero effect (maintenance of pre-splinting status) to a large positive treatment effect. Non splint-wear resulted in negative clinical effects ranging from zero effect to a large negative treatment effect. CONCLUSION Individualized resting splints for adults with moderate hypertonicity and no soft tissue contracture resulted in positive clinical effects to PROM, muscle stiffness and spasticity. Long-term splint-wear may be more beneficial than short-term wear, and may prevent the negative changes evident with no splint-wear. Resting hand splints should be considered for a select group where reduction in muscle stiffness and spasticity, or maintenance of PROM, is desired.

Casting for upper limb hypertonia: A retrospective study to determine the factors associated with intervention decisions

AIM To determine if a Clinical Reasoning Protocol assisted occupational therapists to consistently choose casting as an intervention in the context of moderate/severe upper limb hypertonia and possible contracture. METHODS Sixty-four intervention decisions (including strength/movement training, splinting and/or casting) were drawn retrospectively from initial reports at a community clinic. Associations between identified upper limb characteristics, stated clinical aims and intervention decisions were analysed using logistic regression. RESULTS Casting was statistically significantly likely to be chosen in the presence of moderate (CI(95) 1.88-39.80, p=0.01) or severe hypertonicity (CI(95) 1.34-135.98, p=0.03), and if the stated clinical aim was to reduce hypertonicity (CI(95) 2.01-18.10, p=0.001) or contracture (CI(95) 1.31-12.73, p=0.02). When reports included both these clinical aims, there was a highly significant association with the decision to cast (CI(95) 5.67-9.13, p=0.001). Where casting was indicated as appropriate, but not chosen as an intervention, mitigating factors included older age (70-95 years), limited personal support and a clinical aim of comfort/hygiene maintenance. CONCLUSION Occupational therapists using the Protocol consistently chose casting as an upper limb intervention for adults who demonstrated moderate/severe hypertonicity, contracture or limited functional ability. Prospective research is required to determine intervention outcomes following use of the Protocol.

The process of developing a non-medical (advanced allied health) botulinum toxin A prescribing and injecting model of care in a public rehabilitation setting

OBJECTIVE The aim of this paper was to describe the process undertaken to develop a non-medical (advanced allied health extended role) botulinum toxin A prescription and injection project for adults with upper and lower limb spasticity secondary to an acquired brain injury. The hypertonicity clinic in the present study was located in a metropolitan public hospital in Queensland where multidisciplinary services are provided by a rehabilitation specialist and an advanced occupational therapist and physiotherapist. METHODS The process of developing the model included establishing potential benefits for the role extension project and documentation of a project plan. RESULTS Project outcomes included the development of a relevant governance structure, a research evidence-based project evaluation framework, a draft research ethics application, delineation of the key eligibility criteria and competencies required for physiotherapist and occupational therapist prescribers, and a final project report. CONCLUSION Non-medical prescribing has the potential to increase patient access to botulinum toxin A injection for the management of focal spasticity. A process that supports early patient engagement, extensive consultation with relevant stakeholders, a strong governance structure, a high-quality research project and a long lead time may maximise the potential for successful completion of advanced allied health role extension projects, including prescription and injection of botulinum toxin A.

Caring for country was associated with positive health outcomes for Indigenous people living in remote areas of Northern Australia

Research objective: The research aimed to investigate associations between caring for country activities and clinical outcomes relevant to obesity, type 2 diabetes, coronary heart disease, cardiovascular disease (CVD), chronic kidney disease and mental health problems. Design: Two-year cross-sectional study. Setting: A remote Arnhem Land township and 16 surrounding Aboriginal homelands in the Northern Territory, Australia. Participants: Two hundred and ninety-eight people (township residents = 196, homeland residents = 102) were purposively recruited over a six-month period during an outreach programme of preventive health checks. Participants were aged between 15 and 54 years to ensure a variety of levels of involvement in caring for country activities (mean age: 30.9 years, SD: 10.2 years). Men represented 59% (n = 175) of the participants. Outcome measures: Three categories of outcome measures were used: self-reported involvement in caring for country activities, self-reported health behaviours and clinical measures. (i) Participation in caring for country activities was recorded on an intervieweradministered ‘Caring for Country’ questionnaire (activities included time on country, burning of annual grasses, gathering food and medicinal resources, ceremony, protecting sacred areas and producing artwork). (ii) Self-reported information about primary place of residence, education, income and health behaviours (smoking, alcohol, exercise and consumption of takeaway food, store-bought fruit and vegetables and bush meat, fruit and vegetables) were also recorded on an interviewer-administered questionnaire. (iii) Clinical measures included body mass index (BMI), waist circumference, blood pressure, type 2 diabetes status, albumin to creatinine ratio (ACR), levels of glycated haemoglobin (HbA1c, a measure of blood glucose), high-density lipoprotein cholesterol (HDL), lipid ratio, very low-density lipoprotein, Kessler Psychological Dis-

Foundations of the research foundation

Back in 1946, the Occupational Therapy Research Group was established by the Occupational Therapy Club. This group encouraged occupational therapists to obtain, collate and disseminate information and record systems relevant to practice. First-generation Australian occupational therapists knew their techniques would be more effective, patients would have better recovery and their professional reputation would be stronger, if occupational therapy was informed by and contributed to research. In a post-war health service environment with limited resources and few biomedical treatment alternatives, occupational therapists carved out professional roles that earned the confidence and respect of health-administrators. They commanded significant investments of space, equipment and staff providing convalescence, remediation and rehabilitation services. Their systematic approach to record-keeping, monitoring of patient progress, activity prescriptions and use of best available information regarding conditions, materials and methods, meant the occupational therapy profession was given significant responsibility. Research has always informed practice, in different guises over the decades, and this was integral to the professionalization and success of Australian occupational therapy. Pioneers of the 1940s Occupational Therapy Research Group were the first in a long line of Australian occupational therapists who built a professional culture where education, enquiry and experimentation were considered essential to good practice. Each decade built upon past achievements to ensure sound research foundations for further research development. A highlight from each decade illustrates extraordinary achievements made: ● In the 1950s the Australian Occupational Therapy Bulletin was established (1953) by the Association, and its successor the Australian Occupational Therapy Journal continues as the official publication of OT Australia. ● In the 1960s occupational therapy national conferences were first organised by the Association. ● In the 1970s bachelor-level qualifications were adopted in jurisdictions where they had not previously existed. Key to this success was the demonstrated need for a research-literate, research–informed and research-ready professional workforce. ● In the 1980s a national focus on building research capacity and narrowing the gap between research, practice and education was made. The Australian Association of Occupational Therapists’ (AAOT) Standing Committee on Research was established, national research awards were launched, and the flagship AAOT ‘Partners in Research’ program implemented. Opportunities for PhDs had previously been limited, but now with bachelor qualified occupational therapists, more were eligible to enrol in research higher degrees. ● In the 1990s researchers were encouraged to publish their work, and the AAOT National Register of Research booklet was released to alert occupational therapists to the array and depth of research evidence emerging. In jurisdictions new to university level education, the first PhD qualified occupational therapists began to emerge, and in others such as Queensland where university qualifications were the norm, PhD numbers increased. Fledgling efforts were made to establish an Australian Research Foundation, but these lost traction. ● In the first decade of the 21st Century, evidence-based practice approaches normalised the place of research in practice and education, providing a framework for researchers to consider the utility and rigour of their work. Importantly, it galvanised efforts to provide research resources for all occupational therapists. Now as the second decade of the 21st Century unfolds, Australian occupational therapy sets yet another pillar into the strong research foundations laid nearly 70 years ago. In 2013, the OT Australia Research Foundation was launched. It will invest in research capacity building, recognition, development and dissemination to ensure the professional legacy of future Australian occupational therapists that is at least as proud and enduring as that left to us.

Healthy eating in urban Aboriginal households may be promoted through cooking workshops and by recognising the importance of women's work, shared meals, time and cost management: Synopsis: Commentary

Research objective: The research aimed to investigate food attitudes and practices among urban Aboriginal Australians and to assist health professionals to provide appropriate dietary advice. Design: Two-year ethnographic study utilising in-depth interviews, participant observation, informal discussions and participation in author-facilitated cooking workshops. Setting: A suburb in Brisbane, the capital city of Queensland, Australia, with the highest proportion of Indigenous people for any Brisbane suburb (7.3%). Participants: Purposive recruitment through local organisations (a community Indigenous Health Service, an Aboriginal and Torres Strait Islander Elders’ Corporation and Mission Australia). The sample included 31 Aboriginal participants (24 women, 7 men). Eligibility for participation included either having diabetes or recognised risk factors for diabetes, or a family member with diabetes. Additional people (number unknown) contributed to informal discussions during cooking workshops offered by the author. Data collection and analysis: Data were collected at a variety of community groups (a walking group, and cooking workshops provided as diabetes support, healthy lifestyle and mothers’ groups). Interview topics included diabetes, family food practices, healthy lifestyle attitudes and experiences of nutrition promotion. Informal conversations and supplementary participant observation at workshops, local shops and community events explored food practices and attitudes. The author recorded observations in a study diary and used a quali-

Healthy eating in urban Aboriginal households may be promoted through cooking workshops and by recognising the importance of women’s work, shared meals, time and cost management: CRITICALLY APPRAISED PAPERS

Research objective: The research aimed to investigate food attitudes and practices among urban Aboriginal Australians and to assist health professionals to provide appropriate dietary advice. Design: Two-year ethnographic study utilising in-depth interviews, participant observation, informal discussions and participation in author-facilitated cooking workshops. Setting: A suburb in Brisbane, the capital city of Queensland, Australia, with the highest proportion of Indigenous people for any Brisbane suburb (7.3%). Participants: Purposive recruitment through local organisations (a community Indigenous Health Service, an Aboriginal and Torres Strait Islander Elders’ Corporation and Mission Australia). The sample included 31 Aboriginal participants (24 women, 7 men). Eligibility for participation included either having diabetes or recognised risk factors for diabetes, or a family member with diabetes. Additional people (number unknown) contributed to informal discussions during cooking workshops offered by the author. Data collection and analysis: Data were collected at a variety of community groups (a walking group, and cooking workshops provided as diabetes support, healthy lifestyle and mothers’ groups). Interview topics included diabetes, family food practices, healthy lifestyle attitudes and experiences of nutrition promotion. Informal conversations and supplementary participant observation at workshops, local shops and community events explored food practices and attitudes. The author recorded observations in a study diary and used a quali-

Healthy eating in urban Aboriginal households may be promoted through cooking workshops and by recognising the importance of women’s work, shared meals, time and cost management

Research objective: The research aimed to investigate food attitudes and practices among urban Aboriginal Australians and to assist health professionals to provide appropriate dietary advice. Design: Two-year ethnographic study utilising in-depth interviews, participant observation, informal discussions and participation in author-facilitated cooking workshops. Setting: A suburb in Brisbane, the capital city of Queensland, Australia, with the highest proportion of Indigenous people for any Brisbane suburb (7.3%). Participants: Purposive recruitment through local organisations (a community Indigenous Health Service, an Aboriginal and Torres Strait Islander Elders’ Corporation and Mission Australia). The sample included 31 Aboriginal participants (24 women, 7 men). Eligibility for participation included either having diabetes or recognised risk factors for diabetes, or a family member with diabetes. Additional people (number unknown) contributed to informal discussions during cooking workshops offered by the author. Data collection and analysis: Data were collected at a variety of community groups (a walking group, and cooking workshops provided as diabetes support, healthy lifestyle and mothers’ groups). Interview topics included diabetes, family food practices, healthy lifestyle attitudes and experiences of nutrition promotion. Informal conversations and supplementary participant observation at workshops, local shops and community events explored food practices and attitudes. The author recorded observations in a study diary and used a quali-

There was insufficient evidence to conclude that upper extremity casting was effective for individuals with central nervous system disorders

© 2009 The Authors Journal compilation