Literature Supporting TherapyForte’s Practice Model for an Evidence Based Practice
TherapyForte’s practice model can be broken down into three components
1) Therapy with a mandatory Home Practice Program
2) Home Health Context
3) Piano Instruction & Performance as the Primary Modality for Therapy
We will discuss the evidence from scientific literature in the first two. Evidence from practice does not yet exist for component three and is the subject of TherapyForte’s ongoing research.
Evidence for the Efficacy of Home Practice Programming
First let’s examine the literature for the efficacy of having a home practice program. There are many synonymous names therapists will assign to a home practice program: home program, home exercise program, home activity program. They all refer to a specific regimen of activities, tasks or exercises assigned by the occupational therapist for the client to perform outside of occupational therapy sessions. Depending on the client’s level of independence, they may carry out their home practice program independently or with the assistance/supervision of a caregiver. The intention of a home practice program is to promote the progress the client makes on a certain set of skills or behaviors via consistent practice and repetition. Home programs may also be used to maintain skills and prevent regression.
Humans are able to learn new skills, movements and behaviors due to a phenomenon called “neuroplasticity. Neuroplasticity is induced by having a high “dose” of activity in a consistent and intentional manner (Novak & Berry, 2014). Receiving therapy once a week does not give a child the requisite dose of activity required to induce neuroplasticity. Performing home practice programs outside of therapy sessions increases the dose of therapy to a level that is capable of inducing neuroplasticity in most children, increasing the rate of learning and decreasing the learning period (Novak & Berry, 2013).
Therapy supplemented with a structured home activity program (HAP) has been shown to produce statistically significant results in the areas of cognition, language, motor skills and social skills for children with undefined developmental delay. A randomized, double-blind study by Tang, Lin, C. K, Lin, W. H., Chen, Tsai, & Chang (2011) looked at children with motor development delay (MD) and children with multi-domain development delay (MDD). The study excluded children with developmental delays if the etiology was specified. The children who participated in the study ranged from 6-48 months old. Over the course of the 12 week intervention, half of the children received occupational therapy only while the other half of the children received occupational therapy as well as a HAP which was facilitated by parents at home.
On average, the children who had therapy + HAP demonstrated 3.11 month increase in developmental age whole the children who only received only therapy grew 2.11 months in developmental age by the end of the 12 week period. Based on the data gathered, Tang, et al. (2011) were able to conclude that the children who received therapy + a HAP demonstrated greater progress in cognition, language, motor skills and social skills in comparison to the children who received therapy only. The one category measured that showed no statistical significance between the two groups was self-care skills. This may be attributed to the relatively young ages of the participants. It should be noted that the researchers were not able to determine how much improvement could be attributed to natural maturation, and how much was the result of therapy (without or without a HAP).
As study by Novak, Cusick & Lannin (2009) examined the effects of having an occupational therapy home program (OTHP) in school aged children with cerebral palsy, a condition specifically not examined by Tang, et al. (2011). They categories they examined were function, parent satisfaction with child’s function, activity participation, goal attainment, and quality of upper limb skill. Children were assigned to three groups: only therapy, therapy + OTHP for 4 weeks, and therapy + OTHP for 8 weeks. On average, 17.5 home sessions were carried out per month with leach session lasting an average of 16.5 minutes. Statistical significance difference was found between all three groups. The study concluded that this frequency and duration of home programming was effective and made recommendations for OTHP’s to be assigned as a standard part of occupational therapy.
It was noted that the parents of the children who were assigned to the 4 weeks group did not discontinue the home program as they were instructed to, but instead continued their child’s OTHP out till the end of the period (8 weeks). In other words, the 4 weeks group parents continued to perform the same home program after the 4 weeks ran out. Meanwhile the 8 weeks group continued to get updates and modifications to their OTHP’s up until the end of the program. The statistical difference between the 4 weeks and 8 weeks groups may point to the importance of having an occupational therapist continuously involved. The therapist is able to evaluate how well the child is performing their home program, make note of what could be improved or made more difficult, the prescribe modifications in an updated OTHP to optimize the child’s outcomes.
Wuang, Ho & Su (2013) examined the effects of having an OTHP regarding occupational performance, fine motor functions and activity participation. The population studied children with intellectual disabilities, ages 3 to12 for a duration of 20 weeks. The parents were given instructions to perform the OTHP a minimum of 15 days per month. Per self-report, sessions lasted an average of 15 minutes in length. In comparison to the group that received therapy with no OTHP, the group that received therapy and 20 weeks of OTHP showed improvement in fine motor function, activity participation, and parent satisfaction in child’s functioning. Recalling Novak & Berry (2013) it may be concluded that 15 home practice program sessions + 4 weekly therapy sessions for a total of 19 separate activity sessions per month is a sufficient therapy dose to induce neuroplasticity and facilitate learning in children.
Following a home program, as it has been prescribed by therapists, has been statically shown to lead to functional improvements in children with a range of disabilities. When a home practice program is involved, parents have the responsibility of being the facilitator in the stead of the occupational therapist. Parents and caregivers enhance their child’s progress by making sure that the home program activities are carried out in a consistent and accurate manner. The sessions do not even have to be long in duration, just a quarter hour.
Parental buy-in, participation in home programming, and satisfaction with their child’s outcomes are critical components of successful therapy. As the child makes progress on their goal, parental satisfaction is increased, a rewarding positive feedback loop that further motivates home program performance. It should be noted that for optimal results, the parents should consult with the therapist regularly to ensure that the home practice program activities promote progress toward the child’s goals.
Therapists’ Corner: Increasing Adherence to the Home Practice Program
Per a small study done in the United Kingdom, when clients were asked to write down the details of their next appointment and repeat the details out loud to the receptionist, client adherence was greatly increased. No-shows were reduced by 18-30% and 95% of clients showed up on time (Stephen, 2011).
The study was small study and has yet to be replicated on a larger scale, but the following principles can be applied to TherapyForte’s practice.
1) When the client or their caregiver takes an active role in the process, it increases their buy in. Writing down one’s appointment and reading the details aloud is an active process. Receiving a card with the appointment written by the receptionist is a passive process.
2) When a client or their caretaker buys-in to the process, they are more likely to be an accountable participant.
These principles can be applied to TherapyForte’s practice in any number of ways. The specifics of how it is carried out depends on the abilities of the child but all methods of noting the weekly home practice program will involve active participation on the part of the client and/or their caregiver. See the following examples:
1) If the child cannot write or read but can speak: Child repeats the home program back to the therapist verbally and indicates the assignments by gestures or other visual cues such as marking specific pages or passages. Child informs parent on what their home program is, again verbally and visually, so that the parent is informed and can hold the child accountable.
2) If the child can write and speak: Child writes down their assignments and makes visual indications. Child informs parent on what their home program is, verbally and visually, so that the parent is informed and can hold the child accountable.
3) If the child cannot write and is non-verbal OR child requires a high level of assistance to complete activities: Parent writes down the child’s Home Program for the week, reads the details back, and is trained by the therapist in how to carry out the activities.
Evidence for the Benefits of a Home Health Context
To have a successful home practice program, it is important to have a family-centered practice (FCP) where the family and/or caregivers are involved in the process. Families are a consistent component in a child’s life as they develop physically, cognitively and socially. Family involvement is crucial in ensuring that the child performs his/her home practice program consistently and accurately. The level of involvement of the parent/caregiver may range from holding the child accountable for performing their home practice program to facilitating/participating in the activities themselves. Family members are the ones that spend the most time with the child. They know the child best. They have the power to determine how much and how often the child performs their home practice program, either by holding the child to follow the recommended practice frequency or by facilitating the practice session with the recommended frequency. The therapist is a counselor that supports the family and child by troubleshooting complications and providing guidance through a clinical lens.
The context of home health is an ideal pairing with TherapyForte’s home practice program component because family-centered practice has been shown to be effective at improving child-related outcomes in multiple studies (Fingerhut, Piro, Sutton, Campbell, Lewis, Lawji & Martinez, 2013). Because of the home practice program component, TherapyForte’s practice model is heavily family-centered and dependent. Home health therapy is the most family-centered model of occupational therapy (Fingerhut, et al., 2013).
Therapists’ Corner: Considerations for Home Health
Though it may be possible to carry out occupational therapy entirely with household items, therapists should consider integrating a few select pieces of specialized equipment into the therapy sessions and the home practice program.
Take for example 1 pound dumbbell weights for upper extremity strengthening vs a water bottle which is roughly also a pound. Both items achieve the same goal but one is perceived as more “legitimate” as a therapy tool than the other. A therapist should first recommend the dumbbells for the client to use during their home program, then offer the water bottles as an alternative.
This recommendation comes from various interviews with healthcare professions across a variety of medical practices and personal experience. Professionals should make use of specialty equipment and recommend specialty equipment to clients as necessary because the items status and significance. When a professional carries or uses an item, that item’s status and significance colors how the professional and treatment process is perceived. Using only mundane items that are easily accessible by the general population seems to subconsciously “degrade” the therapy process, and by association, the perceived credentials of the trained therapist. When the item is recommended to a client, the status and significance are transferred to the client, consciously or unconsciously.
In summary, don’t try to find or create a commonplace substitution for everything. You may create a situation where the client does not taking the treatment seriously. If the client is left feeling that their therapy experience is not valuable enough to justify continuation, they may end therapy prematurely and rob themselves of their full potential. This pitfall can easily be avoided by integrating at least a couple special tools/apparatuses, thus marking the therapy experience as “special time”. If the client requests a mundane, cost-effective alternative for specialized therapy equipment, then the therapist of course should oblige to the best of their ability.
References
Fingerhut, P. E., Piro, J., Sutton, A., Campbell, R., Lewis, C., Lawji, D., & Martinez, N. (2013). Family-centered principles implemented in home-based, clinic-based, and school-based pediatric settings. American Journal of Occupational Therapy, 67(2), 228-235.
Novak, I., & Berry, J. (2014). Home program intervention effectiveness evidence. Physical & Occupational Therapy in Pediatrics, 34(4), 384-389.
Novak, I., Cusick, A., & Lannin, N. (2009). Occupational therapy home programs for cerebral palsy: double-blind, randomized, controlled trial. Pediatrics, 124(4), e606-e614.
Stephen, Adams, S. (2011, July 27). Writing own appointment cards could save NHS £250m.
Tang, M. H., Lin, C. K., Lin, W. H., Chen, C. H., Tsai, S. W., & Chang, Y. Y. (2011). The effect of adding a home program to weekly institutional-based therapy for children with undefined developmental delay: A pilot randomized clinical trial. Journal of the Chinese Medical Association, 74(6), 259-266.
Wuang, Y. P., Ho, G. S., & Su, C. Y. (2013). Occupational therapy home program for children with intellectual disabilities: A randomized, controlled trial. Research in Developmental Disabilities, 34(1), 528-537.a