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OT Adds Purpose and Meaning to Patients' Therapy - and Lives

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Vol. 26 • Issue 20 • Page 10

While the definition of "purposeful activity" may be up for debate, there's no question that occupational therapists approach each patient with a specific outcome in mind. The measures and strategies used to reach the desired outcome, in each case, may determine what that purpose truly is.

But in a more general sense, does purposeful activity always mean doing something meaningful to the patient? Or does it refer to any activity that helps restore the patient's natural abilities? Ask OTs for a true definition of the concept, and you're liable to receive responses as different as the individuals you interview.

In an attempt to find out more about how purposeful activity is generally defined and used in today's clinic, ADVANCE spoke to Debbie Amini, EdD, OTR/L, CHT, director of the occupational therapy assistant program at Cape Fear Community College in Wilmington, NC, and Donna Frazier, corporate rehabilitation director for Elant Inc. in Goshen, NY.

ADVANCE: In clinical OT treatment, do 'purposeful' and 'meaningful' activities mean the same thing to you? If not, how do they differ, and is either more important than the other?

Amini: No, "purposeful" and "meaningful" do not mean the same thing, nor are they mutually exclusive. A purposeful activity is one that has both a reason for being used and an almost immediate and recognizable outcome of some type. Those two conditions must exist for the activity to be "purposeful."

In other words, enabling or contrived activities such as stacking cones or operating an upper-body bike may have a clinician-described purpose of "increasing endurance or improving range of motion," but if there is no other reason or distinct and separate outcome (and there is not with these activities), then they are not truly purposeful.

A purposeful activity may be playing a game where fine-motor coordination and reaching are required, with the end product being that someone wins the game. Completing a video game is similar in that the purpose is "play" and to address client motivation and body factors (cognition, ROM, strength, etc); the outcome of the game (score, win/lose) is the end product.

Things like unfolding and refolding towels are not purposeful because there was no reason to begin the activity by undoing something that was already completed. What may seem like a purposeful task has no purpose if it had no reason to exist in the first place. Instead, taking a basket of towels from the dryer and folding them for storage would have reason, outcome and, therefore, purpose.

A meaningful activity is also one that is desirable to the client. The activity should be purposeful in some way (and likely will be as most people will not ask for busywork), and must have the additional feature of evoking an emotion or some type or motivational state within the client.

A clinician should never make the determination of what is or is not meaningful unless an occupational profile has been completed that has specifically addressed that class of occupations. For example, a clinician cannot assume that cake decorating will be meaningful to the 65-year-old female stroke victim unless she has been asked or has mentioned during the course of the evaluation that she would like to be able to get back to her favorite leisure activity, cake decorating.

The best OT treatments are obviously those conducted with activities, and are both meaningful and purposeful. The OT Practice Framework does have a category known as "preparatory methods" where activities that have no purpose and no meaning do exist. Engagements such as therapy putty exercise, weight PREs, clothespin pinching and range of motion exercises exist here. They are recognized by the profession as being used in direct preparation for purposeful and meaningful engagements.

On a related note, an activity must involve active engagement on the part of the client, therefore physical agent modalities, splinting and massage (as examples) are not considered activities at all.

Frazier: If you were to look up the definitions of purposeful and meaningful they may appear to have very similar definitions and are often used synonymously in therapy clinics and when teaching students in an occupational therapy program. However, in my opinion I do not think they mean the same thing.

I do not feel that a purposeful activity has the same impact for someone as a meaningful activity. Purposeful activities are key to planning an occupational therapy program, but meaningful activities are key to achieving the goals of the program through an intrinsic motivation for the patient.

Purposeful activity is a planned and directed task; however it may not be meaningful or important to the individual, thus not having the same impact of motivating him to actively engage in the task. For example, a purposeful activity can be getting a meal ready because you have to eat to sustain yourself. This is a purposeful activity by definition; but for someone who does not enjoy the activity of cooking, it may not have meaning.

On the other hand, meaningful activities have more of an intrinsic feeling; a different feeling about doing the actual activity is experienced, thus having more of a positive outcome and potentially reaching goals quicker.

ADVANCE: How do the roles your patient plays in his or her life right now contribute to the creation of purposeful treatment activities?

Amini: If clients find activities related to their current lives interesting and meaningful, they will likely indicate their desire to return to these engagements. The therapists will know this through discussions and the creation of the occupational profile. A therapist cannot read a chart and assume that an activity will hold meaning or be desirable for a client at that moment in time.

The only way clinicians will know how the roles of the client impact treatment-activity choice is through dialogue with the client or their proxy.

If a client does ask for an activity that relates directly to their life role, the activity should be created to be as realistic as possible - having both meaning and purpose.

Frazier: It is integral to incorporate the patient's roles into treatment activities, as that becomes the motivation for the person to actively engage. If a therapist does not take into consideration a patient's role, and the therapist is not providing an opportunity for the patient to know if he or she will be able to return to that role, it is an injustice to the patient.

Also it has been my experience that insurance companies are really beginning to make sure that they will only reimburse for services of their beneficiaries if the goals are applicable to what they will have to do upon discharge, no matter what the setting it is.

ADVANCE: What steps do you take to make your treatment plan personally 'purposeful' to an individual patient? (narrative interview, choice of assessment tool, etc.)

Amini: An interview or interview-based assessment such as the Canadian Occupational Performance Measure must be completed with focus on listening to the client (or a proxy) and asking pointed questions that gain information about these areas.

Frazier: When doing the evaluation we find out past occupation, present role, and what they will have to be able to do upon discharge. Basically [we conduct a] narrative interview with patient and family; and then as we get more information, we incorporate their role into treatment somehow. I would like to see more therapy departments incorporate more standardized assessment tools about roles and interests for their patients, especially in sub-acute rehabilitation settings.

ADVANCE: How important is the natural environment to purposeful OT treatment (i.e., are simulated activities as good as the real thing)? Do we need to be working more in the natural environment (home, workplace, playground, school, etc.)?

Amini: In the perfect world, we would be working in contexts that either are the natural environment or closely resemble the natural environment. In other words, OT clinics would optimally have a full non-adapted kitchens, bathrooms, bedrooms and living rooms where occupations can be realistically completed.

Treating clients in their own homes with focus on occupational engagement, not preparatory methods, is also optimal. When [you are] treating clients in outpatient settings that do not have natural environments, or when trying to create workplace environments, the clients can be asked to complete "home work" activities where they engage in the actual activity independently following simulation in the OT clinic , if that is all that is available.

Simulating an occupation or practicing the occupation independently at home is still preferable to having a client complete contrived or enabling activities.

In other words, having a client [who is] a carpenter complete a small woodcraft in the clinic and then build his daughter a play house at home (with reports and photos being brought to the therapist) is better than having the client work on putty exercises and hand grippers in the clinic.

Frazier: The natural environment is the optimal best choice when working with someone, and if possible, should be the first choice if available.

The next best thing would be a simulated environment, and then simulated activities.

In my opinion every therapist should make every effort to assure that we work in situations that are closest to the patient's natural environment at all times. This is why I think occupational therapy should be the discipline of choice in home care and community-based services.

ADVANCE: Does purpose in OT activities differ from purpose in PT activities? If so, how?

Amini: Yes, PTs can use activities that an OT would consider 'contrived' or 'enabling'. PTs are not obligated to ensure that there is true inherent purpose in the activity. The PT might consider the long range impact of the activity to be purposeful enough. OTs define purpose and use purpose in a different way-if they are practicing authentic OT, that is!

PT may see the activity [itself] as having the reason for being-to strengthen-but the immediate outcome may not be present. For example, doing knee extension exercise may strengthen knee muscles, but the client will not immediately walk better that moment because he just completed that activity. There is typically no emotional, motivational or learning connection to that particular "activity" as in OT.

In this case, the "activity" is actually more of an enabling task. PTs are not obligated to ensure that activities have purpose beyond the enabling properties.

Frazier: The goals of PT and OT are different, therefore the choice of activities are different.

It is my experience that the PTs I work with are very much aware of meaningful and purposeful when choosing activities for their patients. Both PTs and OTs that I work with and supervise take into consideration the individual's environment and current level of functioning, then work with the patient on choosing activities that will help get them to their highest practical level of independence.

Often, insurance companies, especially HMOs and commercial insurance, will only take into consideration how far a person can walk rather than what are the potential barriers in the person's environment that could prevent them from returning home. We have had some denials of payment when a resident is able to walk 100 feet with a cane and can negotiate eight steps, but still cannot perform lower-body dressing independently. We often appeal, and with more explanation, get approval for more time.

[But] it is time consuming and challenging to have to justify something that seems to be so easy to see.

Rob Senior is ADVANCE managing editor.




     

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