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AOTA T H E

A MERIC A N

OC CUPAT IONAL

T HE RAPY

ASSOCIAT ION

®

OCTOBER 8, 2012

Reducing Hemiplegic Shoulder Pain UE Function & Home-Based CIMT Stroke & Ankle Foot Orthotics Community Integration & More

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PLUS

Occupational Therapy News Going Beyond the Vote: AOTPAC Continuing Education Employment Opportunities

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Chief Operating Officer: Christopher Bluhm Director of Communications: Laura Collins Director of Marketing: Beth Ledford Editor: Ted McKenna Associate Editor: Andrew Waite CE Articles Editor: Maria Elena E. Louch Art Director: Carol Strauch Production Manager: Sarah Ely Director of Sales & Corporate Relations: Jeffrey A. Casper Sales Manager: Tracy Hammond Advertising Assistant: Clark Collins

AOTA • THE AMERICAN OCCUPATIONAL THERAPY ASSOCIATION
VOLUME 17 • ISSUE 18 • OCTOBER 8, 2012

FEATURES
Shoulder Pain and Stroke
Reducing Hemiplegic Shoulder Pain Through Practical Handling Skills

Ad inquiries: 800-877-1383, ext. 2715, or e-mail sales@aota.org
OT Practice External Advisory Board

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Donna Costa: Chairperson, Education Special Interest Section Michael J. Gerg: Chairperson, Work & Industry Special Interest Section Dottie Handley-More: Chairperson, Early Intervention & School Special Interest Section Kim Hartmann: Chairperson, Special Interest Sections Council Gavin Jenkins: Chairperson, Technology Special Interest Section Tracy Lynn Jirikowic: Chairperson, Developmental Disabilities Special Interest Section Teresa A. May-Benson: Chairperson, Sensory Integration Special Interest Section Lauro A. Munoz: Chairperson, Physical Disabilities Special Interest Section Linda M. Olson: Chairperson, Mental Health Special Interest Section Regula Robnett: Chairperson, Gerontology Special Interest Section Tracy Van Oss: Chairperson, Home & Community Health Special Interest Section Jane Richardson Yousey: Chairperson, Administration & Management Special Interest Section
AOTA President: Florence Clark Executive Director: Frederick P. Somers Chief Public Affairs Officer: Christina Metzler Chief Financial Officer: Chuck Partridge Chief Professional Affairs Officer: Maureen Peterson
© 2012 by The American Occupational Therapy Association, Inc. OT Practice (ISSN 1084-4902) is published 22 times a year, semimonthly except only once in January and December, by The American Occupational Therapy Association, Inc., 4720 Montgomery Lane, Suite #200, Bethesda, MD 20814-3449; 301-652-2682. Periodical postage is paid at Bethesda, MD, and at additional mailing offices. U.S. Postmaster: Send address changes to OT Practice, AOTA, 4720 Montgomery Lane, Suite #200, Bethesda, MD 20814-3449. Canadian Publications Mail Agreement No. 41071009. Return Undeliverable Canadian Addresses to PO Box 503, RPO West Beaver Creek, Richmond Hill ON L4B 4R6. Mission statement: The American Occupational Therapy Association advances the quality, availability, use, and support of occupational therapy through standard-setting, advocacy, education, and research on behalf of its members and the public. Annual membership dues are $225 for OTs, $131 for OTAs, and $75 for student members, of which $14 is allocated to the subscription to this publication. Subscriptions in the U.S. are $142.50 for individuals and $216.50 for institutions. Subscriptions in Canada are $205.25 for individuals and $262.50 for institutions. Subscriptions outside the U.S. and Canada are $310 for individuals and $365 for institutions. Allow 4 to 6 weeks for delivery of the first issue. Copyright of OT Practice is held by The American Occupational Therapy Association, Inc. Written permission must be obtained from the Copyright Clearance Center to reproduce or photocopy material appearing in this magazine. Direct all requests and inquiries regarding reprinting or photocopying material from OT Practice to www.copyright.com.

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Jan Davis provides guidance for occupational therapy practitioners on reducing the incidence of shoulder pain in their poststroke clients.

COVER ILLUSTRATION © DAVID RIDLEY / SIS

DEPARTMENTS
News Capital Briefing
AOTA to Cast Historic Shadow on Capital

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Improving Upper Extremity Function Through a Home-Based Modified Constraint-Induced Movement Therapy Program

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Careers

Stroke and Ankle Foot Orthotics: An Entrepreneurial Solution

Perspectives

Promoting a Renewed Focus on Community Integration for Stroke Survivors

Calendar

Continuing Education Opportunities

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Ellen Herlache, Donald Earley, Jill Ewend, Alissa Pasant, Caleb Johnson, Chelsea Schwab, Nicole Farrand discuss the benefits of home-based therapy for increasing the use of upper extremities poststroke.

Employment Opportunities Questions and Answers
Rebecca Dutton

SPECIAL

Going Beyond the Vote: Support AOTPAC Today!

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• Discuss OT Practice articles at www.OTConnections.org in the OT Practice Magazine Public Forum. • Send e-mail regarding editorial content to otpractice@aota.org. • Go to www.aota.org/otpractice to read OT Practice online. • Visit our Web site at www.aota.org for contributor guidelines, and additional news and information.
OT Practice serves as a comprehensive source for practical information to help occupational therapists and occupational therapy assistants to succeed professionally. OT Practice encourages a dialogue among members on professional concerns and views. The opinions and positions expressed by contributors are their own and not necessarily those of OT Practice’s editors or AOTA. Advertising is accepted on the basis of conformity with AOTA standards. AOTA is not responsible for statements made by advertisers, nor does acceptance of advertising imply endorsement, official attitude, or position of OT Practice’s editors, Advisory Board, or The American Occupational Therapy Association, Inc. For inquiries, contact the advertising department at 800-877-1383, ext. 2715. Changes of address need to be reported to AOTA at least 6 weeks in advance. Members and subscribers should notify the Membership department. Copies not delivered because of address changes will not be replaced. Replacements for copies that were damaged in the mail must be requested within 2 months of the date of issue for domestic subscribers and within 4 months of the date of issue for foreign subscribers. Send notice of address change to AOTA, 4720 Montgomery Lane, Suite #200, Bethesda, MD 20814-3449, e-mail to members@aota.org, or make the change at our Web site at www.aota.org. Back issues are available prepaid from AOTA’s Membership department for $16 each for AOTA members and $24.75 each for nonmembers (U.S. and Canada) while supplies last.

OT PRACTICE • OCTOBER 8, 2012, 2012

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Read Up on Occupational Therapy in a Hospital Setting

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KEY STRATEGIES FOR EXCELLENCE IN POSTACUTE CARE

Occupational Therapy in Acute Care
Edited by Helene Smith Gabai, OTD, OTR/L, BCPR

AOTA CEonCD™

An Occupation-Based Approach in Postacute Care to Support Productive Aging
Authors: Denise Chisholm, PhD, OTR/L, FAOTA; Cathy Dolhi, OTD, OTR/L, FAOTA; and Jodi L. Schreiber, MS, OTR/L With contributions from Genesis Staff: Susan M. LaCroix, MS, OTR/L; Bronwyn Keller, MS, OTR/L; and Jeanne Coviello, OTR/L

Occupational Therapy in Acute Care is designed specifically for therapists working in a hospital setting to acquire better knowledge of the various body systems, common conditions, diseases, and procedures. Students and educators will find this new publication to be the most useful text available on the topic. The book features color illustrations of the human body’s systems and functions, as well as tables delineating the signs and symptoms for various diseases.
Order #1258 AOTA Members: $109 Nonmembers: $154

Earn .6 AOTA CEU (7.5 NBCOT PDUs/ 6 contact hours). Enjoy the portability of this CEonCDTM. CDs will play in DVD players. Order #4875 AOTA Members: $210, Nonmembers: $299

To order, call 877-404-AOTA, or visit http://store.aota.org/view/?SKU=4875
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To order, call 877-404-AOTA, or visit http://store.aota.org/view/?SKU=1258
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News
Association updates...profession and industry news
AOTA News

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Register for AOTA’s Stroke Specialty Conference

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Attention Students
nterested in being a student leader on the national level? Run for a position on AOTA’s Assembly of Student Delegates. The deadline to apply is October 22. For more, visit www. aota.org/students/asd.

AOTA Hosts 2nd Annual Leadership Development Program
OTA recently brought together a select group of occupational therapy managers from around the country to discuss professional leadership strategies and tactics, in a 3-day program at its headquarters in Bethesda, Maryland. “Cultivating Your Power and Influence: The AOTA Leadership Development Program for Managers,” held from September 11 to 13, included participants from Alaska to Alabama working in settings from public health to pediatrics, with a range of experience levels. The meeting’s agenda, facilitated by Maureen Peterson, MS, OT/L, FAOTA, AOTA’s chief professional affairs officer, included discussion on leadership formation, values, and sustainability that was led by AOTA Vice President Ginny Stoffel, PhD, OT, BCMH, FAOTA, and Nancy Stanford-Blair, PhD; a seminar on power and confidence led by AOTA President Florence Clark, PhD, OTR, FAOTA; and a presentation on strategic planning by Brent Braveman, PhD, OTR/L, FAOTA. Speakers also included Sue Bowles, OTD, MBA, OTR/L; Christina Metzler, AOTA’s chief public affairs officer; and Chris Bluhm, AOTA’s chief operating officer. For more on the program, including a listing of all the participants, go to http://aota.org/practitioners/ resources/leadership-development-program-for-managers/ leadership-development-2012.

Industry News

f you work with older adults, be sure to attend the AOTA Adults With Stroke Specialty Conference, to be held from November 30 to December 1 in Baltimore, Maryland. An estimated 5.4 million people in America live with the disabling effects of stroke, and that number is predicted to increase as the population ages. Occupational therapy helps those recovering from a stroke resume valued activities through a holistic approach to intervention. Join keynote speaker Carolyn Baum, PhD, OTR/L, FAOTA, and other renowned experts offering comprehensive sessions, while earning up to 13 contact hours (1.3 CEUs/13 NBCOT PDUs). Register now at www.aota.org/ confandevents/stroke.

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Chats Ahead
now someone interested in joining the occupational therapy profession? Direct him or her to AOTA’s prospective student chats this fall, to be held on October 17 and November 15 at 7 p.m. EST. To participate or listen to archived chats, head to www. aota.org/students. Meanwhile, AOTA’s next pediatric chat, OT Excellence in the Inclusive Classroom: The ASD Nest Model, will be held October 19 at 2:30 p.m. EST. For more, visit www.talkshoe.com/tc/73733.

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Manual Medical Reviews began October 1

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Sign Up for Student Conclave

ccupational therapy students and soon-to-be new practitioners can get a head start on a successful career by attending the 2012 AOTA/NBCOT National Student Conclave, to be held from November 9 to 10 in Columbus, Ohio. For more information, or to register, go to www.aota.org/ confandevents/conclave. The Conclave will provide attendees with evidence-based knowledge about current issues and emerging practice areas, exclusive opportunities to speak with leaders and experts, opportunities to meet with job recruiters and have résumés critiqued, and much more.
OT PRACTICE • OCTOBER 8, 2012

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AOTA Award Nominations Deadline Approaching
he AOTA Recognitions Committee encourages you to recognize colleagues who have made significant contributions to the profession by nominating them for one of the awards offered by the Association each year. The deadline to submit nominations is October 25. Description of the awards, nominations forms, FAQs, and the general point system can be found on the AOTA Web site under Practitioners/Professional Development/Awards or www.aota.org/ practitioners/profdev/awards. Questions can be directed to awards@aota.org.

he Middle Class Tax Relief and Job Creation Act of 2012 requires that outpatient therapy claims of more than $3,700 ($3,700 for occupational therapy services, and $3,700 for physical therapy and speech-language therapy services combined) be subject to manual medical reviews. Last month, the Centers for Medicare & Medicaid Services announced that reviews would begin on October 1. Occupational therapy practitioners providing services to Medicare beneficiaries will be affected, including those working in private practice, Part B skilled nursing facilities, home health agencies (TOB 34X), rehabilitation agencies (outpatient rehabilitation facilities), and comprehensive outpatient rehabilitation facilities. For updates, visit www.aota. org/news/advocacynews.

A World of Opportunity for Occupational Therapy
orld Occupational Therapy Day 2012, on October 27, is an opportunity to promote and celebrate the global profile of the profession. For ideas on ways to take part, check out www.wfot.org/ resourcecentre.aspx. A related initiative, the OT Global Day of Service (OTGDS), calls for occupational therapy practitioners and students to volunteer a small amount of time to promote
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A O TA B u l l e T I N B O A r d
OUTSTANDING RESOURCES FROM

Using the Occupational Therapy Practice Guidelines for Adults With Stroke to Enhance Your Practice
(CEonCD™) J. Sabari Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). ourse participants will learn key considerations for occupational therapy intervention, whether their clients are in the acute phase after stroke, the rehabilitation phase, or the continuing adjustment phase. Findings from published research that guide best practice in occupational therapy intervention with the stroke population are presented. For those interested in this area of practice, Occupational Therapy Guidelines for Adults With Stroke is essential reading. $68 for members, $97 for nonmembers. Order #4845. http://store. aota.org/view/?SKU=4845

Occupational Therapy Practice Guidelines for Adults With Stroke

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J. Sabari etails the significant contribution of occupational therapy in treating adults with functional limitations after stroke. Appendixes include valuable resources, such as CPT™ codes related to occupational therapy for stroke survivors. $59 for members, $84 for nonmembers. Order #2211. http://store. aota.org/view/?SKU=2211

the profession. The World Federation of Occupational Therapists is partnering with www.promotingot.org to support OTGDS. In addition, OT4OT (www.ot4ot.com) is hosting an OT 24-Hour Virtual Exchange from October 29 to October 31 (depending on participants’ locations). The virtual exchange is a way for occupational therapy practitioners around the globe to share ideas about occupational therapy practice, education, and research.

Nebraska chapter of AIGA, which was originally founded as the American Institute of Graphic Arts. The AOTF-sponsored participants were Julie Bass, PhD, OTR/L, FAOTA; Charles Christiansen, EdD, OTR, FAOTA; Lisa Ann Fagan, MS, OTR/L, CALA; René Padilla, PhD, OTR/L, FAOTA; Dory Sabata, OTD, OTR/L, SCEM; Patricia Schaber, PhD, OTR/L; and Catherine Sullivan, PhD, OTR.

Resources

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New AOTPAC Chair
ail Fisher, MPA, OTR/L, is the new American Occupational Therapy Political Action Committee (AOTPAC) chair. Learn more about Fisher by visiting www.aota.org/practi tioners/advocacy/aotpac/news/ new-chair.

What Is OT?
ant to help others understand OT? The new AOTA What Is Occupational Therapy? brochure is a valuable resource for consumers and other professionals to better understand the role of occupational therapy and the important service it provides for people with injuries, disabilities, and illness. For more, search “What is OT?” on the AOTA store at myaota.aota.org/shop_aota/ index.aspx.

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Screening Adult Neurologic Populations: A Step-by-Step Instruction Manual, 2nd Edition

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Hand Rehabilitation: A Client-Centered and Occupation-Based Approach (CEonCD™)
D. Amini Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). overs best practices for evaluating clients, creating occupational profiles and occupation-focused interventions, and setting short- and long-term goals. Includes case examples to illustrate clinical application. $68 for members, $97 for nonmembers. Order #4832. http://store. aota.org/view/?SKU=4832

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S. Gutman & A. Schonfeld rovides detailed steps for cognitive, functional-visual, perceptual, sensory, motor, cerebellar function, cranial nerve function, neuropathy and peripheral nerve function, and dysphagia screening, as well as a new section on mental status. Each chapter has screening forms that can be printed from the enclosed CD. This book is ideal for occupational therapy students and remains an essential tool for clinicians working in community and home health settings. $59 for members, $84 for nonmembers. Order #1226A. http:// store.aota.org/view/?SKU=1226A

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AOTF Co-sponsors Workshop to Develop Senior Services

Bulletin Board is written by Amanda Fogle, AOTA marketing specialist.

Ready to order? Call 877-404-AOTA or go to http://store.aota.org Enter Promo Code BB

Questions? Call 800-SAY-AOTA (members); 301-652-AOTA (nonmembers and local callers); TDD: 800-377-8555

even occupational therapists sponsored by the American Occupational Therapy Foundation (AOTF) participated in a 3-day workshop organized by The Evangelical Lutheran Good Samaritan Society’s Vivo: Innovation for Well-Being to develop new services for seniors and their families. The 3-day workshop, held in Omaha, Nebraska, involved nearly 60 individuals organized into four design teams who were challenged to imagine creative new ways for addressing age-related issues such as isolation, dementia, and informal caregiving. The Good Samaritan Society, which is the largest nonprofit provider of senior care and services in the United States, plans to apply the concepts in developing services for a 20-acre mixed-use site under development in Papillon, Nebraska. The event was co-sponsored by AOTF and AIGA-Nebraska—the

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Health Care Changes and State Essential Health Benefits
he Affordable Care Act requires that everyone in the United States have health insurance beginning in 2014. To facilitate this, the law also calls for the establishment of staterun health insurance purchasing “exchanges” to help improve insurance access, choice, cost, and coverage. Qualified insurance plans participating in these exchanges are required to cover, at a minimum, a package of “essential health benefits,” and AOTA helped ensure that rehabilitation and habilitation were included. AOTA has also been working with state associations to keep them updated on the law’s implementation. For details about essential health benefits
OCTOBER 8, 2012 • WWW.AOTA.ORG

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c A p Ii T A l B r Ii e f Ii N G a ta b ng

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AOTA to Cast Historic Shadow on Capital
Tim Nanof
many recovering from traumatic brain injury and posttraumatic stress disorder. The briefing provided clinicians representing AOTA, APTA, and ASHA with the opportunity to highlight to Congressional staffers the role each profession plays in helping wounded warriors. Although Congressional briefings are a high-level format for educating members of Congress and their staff, there is no grassroots activity more valuable than an energetic, passionate, and well-attended Hill Day. Every year, AOTA works to facilitate the ability of AOTA members to come to Capitol Hill with their peers and advocate collectively in support of occupational therapy and to drive AOTA’s legislative agenda forward. Successful advocacy combines grassroots action and a direct lobbying presence in Washington, which for occupational therapy is provided by AOTA’s Federal Affairs staff and its key advocacy consultants. Both aspects, grassroots and direct lobbying, depend on each other to achieve maximum success. Although Federal Affairs staff pride themselves on the knowledge and passion with which we represent the profession on Capitol Hill, nothing can take the place of constituents like you taking the time and initiative to come to Washington to advocate for yourselves and the clients you serve. AOTA’s members are the best advocates and representatives of occupational therapy. Your personal stories of challenge, perseverance, and success with your clients make the best arguments for the profession. Because member advocacy is the key to AOTA’s continued and expanding presence and success on Capitol Hill, we are announcing the “50 for 50 Campaign” for 2013. “50 for 50” will be focused on delivering an advocate from every state to Washington, DC, for AOTA’s Capitol Hill Day in fall 2013. Although attendance at Capitol Hill Day has grown seven-fold over the past 5 years, we have yet to achieve participation from more than 37 states. Next year, AOTA is engaging in an effort to ensure there is representation at Hill Day from every state in order to truly maximize our advocacy footprint on Capitol Hill. To achieve this goal, AOTA will need the support of all 50 of its affiliated state associations, and the hundreds of schools of occupational therapy and student associations across the country. From doctorate programs to occupational therapy assistant programs and every other program in between, we can together raise the funds and provide other resources needed to ensure someone from every state can come to Washington to be the voice of occupational therapy. Collectively, we can achieve this goal and bring 50 for 50 to Capitol Hill. More information will be forthcoming about the 50 for 50 Campaign. In the meantime, AOTA will be working with affiliated state associations, student associations, and the schools of occupational therapy in every state to ensure we reach this critical and ambitious goal. Together we can bring something special to fruition in 2013 and ensure that we expand the reach of AOTA’s advocacy on the Hill more than ever before. For more information on our advocacy efforts, visit http://capwiz. com/aota. See you in Washington! n
Tim Nanof is AOTA’s director of Federal Affairs.
OCTOBER 8, 2012 • WWW.AOTA.ORG

OTA has been working diligently throughout 2012 to expand its reach and presence on Capitol Hill. Attendance at AOTA’s annual Capitol Hill Day in Washington, DC, has grown by more than 400 participants over the past 5 years, with attendance at the latest Hill Day, on September 24, totaling more than 500. In addition, local universities within driving distance of the capitals of New York, North Carolina, Ohio, and other states have scheduled their own Hill Days with the help and support of AOTA Federal Affairs staff. This year, AOTA’s advocacy on the ground in Washington was emphasized by two Congressional briefings that helped educate Congress about the scope and breadth of the profession of occupational therapy. In May, AOTA held the first ever Congressional briefing on occupational therapy mental health practice, featuring AOTA Vice President and President-Elect Ginny Stoffel, PhD, OT, BCMH, FAOTA. The briefing was well attended by Congressional staff and advocates from the American Psychiatric Association, the Mental Health Liaison Group, and the Consortium for Citizens with Disabilities, who learned details about occupational therapy’s contributions to the treatment and recovery of people with mental health conditions. More recently, AOTA partnered with the American Physical Therapy Association (APTA) and the American Speech-Language-Hearing Association (ASHA) to organize and present a Congressional briefing sponsored by Representative Mike Michaud (D-ME) on the value of rehabilitation for veterans and wounded warriors, including

Careers

Stroke and Ankle Foot Orthotics

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PHOTOGRAPHS COURTESY OF RICARDO BARROS PHOTOGRAPHS

An Entrepreneurial Vision
Diane Vitillo
hemiplegia. He lived alone and was determined to be totally independent with his dressing. Although Joe was making marvelous progress with his upper body dressing, he was unable to independently don his AFO and shoe. In my experience, both occupational therapists and physical therapists have found the task of donning an AFO with one hand to be particularly problematic. Joe was so determined to succeed with this task that he challenged me to make something that would help him achieve his goal. It was his challenge that re-ignited my dream to make something that could change someone’s life for the better. I went home that evening and searched for items in my garage that could be used to keep an AFO in a stable position to allow placement of the foot using a one-handed approach. Lo and behold, I spotted a plastic mitre box (yes…that’s the box a carpenter uses to cut special angles in wood). It was light enough to easily maneuver and wide enough to accommodate Joe’s AFO, and its flat bottom would keep it stable during the donning process. With some minor adjustments, I was excited that this first prototype would be successful. The following morning, Joe arrived in the gym and I couldn’t wait to begin our training. As he sat in his wheelchair watching me, I demonstrated for him how to use the device using only one hand. While seated in a long-sitting position on the mat, I placed the adapted mitre box near my foot and positioned the AFO within the mitre box. I then used a leg lifter to lift and place my leg into the AFO. Success! Needless to say, I was thrilled, and Joe couldn’t wait to try his luck at it.
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am a polio survivor. I’m also a dreamer. Perhaps that’s why over the past 2 decades in my career in the rehabilitation profession, I have tried my best to develop innovative ways for my clients to complete meaningful tasks that are problematic for them due to their disability. Since I was 4 years old, I have not had the use of my right shoulder due to the effects of polio. As an inquisitive child, a blossoming adolescent, a young adult, and now an active senior, I have stockpiled an arsenal of strategies that have facilitated my life’s journey while living with a disability. As a therapist, I have shared many of these strategies with those under my care. I’ve always had a dream of inventing something that could change the life of at least one person. This is my story of how my dream, plus one challenge, created a life-changing moment for a client. My career in the rehabilitation profession as both an occupational therapist and a physical therapist assistant has given me the opportunity to work with clients ranging in age from birth to end of life—many of whom have personally touched my life. However, one in particular, a person recovering from stroke, gave me the opportunity to make a real difference in his. For many people recovering from stroke, the occupational performance area of lower body dressing— specifically, independently donning an ankle foot orthosis (AFO) and shoes—is quite daunting. Throughout my years of practice, when it came time to assist a client with hemiplegia with donning an AFO, I would often say (with some frustration in my voice), “I wish someone would make something

that would hold the AFO in an upright position so you could easily slip your foot into it before it falls over.” Joe was a 35-year-old male who had a stroke that resulted in right

OT PRACTICE • OCTOBER 8, 2012

The device can be used to facilitate the donning of different types of foot orthotics.

2012 AOTA/NBCOT National Student Conclave
November 9–10, 2012 • Columbus, Ohio
As an occupational therapy student and soon-to-be new practitioner, you have already started setting up the field goals for your career. The 2012 AOTA/NBCOT National Student Conclave is a terrific opportunity for you to know how to score those points and be an OT pro! Here’s why you should attend— • Evidence-based knowledge about current issues and emerging practice areas • Exclusive opportunities to speak with leaders and experts • Perfect chances to meet with job recruiters and have your résumé critiqued • Important information on the NBCOT certification exam • Super networking with peers from your school and across the country

He was successful on his first attempt and his smile said it all. On the days that followed, Joe and I discussed my plans to add another design feature to this device. The current design allowed him to don the AFO while in a long-sitting position. But what about clients who preferred to sit at the edge of the bed or in their favorite chair to don the AFO? Back to the drawing board for me! I now enlisted the help of my husband (an engineer by trade and a skilled craftsman) to come up with a design that would allow the AFO to articulate from the originally designed long-sitting position to either a 90° or 45° angle, depending upon the client’s donning preference. The design of this device evolved over many months of beta testing a prototype (made from wood and PVC) not only with clients recovering from stroke but also with clients who had other medical conditions that warranted the use of an AFO for safe ambulation. My dream of becoming an inventor came true, but, more importantly, my dream of changing the life of at least one person, Joe, became a reality. n
Diane Vitillo, MS, OTR, PTA, is the owner of Home Heart Beats, LLC and the inventor of The Original AFO Assist (patent pending). Home Heart Beats provides evaluative home assessments to clients who wish to successfully and safely age in place. For more information, contact Vitillo at homeheartbeats@comcast.net or visit www.homeheartbeats.com.

Register today at www.aota.org/conclave!
®

CONNECTIONS
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Become a Member

AOTA’s Online Community www.otconnections.org
OCTOBER 8, 2012 • WWW.AOTA.ORG

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PHOTOGRAPH COURTESY OF THE AUTHOR

Go For Your Career Touchdown!

Shoulder Pain and Stroke

JAN DAVIS

Reducing Hemiplegic Shoulder Pain Through Practical Handling Skills

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PHOTOGRAPH COURTESY OF THE AUTHOR

ne day, as I was walking through the dining room of a rehab center, I overheard a physician tell a family member, “Shoulder pain is one of those things that goes along with having a stroke.” I nearly stopped in my tracks. I was shocked and saddened at the same time. But not surprised. I used to feel the same way before I learned how to prevent shoulder pain. Many years ago, our inpatient rehab center was experiencing the same problem. Nearly half of our clients who were recovering from stroke experienced debilitating shoulder pain at the time of discharge. We tried everything we could think of, reviewed the literature, and consulted physicians, but nothing seemed to make a difference. Then I took courses from master clinicians who provided the in-depth knowledge and practical handling skills I needed to be successful. I learned how the structures of the shoulder were compromised following a stroke, how to prevent trauma, and specific handling methods for preparing the upper extremity for skilled function. I took meticulous notes, practiced the clinical skills in class, and returned to work to give it a try. The results were immediately evident. Not only did fewer of my clients complain of pain, but those with pain began to improve.

Guidance for occupational therapy practitioners on reducing the incidence of shoulder pain in their poststroke clients.

KNOWLEDGE + IMPROVED CLINICAL SKILLS = REDUCTION OF SHOULDER PAIN
As I shared my new skills with colleagues (occupational therapy, physical therapy, and nursing), we saw the incidence of shoulder pain decrease dramatically within our facility. Within a year, the incidence of hemiplegic shoulder pain (HSP) at our center dropped from nearly 50% to less than 15%, by just changing the way we handled, moved, and positioned our clients. Within 2 years we had almost eliminated HSP altogether. I began to wonder: Had we been contributing to HSP, unknowingly, all along? As years went by and other members of the rehab team were trained and began to use these methods, the evidence became clear: HSP can be reduced when proper handling methods are used to treat clients recovering from strokes. I am convinced that with a better understanding of the shoulder complex and improved clinical skills, other occupational therapy practitioners can also dramatically reduce the incidence of HSP in their treatment settings.

HSP INTERFERES WITH QUALITy OF LIFE
HSP is reported to affect anywhere between 7% and 88% of all persons poststroke.1 HSP can adversely affect a client’s entire therapy program as well as his or her overall quality of life.2 A client with a painful shoulder may have difficulty sleeping, require pain medication, and refuse to get out of bed or get dressed.3 Poststroke clients in acute care, rehabilitation, or skilled nursing settings may choose not to participate in occupation-based activities due to the severity of their shoulder pain.4 Therefore, it is extremely important for occupational therapy practitioners to be up to date on current evidence, hone their clinical skills, and implement effective treatment programs to prevent hemiplegic shoulder pain. But there is much controversy and confusion about managing the hemiplegic

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shoulder. Occupational therapy practitioners today face a dilemma in trying to determine the evidence and best practice for treating HSP. A full literature review can be an overwhelming and daunting task, as it entails reading through hundreds of articles, many with opposing views and each supported with evidence. Numerous studies address questions related to HSP such as: Does subluxation cause shoulder pain? Should slings be used? What are the causes of HSP? With an abundance of research, but few practical guidelines for intervention, even well-informed therapists often look elsewhere for guidance in determining effective therapeutic treatment methods based on evidence. I encourage occupational therapy practitioners to implement an evidence-based approach using their own clinical experiences. Sharpen your observation and handling skills. Expand your knowledge. Reevaluate your client. Do you observe any changes? At the end of every treatment session, you should be able to observe positive changes. Every practitioner should be able to see, however small, changes that demonstrate effectiveness during each treatment session. If no measurable changes are observed, then your handling methods and treatment plan must be modified. If occupational therapy practitioners are to be effective change agents in treating clients with stroke, we must have the clinical skills to make a difference.

Figure 1. Key Points to Remember
Don’t force range of motion (ROM). When performing passive or active ROM, range only to the point of resistance or discomfort. Any resistance against shoulder flexion or abduction can be an indication that the scapula is not gliding. Discomfort can indicate trauma or impingement to the soft tissue structures of the joint. Never use reciprocal overhead pulleys. The evidence strongly concludes that using reciprocal overhead pulleys markedly increases the incidence of painful shoulders. Do not raise the arm in flexion or abduction (past 90˚) without external rotation of the humerus and scapular gliding. ROM is safe as long as the scapula is gliding and the humerus is in external rotation. Never pull on the hemiplegic arm to help move a client. Place your hand on the trunk or scapula when helping a client transfer or stand up. Pulling on the involved arm can easily cause a traction injury. Avoid placing your hands under the client’s arms. Lifting or repositioning a client under the arms can put the shoulder structures at risk for impingement. Avoid static positioning of the upper extremity (UE) in internal rotation and adduction. The use of slings, or any device that maintains internal rotation and adduction while sitting in a chair or resting in bed, contributes to soft tissue tightness and shortened muscle length. Avoid strapping the UE to an arm trough. A weak arm strapped to an arm trough is at risk for impingement and traction injury. For clients attempting to stand or who have poor postural control, that “slide” down in their wheelchair while their arm is strapped to an arm trough can cause an impingement through malalignment of the glenohumeral joint.

POSSIBLE CAUSES OF HEMIPLEGIC SHOULDER PAIN
Our first experience with HSP may begin with a client clutching his or her shoulder, or it may be initiated by a physician’s referral. Next we’re confronted with the big question, “What do I do?” For occupational therapists to determine the most effective plan of treatment, an accurate clinical diagnosis of the source of the shoulder pain should be made. Unfortunately, this is difficult for physicians to do. Multiple impairments related to stroke, such as sensory, motor, and language deficits, along with the complexity of the shoulder structures, can make it difficult to get an accurate diagnosis. Physicians typically order an x-ray,
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but the results are often inconclusive. Problems involving soft tissue typically do not show up on an x-ray, and most physicians decide that expensive tests (such as MRI or arthrogram studies) are not warranted for a painful upper extremity that is also nonfunctional. Consequently, physicians and practitioners are at a loss of how to proceed and often fall back to “old ways of practice” based on common misconceptions. For decades, the HSP spotlight has been on glenohumeral subluxation as the major source of pain, with reducing subluxation a treatment priority. In fact, no fewer than 19 studies have been published on the association between shoulder subluxation and pain (eight studies supported the role of subluxation in pain, and 11 studies did not support the role of subluxation in pain).1 This is where a review of the most current literature can be extremely helpful. Fortunately for all of us, Robert Teasell, MD, and his team have created an excellent resource, available on the Internet (www.ebrsr.com), that reviews, summarizes, and provides conclusions based on a comprehensive

review of evidence related to stroke. Included in the review are lists of the possible sources of HSP, such as muscle imbalance, spasticity, trauma of the rotator cuff, humeral fracture, bursitis, tendonitis, glenohumeral subluxation, adhesive capsulitis, and reflex sympathetic dystrophy.1 Contrary to what many occupational therapy practitioners have learned in the past, the evidence does not support subluxation of the glenohumeral joint as the primary source of hemiplegic shoulder pain. The strongest evidence, according to Teasell’s team at www. ebrsr.com, supports the following conclusion: “Although many etiologies have been proposed for hemiplegic shoulder pain, increasingly it appears to be a consequence of spasticity and the sustained hemiplegic posture.”1 Based on the current evidence, occupational therapy practitioners should focus on the following guidelines to get a head start on reducing the incidence of shoulder pain in their setting: 1. Develop an in-depth understanding of the shoulder complex. 2. Know what to avoid. 3. Learn advanced clinical skills.
OCTOBER 8, 2012 • WWW.AOTA.ORG

Figure 2. protecting the hemiplegic shoulder
proper Bed positioning (1)
Although supine is the most common position, the most therapeutic position for clients poststroke is sidelying on the hemiplegic side. Make sure your client is lying on the scapula and not on the head of the humerus. A fully protracted scapula feels smooth along the thoracic wall, not “winged,” and is comfortable for the client. Watch the video: http://www.icelearningcenter.com/bed-positioning-involved-side.

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therapies and range of motion (ROM) performed incorrectly are also sources of HSP.1 Avoid the use of inappropriate exercise equipment, such as overhead pulleys, as there is strong evidence that they contribute to a markedly increased incidence of shoulder pain.1 For more on proper handling, see Figures 1 and 2 on pp. 10 and 11.

learn advanCed CliniCal skills
New practitioners, afraid of hurting their clients, may avoid handling the shoulder altogether. Don’t let fear keep you from using the clinical skills necessary to prevent shoulder pain. Learn how to mobilize the scapula and move the arm correctly, avoiding trauma to the shoulder and better preparing the upper extremity (UE) for functional gains. Develop sharp observation skills. Learn to evaluate tone of the UE. Always work within a pain-free range. As treatment begins, I ask my clients for feedback: “If anything hurts or is uncomfortable, let me know.” If your client expresses pain or discomfort, discontinue the movement and determine the source of the pain. Ask, “Is it a pulling pain or a stabbing pain?” A sharp pain may indicate an impingement or problem with alignment. A pulling pain can be more indicative of soft tissue tightness due to immobilization.3 Pain, whether caused by impingement or soft tissue limitation, can interfere with daily care activities such as brushing hair (shoulder external rotation with abduction), dressing, or any overhead activity. Practitioners should focus on maintaining muscle length through scapular mobilization and ROM, most specifically on the muscles that contribute to spastic internal rotation and adduction of the arm: the subscapularis, pectoralis major, teres major, and latissimus dorsi. “Shortened muscles inhibit movement, reduce range of motion, and prevent other movements especially at the shoulder where external rotation of the humerus is necessary for arm abduction greater than 90˚” (p. 14).1 Your hands should be firm but never forceful. Pain or discomfort can be an indication of impingement or trauma to the shoulder structures. For optimal alignment of shoulder structures, be sure your client is in a good starting position. In sitting, position the client
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proper Wheelchair positioning (2)
Good seating allows for better alignment of the entire shoulder girdle and reduces the possibility of impingement. Use a seat insert to provide a good base of support and reduce a posterior pelvic tilt. Position the arm on a lap tray or half lap tray if your client exhibits problems of edema or neglect.

2

moving in and out of the Wheelchair (3,4) When transferring clients, helping
them stand, or repositioning in the wheelchair, always assist through the scapula and trunk. Never pull on the involved arm.

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3

Understanding the shoUlder Complex
The shoulder is one of the most complex structures in the human body, made up of seven joints that need to work synchronously in order to have full, pain-free range of motion.5 An in-depth understanding of how the shoulder structures work can help in understanding the importance of proper alignment and its role in preventing shoulder pain. The scapula has three primary planes of motion: elevation/depression, protraction/retraction (also referred to as scapular abduction/adduction), and upward rotation/downward rotation.
OT PRACTICE • OCTOBER 8, 2012

Most functional movements require a combination of all three planes of motion. There are 16 muscles that attach to the scapula, and care must be taken to maintain full excursion in order to maintain mobility and avoid impingement. Every time clients are handled, they are at risk for injury. Even well-intentioned health care providers or family members can unknowingly cause trauma to the shoulder. Moving clients incorrectly (such as taking hold of their arm to help them out of a chair) or poor positioning (an arm trapped or pinned beneath them) can contribute to impingement and HSP. Aggressive

PhotograPhs CoUrtEsY oF thE aUthor

Figure 3. Scapular Mobilization
Starting Position:
Position the client with the feet flat on the floor and pelvis in a neutral position (not in a posterior pelvic tilt).

1

Elevation and Depression: (1, 2)
1. Cup your hand and place it over the head of the humerus. Don’t apply pressure on the head of the humerus; apply pressure with the heel of your hand on the pectoralis, medial to the humeral head. 2. Place your other hand along the medial and inferior border of the scapula. Use the heel of your hand, not your thumb, to cradle the inferior border of the scapula. 3. Bring your elbows down to your side. You will have more strength and protect your wrists by keeping them in good alignment. 4. Apply pressure through the heels of both hands and bring the entire shoulder girdle into elevation. 5. Elevate the scapula to end range (or the point of discomfort). Hold for a few seconds and allow it to return to a resting position. It may feel heavy or tight. With repetition the movement will get easier. Variations: Position your patient in supine or sidelying (on the strong side) if your client is unable to sit unassisted, has poor trunk control, or has an extremely heavy arm. Watch the video: http://www.icelearningcenter.com/mobilizing-scapula-elevation.

2

Protraction (scapular abduction) and Retraction (scapular adduction) (3)
Handling: 1. Stand in front of your client. 2. Gently take the hemiplegic arm and bring it into forward flexion of less than 90˚. 3. Support the arm at the elbow and tuck it along your side. This helps to keep it in neutral and doesn’t allow it to fall into internal rotation. 4. With your other hand, reach along the scapula and find the medial border. With a flat open hand, press along the medial border and glide the scapula forward into protraction. Do not hook your fingers around the scapula. 5. Maintain protraction for a few seconds and then allow the scapula to return to the resting position. 6. As the scapula returns to its resting position, allow it to follow the natural curvature of the rib cage. Variations: If you client has poor trunk control, use a supine or sidelying position. (4) Watch the video: http://www.icelearningcenter.com/mobilizing-scapula-protraction.

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4

Upward Rotation (5)
Handling: 1. While the scapula is forward in protraction, slide one hand from the client’s scapula to the elbow and use a lateral grip to hook onto the epicondyles. This will keep you from grasping and stimulating the biceps. 2. Slide the other hand from the elbow to the client’s hand (as if you were shaking hands). 3. Put your middle finger along the base of the metacarpophalangeal joints, your index finger along the thenar eminence, and your other fingers along the client’s fingers. 4. Keeping the arm in forward protraction, give a slight amount of external rotation and gently bring the arm past 90˚ and into forward flexion. 5. Remember: Go only to the point of resistance or discomfort and no further. 6. Carefully watch the client’s facial expression for any signs of discomfort. Tip: If your client does not have full range of motion in scapular excursion, check the other shoulder. The non-affected side may also have a loss of range that is unrelated to the stroke. Watch the video: http://www.icelearningcenter.com/mobilizing-scapula-upward-rotation.

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OCTOBER 8, 2012 • WWW.AOTA.ORG

PhotograPhs CoUrtEsY oF thE aUthor

F O R M O R E I N F O R M AT I O N
resources for Stroke: http://www.aota.org/Consumers/consumers/Adults/Stroke.aspx Functional Treatment Ideas & Strategies in Adult Hemiplegia (2nd ed.). By J. Davis, 2009. Port Townsend, WA: International Clinical Educators. (Earn 1.5 CEUs [18.75 NBCOT PDUs/15 contact hours]. $195. To order, call toll free 888-665-6556 or shop online at http://www.icelearningcenter.com.) Teaching Independence: A Therapeutic Approach to Stroke Rehabilitation (2nd ed.). By J. Davis, 2009. Port Townsend, WA: International Clinical Educators. (Earn 1.5 CEUs [18.75 NBCOT PDUs/15 contact hours]. $195. To order, call toll free 888-665-6556 or shop online at http://www.icelearningcenter.com.) Treatment Strategies in the Acute Care of Stroke Survivors. By J. Davis, 2007. Port Townsend, WA: International Clinical Educators. (Earn 1.5 CEUs [18.75 NBCOT PDUs/15 contact hours]. $195. To order, call toll free 888-665-6556 or shop online at http://www.icelearningcenter.com.) CD Course. ASHT Management of Upper Extremity Problems: Cadaver Demonstrations and Therapeutic Management. By P. Bonzani, D. Kline, K. Landrieu, M. Robichaux, & H. Stokes. Mt. Laurel, NJ: American Society of Hand Therapists. (Earn .6 AOTA CEU [6 NBCOT PDUs, 6 contact hours]. $70 for members, $95 for nonmembers. To order, call toll free 877-404-AOTA or shop online at http:// store.aota.org/view/?SKU=4851. Order #4851. Promo code MI) DVD: Basics and Beyond: Everything You Need to Know—Shoulder To Finger: Part 1 (CHT Prep Course). By N. Falkenstein & S. Weiss, 2011. St. Petersburg, FL: Treatment2Go. (Earn 3 AOTA CEUs [30 NBCOT PDUs, 30 contact hours]. $399 for members & nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota. org/view/?SKU=4858A. Order #4858A. Promo code MI) CD: Basics and Beyond: Everything You Need to Know—Shoulder To Finger: Part 2 (CHT Prep Course). By N. Falkenstein & S. Weiss, 2011. St. Petersburg, FL: Treatment2Go. (Earn 2.5 AOTA CEUs [25 NBCOT PDUs, 25 contact hours]. $349 for members & nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/ view/?SKU=4858B. Order #4858B. Promo code MI) CD: Basics and Beyond: Everything You Need to Know—Shoulder To Finger: Part 1 & 2 (CHT Prep Course). By N. Falkenstein & S. Weiss, 2011. St. Petersburg, FL: Treatment2Go. (Earn 5.5 AOTA CEUs [55 NBCOT PDUs, 55 contact hours]. $649 for members & nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota. org/view/?SKU=4858. Order #4858. Promo code MI) DVD: Cumulative Trauma Disorders: An EvidenceBased Approach. By P. Bonzani. St. Petersburg, FL: Treatment2Go. (Earn 1.2 AOTA CEUs [12 NBCOT PDUs, 12 contact hours]. $359 for members and nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=4863. Order #4863. Promo code MI) Hand and Upper Extremity Rehabilitation: A Practical Guide, 3rd Edition. Edited by S. Burke, J. Higgins, M. McClinton, R. Saunders, & L. Valdata, 2006. St. Louis, MO: Elsevier. ($93.95 for members, $133.50 for nonmembers. To order, call toll free 877-404-AOTA or shop online at http:// store.aota.org/view/?SKU=1348. Order #1348. Promo code MI) Occupational Therapy Practice Guidelines for Adults With Stroke. By J. Sabari, 2008. Bethesda, MD: AOTA Press. ($59 for members, $84 for nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=2211. Order #2211. Promo code MI) DVD: Orthotics: Creative Mobilization Splinting— Dynamic & Static Progressive Splinting (SPS) By D. Schwartz, 2011. St. Petersburg, FL: Treatment2Go. (Earn .9 AOTA CEU [9 NBCOT PDUs, 9 contact hours]. $299 for members & nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=4857. Order #4857. Promo code MI) DVD: Orthotics: Creative Static Splinting Made Simple. By D. Schwartz, 2011. St. Petersburg, FL: Treatment2Go. (Earn .7 AOTA CEU [7 NBCOT PDUs, 7 contact hours]. $249 for members & nonmembers. To order, call toll free 877-404-AOTA or shop online at http://store.aota.org/view/?SKU=4856. Order #4856. Promo code MI)

scapula in upward rotation, the third plane of motion, is last. Only when the scapula has been prepared and glides in elevation/depression and protraction/retraction can upward rotation of the scapula be attempted. For step-bystep instructions, see Figure 3 on p. 12.

Summary
The incidence of shoulder pain in clients who have had a stroke can be dramatically reduced. Clients who are managed correctly can avoid many of the painful syndromes that frequently occur during recovery, allowing for greater participation in activities of daily living (ADLs) and instrumental ADLs and improved quality of life. Each and every person working with the client, including all practitioners, nurses, family members, and caregivers, should be trained in protecting the shoulder from injury. Occupational therapy practitioners, with skilled expertise and an in-depth knowledge of the shoulder complex, can take the lead in training staff, educating families, and empowering patients in properly managing and caring for the hemiplegic shoulder. n references
1. Teasell, R., Foley, N., & Bhogal, S. K. (2011). EBRSR: Evidence-based review of stroke rehabilitation, module 11: The painful hemiplegic shoulder. Retrieved from http://www.ebrsr.com/ uploads/Module-11_hemiplegic-shoulder.pdf 2. Chae, J., Mascarenhas, D., Yu, D. T., Kirsteins, A., Elovic, E. P., Flanagan, S. R.,…Harvey, R. L. (2007). Poststroke shoulder pain: Its relationship to motor impairment, activity limitation, and quality of life. Archives of Physical Medicine and Rehabilitation, 88, 298–301. 3. Davis, J. (2009). Teaching independence: A therapeutic approach to stroke rehabilitation (2nd ed.). Port Townsend, WA: International Clinical Educators. 4. Jonsson, A., Hallstrom, B., Norrving, B., & Lindgren, A. (2007). Prevalence and intensity of pain after stroke: A population-based study focusing on patients’ perspectives. Journal of Neurology, Neurosurgery and Psychiatry, 77, 590–595. 5. Cailliet, R. (1980). The shoulder in hemiplegia. Philadelphia: F. A. Davis. 6. Davies, P. (2000). Steps to follow: The comprehensive treatment of patients with hemiplegia (2nd ed.). Heidelberg, Germany: Springer-Verlag.

CONNECTIONS
Discuss this and other articles on the OT Practice Magazine public forum at http://www.OTConnections.org.

with the feet flat on the floor and pelvis in a neutral position (not in a posterior pelvic tilt). Mobilization begins with scapular elevation—it is safe, does not cause impingement, and helps you evaluate excursion of the scapula. Is there any resistance? A scapula that has been immobilized may feel tight and, if there is an increase in tone, you may feel resistance against movement. In conOT PRACTICE • OCTOBER 8, 2012

trast, a flaccid or low tone arm will feel heavy but the scapula will glide easily.3 After the scapula is gliding in elevation, carefully bring the arm into forward flexion, no more than 90˚. With your hand on the scapula, glide the scapula forward into protraction. Never pull on the humerus to bring the scapula forward; use only the scapula. With repetition, the scapula will begin to glide more easily. Mobilizing the

Jan Davis, MS, OTR/L, is president of International Clinical Educators. She specializes in creating stateof-the-art training materials filmed with real patients and real therapists. For more information, go to www.icelearningcenter.com or e-mail jandavis@ icelearningcenter.com.

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Improving Upper Extremity Function Through a Home-Based Modified Constraint-Induced Movement Therapy Program
ELLEN HERLACHE ALISSA PASANT DONALD EARLEy CALEB JOHNSON JILL EWEND CHELSEA SCHWAB NICOLE FARRAND

A research project found home-based constraint-induced movement therapy (CIMT), for increasing the use of upper extremities, to be as effective at home and often more convenient than at a clinic or other facility.

E

very 40 seconds, someone in the United States has a cerebral vascular accident (CVA), also known as a stroke.1 CVA is the third-leading cause of death in the United States and the leading cause of serious, long-term disability. CVA involves a sudden interruption of blood supply to the brain that can be caused by occlusion or hemorrhage in the arteries that lead to the brain. When the brain loses part of its supply of oxygen, many functions of the body, such as speech, vision, and motor abilities, can be seriously impaired. An individual’s ability to participate in meaningful or necessary daily tasks, including activities of daily living (ADLs), depends on the effects of the CVA and the various anatomical structures compromised.2 One consequence of CVA that is experienced by many stroke survivors is learned nonuse. Learned nonuse is a loss of extremity function resulting not from damage to the nervous system itself, but rather from learned suppression of movement in an extremity that has been affected by the CVA. Learned nonuse is a behavioral phenomenon
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CONSTRAINT-INDUCED MOVEMENT THERAPy
Constraint-induced movement therapy (CIMT) is a type of rehabilitation therapy that addresses motor performance deficits and learned nonuse occurring after neurological insult by providing intense training of the arm

OCTOBER 8, 2012 • WWW.AOTA.ORG

PHOTOGRAPHS ON PAGES 14-15 COURTESY OF ADAM BAUDOUX AND SAGINAW VALLEY STATE UNIVERSITY

that results from constant negative feedback. When a person with hemiparesis tries to use an affected extremity and experiences failure at task performance, a “downward spiral” often occurs, in which the person knowingly and progressively begins to suppress use of the affected limb. This downward spiral continues to grow based on a number of factors associated with lack of practice and failure when attempting to use the extremity, which ultimately can lead to a near complete loss of upper extremity use.3 The continued suppression of motor activity in the affected limb becomes reinforced by the brain. However, learned nonuse resulting from CVA does not necessarily need to become permanent. The behavioral aspect of learned nonuse is just that: learned. With proper retraining, practice, and motivation, learned nonuse can be overcome.3 After insult to the central nervous system, the brain can oftentimes be reprogrammed.4 This is particularly true for persons who have gross functional use remaining in the affected upper extremity after neurological insult.

affected by CVA.5 The unaffected arm is constrained for a set number of hours a day, to “force” use of the affected arm, leading to improvements in function of the affected upper extremity. During treatment, the client is expected to use his or her affected upper extremity to perform tasks, while the unaffected arm is placed in a constraint.4 Traditional CIMT involves an intense 2-week training protocol during which the participant’s nonaffected limb is constrained during therapy sessions (which are 6 hours in duration), and 90% of his or her waking hours outside of therapy sessions, including weekends. During therapy, fine motor tasks, gross motor tasks, and ADLs are performed on a one-on-one basis. Unfortunately, the large number of hours of direct therapist–client interaction required with traditional CIMT can make it difficult to obtain third-party reimbursement for this form of intervention.4 A week of CIMT therapy at two major centers in the United States costs between $3,000 and $3,500; this does not include the cost of transportation, housing, and meals for each participant. Thus, traditional CIMT is not a therapy regimen that many people have the resources to participate in.6 In response to these barriers, modified constraint-induced movement therapy protocols have been developed. Modified constraint-induced movement therapy (mCIMT) can include a number of different protocols, but it

Facing page: A participant learns to don the constraint. This page: During sessions in the clinic, subjects participated in repetitive task practice. At home, participants engaged in more purposeful activities.

frequently involves intense therapy for at least 5 days per week, for at least 3 hours a day, over a minimum of 4 weeks, for a total of 60 hours of therapy time distributed over 20 sessions.7 The mCIMT approach decreases time spent in the clinic and increases accessibility of this form of therapy for patients.8 Both CIMT and mCIMT have been found to be effective in increasing the use of upper extremities in patients who have experienced a stroke.9

HOME-BASED REHABILITATION PROGRAMS
Prior research has demonstrated that home-based rehabilitation programs can be effective in improving strength, balance, endurance, bimanual hand use, and functional ability of clients who have experienced CVAs. Home-based rehabilitation programs do not involve intense one-on-one intervention with a therapist, which can make them an economically feasible approach to rehabilitation. Participants in home-based programs do not have to frequently
OT PRACTICE • OCTOBER 8, 2012

travel to and from the clinic for therapy, adding to the ease of accessibility.10 Additionally, treatment programs involving home- and community-based rehabilitation programs are becoming a more popular approach to rehabilitation as third-party payers are moving toward decreasing coverage for inpatient rehabilitation services.11 Limited research has examined outcomes associated with home-based rehabilitation programs, particularly for persons with upper-extremity limitations post-CVA. One of the most recent studies, a meta-analysis completed by Coupar et al., reviewed randomized controlled trials comparing home-based therapy interventions focusing on upper-extremity limitations post-CVA to placebo, no intervention, or usual care.11 The results of the review indicated that the home-based programs were no more or less effective than the clinic-based programs (although the authors noted that there was a lack of good-quality evidence upon which to make recommendations regarding the effectiveness

of home-based versus placebo, no intervention, or usual care services). The authors emphasized that additional research focusing on the effects of home-based rehabilitation programs for persons with upper-extremity impairments post-CVA is necessary. It seems that for some clients, a home-based approach to mCIMT may be more realistic than traditional CIMT. Putting an mCIMT program in the participant’s control (including times of constraint wear, and identification of treatment activities that are most meaningful) may make the program more convenient and appealing.12 Furthermore, home-based mCIMT programs would not likely require the large amount of face-to-face clinic time that traditional CIMT programs do, therefore increasing accessibility for persons with limited financial resources and/or those with difficulty attending regular clinic-based therapy. After an extensive review of research on mCIMT, the authors concluded that a home-based form of mCIMT, though its use has not been explored in depth, could potentially be beneficial to persons who experience a CVA. The proven effectiveness of mCIMT, combined with the cost-effectiveness of performing therapy in the home, could be beneficial and convenient for clients and therapists alike.

HOME-BASED MCIMT PROGRAM
The authors conducted a research study in the summer of 2011 that examined the effects of an 8-week home-based mCIMT program on upper-extremity function. The study was approved by the ethics board at the researchers’ university. Participants were recruited through advertisements in the local newspaper. The authors also provided information regarding the
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Going Beyond the Vote
Support AOTPAC Today!
Stephanie yamkovenko

T

he 2012 elections are almost here and, as AOTA members prepare to select the candidates they will support, the American Occupational Therapy Political Action Committee (AOTPAC) is sharing its list of supported candidates for the 2012 federal elections at www.aota.org/ aotpac-support. AOTPAC wants all occupational therapy practitioners to vote in the November 6 elections, regardless of which candidates they choose. Meaningful policy and legislation requires a bipartisan approach, and that is why AOTPAC supports candidates from both parties who support the occupational therapy profession. “Voting is an exercise of our power in choosing legislators who represent our interests,” says AOTPAC Chairperson Gail Fisher, MPA, OTR/L. “Some people take voting for granted, and so many people don’t vote, but really it is a privilege to be able to select our own representatives and feel that we have a personal stake in what they do.” AOTPAC supports candidates in many states, including Tammy Duckworth, who is a big fan of occupational therapy. Duckworth was one of the first women to fly combat missions in Iraq, but she lost both of her legs and part of the use of her right arm in a helicopter crash. Duckworth spoke at AOTA’s Annual Conference & Expo in 2012, praising army occupational therapy for assisting in her recovery. Duckworth is running for Illinois’ 8th district in the U.S. House of Representatives. “Tammy Duckworth is a huge proponent of occupational therapy,” says Fisher. “Certainly having legislators like her who totally understand what we do—we won’t have to explain it—means they will fight for other people’s right to access our services when they need it.” AOTPAC is a vital link to making sure congressional candidates who support occupational therapy are elected. A political action committee (PAC) is the legally sanctioned vehicle through which organizations such as AOTA can engage in

By becoming politically aware and contributing to AOTPAC, occupational therapy practitioners can ensure some influence in the decisions that affect their professional lives so directly.
therapy practitioners can ensure some influence in the decisions that affect their professional lives so directly. The money raised by AOTPAC is through direct AOTA member contributions. Without member contributions, AOTPAC would not have the high profile needed to support occupational therapy in the political process. No matter the amount of the contribution, the support that occupational therapy practitioners give AOTPAC will help its ongoing efforts on behalf of the profession. As an added incentive, members who contribute $1,000 or more to AOTPAC by November 1 will be eligible for a drawing to win a trip to Washington to attend the presidential inaugural events with Fisher and AOTA policy staff. Members who contribute $365 or more by November 1 will be eligible for a drawing to win a trip to Washington to attend the Congressional Swearing In Day activities. More information may be found at www. aota.org/aotpac-contest. In addition to voting and supporting AOTPAC, occupational therapy practitioners can also volunteer their time. “You can go beyond voting and spend an afternoon working for a candidate,” says Fisher. “Work on the campaign, support them financially, or go to a town hall meeting the candidate is holding.” Fisher hopes to use the excitement of the upcoming elections to help AOTPAC have many more successful years. “I feel that AOTPAC is much more visible than it used to be,” says Fisher. “Former Chairperson Amy Lamb has done a tremendous job in bringing us to this point. I want to keep it going.” n
Stephanie yamkovenko is AOTA’s staff writer.

otherwise prohibited political action and work to influence the outcome of federal elections. AOTPAC is a voluntary, nonprofit, and unincorporated committee of members of AOTA. For 35 years, AOTPAC has furthered the legislative aims of AOTA by influencing and supporting candidates. “AOTA is in charge of educating legislators. AOTPAC is in charge of making contributions to legislators,” says Fisher. “The two work very closely together.” AOTPAC follows strict criteria when selecting candidates to support, including analyzing congressional support for occupational therapy legislative issues. AOTPAC supports candidates for the U.S. House of Representatives and U.S. Senate, and it supports AOTA members running for public office. AOTPAC does not endorse presidential candidates. When AOTPAC is successful in helping congressional candidates who support occupational therapy get elected, it allows the profession to be at the table for discussions about health care reform, the Medicare outpatient therapy cap, funding for research, and other issues that affect the practice of occupational therapy. AOTPAC has made political contributions to candidates for election in almost every state in both House and Senate elections, enabling AOTA to broaden its contacts in Congress. By becoming politically aware and contributing to AOTPAC, occupational

OT PRACTICE • OCTOBER 8, 2012

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CALENDAR
Order #WA1010, AOTA Members: $25, Nonmembers: $36. http://store.aota.org/view/?SKU=WA1010

Autism Conference Session Webcast

Community Partnerships: Panel Presentation by Autism Society and Easter Seals, by Marguerite Kirst Colston and Patricia Wright. Panel discus-

sion on parent challenges, policies and programs, Autism Society services, and Easter Seals interventions for autism treatment. Earn 1 Contact Hour. Order #WA1011, AOTA Members: $25, Nonmembers: $36. http://store.aota.org/view/?SKU= WA1011

Occupation-based practice with a focus on postacute care practice settings for older adults and strategies for integrating occupation throughout the OT process to maximize clinical application. Earn .6 AOTA CEU (7.5 NBCOT PDUs/6 contact hours). Order #4875, AOTA Members: $210, Nonmembers: $299. http://store.aota.org/view/?SKU=4875

REhABIlITATION, DISABIlITY, & PARTICIPATION

Self-Paced Clinical Course

Dysphagia Care and Related Feeding Concerns for Adults, 2nd Edition, edited by Wendy Avery.

CEonCD™

Skilled Nursing Facilities 101, by Christine Kroll and Nancy Richman. Importance of documentation, re-

2010 Autism Webcast Set

Presented by experts in the field. These fully nar-

rated PowerPoint™ presentations provide learning from prominent experts and designed to enhance knowledge and skills. With value pricing, purchasing the entire webcast series provides a specialty conference from home or work computer. These webcasts do not require a course exam. Earn up to 13.5 contact hours. Full Set Order #WA1000K. AOTA Members: $175, Nonmembers: $250. http:// store.aota.org/view/?SKU=WA1000K

quirements for different payers, significance of managing productivity, understanding billing considerations, and maintaining ethical practice standards. Earn .3 AOTA CEU (3.75 MBCOT PDUs/3 contact hours). Order #4843, AOTA Members: $108, Nonmembers: $154. http://store.aota.org/view/?SKU=4843

Up-to-date resource in dysphagia care written from an occupational therapy perspective for OTs at entry and intermediate skill levels. Earn 1.5 AOTA CEUs (18.75 NBCOT PDUs/15 contact hours. Order #3028. AOTA Members: $199, Nonmembers: $299. http://store.aota.org/view/?SKU=3028

Self-Paced Clinical Course

CEonCD™

Seating and Positioning for Productive Aging: An Occupation-Based Approach, by Felicia Chew and Vickie Pierman. Manual wheelchair mobil-

MENTAl hEAlTh

Self-Paced Clinical Course

health interventions for children that can be applied in all pediatric practice settings. Earn 2 AOTA CEUs (25 NBCOT PDUs/20 contact hours). Order #3030, AOTA Members: $259, Nonmembers: $359. http:// store.aota.org/view/?SKU=3030

Mental Health Promotion, Prevention, and Intervention With Children and Youth: A Guiding Framework for Occupational Therapy, edited by Susan Bazyk. Framework on the role of OT in mental

ity through review of seating and positioning from evaluation to outcome with a concentration on interventions applicable to a variety of settings. Earn .4 AOTA CEU (5 NBCOT PDUs/4 contact hours). Order #4831, AOTA Members: $97, Nonmembers: $138. http://store.aota.org/view/?SKU=4831

tive, computer-based learning to present the anatomical basis and clinical presentation of problems in the hand and forearm and preparation for Hand Therapy Certification Exam. Earn 1.6 CEUs (20 NBCOT PDUs/16 contact hours). Order #3017, AOTA Members: $182, Nonmembers: $252. http://store. aota.org/view/?SKU=3017

The Hand: An Interactive Study for Therapists, by Judy C. Colditz. Written coursework with interac-

CEonCD™

Occupation-Focused Intervention Strategies for Clients With Fibromyalgia and Fatiguing Conditions, by Rénee R. Taylor. Evidence-based strate-

Online Course

Self-Paced Clinical Course

of recent advances and trends in mental health practice, including theories, standards of practice, and evidence as they apply to OT with content from federal and non-government entities. Earn 2 AOTA CEUs (25 NBCOT PDUs/20 contact hours). Order #3027, AOTA Members: $259, Nonmembers: $359. http://store.aota.org/view/?SKU=3027

Occupational Therapy in Mental Health: Considerations for Advanced Practice, edited by Marian Kavanagh Scheinholtz. Comprehensive discussion

prevention to support OTs in providing evidencebased fall prevention services to older adults at risk for falling or that seek preventive services with sections on prevalence, consequences, and evaluation of fall risk. Earn .6 AOTA CEU (7.5 NBCOT PDUs/6 contact hours). Order #OL34, AOTA Members: $210, Nonmembers: $299. http://store.aota.org/view/?SKU =OL34

Falls Module I—Falls Among Community-Dwelling Older Adults: Overview, Evaluation, and Assessments, by Elizabeth W. Peterson and Roberta Newton. First module in 3-part series on fall

gies for managing fibromyalgia and other fatiguing conditions, such as chronic fatigue syndrome, with interdisciplinary treatment approaches and collaboration with other professionals. Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). Order #4839, AOTA Members: $68, Nonmembers: $97. http:// store.aota.org/view/?SKU=4839

CEonCD™

Pain, Fear, and Avoidance: Therapeutic Use of Self With Difficult Occupational Therapy Populations, by Reneé R. Taylor. Examines strategies

Online Course

PRODUCTIvE AGING

Self-Paced Clinical Course

with older adults, approaches to and prevention of occupational problems, health conditions that affect participation, and practice in cross-cutting and emerging areas. Earn 3 AOTA CEUs (37.5 NBCOT PDUs/30 contact hours). Order #3024, AOTA Members: $245, Nonmembers: $345. http://store.aota. org/view/?SKU=3024

Strategies to Advance Gerontology Excellence: Promoting Best Practice in Occupational Therapy, edited by Susan Coppola, Sharon J. Elliott, and Pamela E. Toto. Core best practice methodology

module in 3-part series on fall prevention with overview of falls that occur in the hospital setting and identification of older adults at risk, factors that contribute to fall risks, and assessment strategies. Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). Order #OL35, AOTA Members: $68, Nonmembers: $97. http://store.aota.org/view/?SKU= OL35

Falls Module II—Falls Among Older Adults in the Hospital Setting: Overview, Assessment, and Strategies to Reduce Fall Risk, by Roberta Newton and Elizabeth W. Peterson. Second

for managing client pain, fear, and avoidance in OT practice with six distinct modes of interacting based on the author’s conceptual practice model. Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). Order #4836, AOTA Members: $68, Nonmembers: $97. http://store.aota.org/view/?SKU=4836

CEonCD™

Hand Rehabilitation: A Client-Centered and Occupation-Based Approach, by Debbie Amini.

Occupation-based intervention to enhance hand rehabilitation protocols without sacrificing productivity or detracting from the concurrent client factor focus. Earn .2 AOTA CEU (2.5 NBCOT PDUs/2 contact hours). Order #4832, AOTA Members: $68, Nonmembers: $97. http://store.aota.org/view/?SKU=4832

Online Course

Falls Module III: Preventing Falls Among Community-Dwelling Older Adults—Intervention Strategies for Occupational Therapy Practitioners, by Elizabeth W. Peterson and Elena Wong Espiritu.

Self-Paced Clinical Course

professional competency through AOTA Specialty Certification in Low Vision Rehabilitation (SCLV) with information on evaluation and lessons related to psychosocial issues and low vision, eye conditions that cause low vision in adults, and basic optics and optical devices. Earn 2 AOTA CEUs (25 NBCOT PDUs/20 contact hours). Order #3025, AOTA Members: $259, Nonmembers: $359. http://store.aota. org/view/?SKU=3025

Low Vision: Occupational Therapy Evaluation and Intervention With Older Adults, Revised Edition. 2008, edited by Mary Warren. Support for

Third module in 3-part series on fall prevention with evidence-based intervention strategies to reduce falls among community-dwelling older adults that include both older adults who are well and those who are living with chronic diseases. Earn .45 AOTA CEU (5.63 NBCOT PDUs/4.5 contact hours). Order #OL36, AOTA Members: $158, Nonmembers: $225. http://store.aota.org/view/?SKU=OL36

Online Course

CEonCD™

An Occupation-Based Approach in Postacute Care to Support Productive Aging, by Denise Chisholm, Cathy Dolhi, and Jodi L. Schreiber. 26

tent and updated links on research, tools, and resources to help advance knowledge about instrumental activity of daily living (IADL) of driving and community mobility. Earn .6 AOTA CEU (7.5 NBCOT PDUs/6 contact hours). Order #OL33, AOTA Members: $180, Nonmembers: $255. http://store.aota. org/view/?SKU=OL33

Driving and Community Mobility for Older Adults: Occupational Therapy Roles, Revised, by Susan L. Pierce and Elin Schold Davis. Expanded con-

“We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidencebased profession with a globally connected and diverse workforce meeting society’s occupational needs.” ••• Join us on the road to the Centennial Vision at

www.aota.org

OCTOBER 8, 2012 • WWW.AOTA.ORG

EMPLOYMENT OPPORTUNITIES
Faculty Faculty

Department of Rehabilitation Sciences Master of Occupational Therapy Program College of Health Sciences Midwestern University
Occupational Therapy Program Downers, Grove, IL Open Faculty Position: Assistant Professor
POSITION DESCRIPTION: This position is a tenure-track, nine-month academic year appointment with the possibility of summer teaching. Faculty duties include teaching graduate occupational therapy courses; advising graduate students; mentoring master's and doctoral students; engaging scholarly research and publication, including external grant proposals; and participation in service opportunities within the department, college, university and profession. The anticipated appointment date is Fall 2013. Preferred candidates will have practice and/or teaching expertise in the areas of mental health or adult physical/neurological dysfunction. THE PROGRAM: For more information about the program, see the Occupational Therapy program website at http://chs.utep.edu/ot/ REQUIRED QUALIFICATIONS: Candidates must (1) have an earned doctorate degree in occupational therapy, (2) be eligible for Texas licensure, (3) be an active member of the American Occupational Therapy Association, and (4) have a minimum of 5 years of experience in occupational therapy practice. Candidates are expected to (5) demonstrate a commitment to, or potential for, teaching excellence at the university level, (6) be able to use technology in instruction, and (7) demonstrate a potential for or record of scholarly research and publication, including development of grant proposals and attracting external funding. (8) Finally, candidates will demonstrate the ability to work effectively with faculty, staff and students from diverse ethnic, cultural, and socioeconomic backgrounds. Preferred candidates will also show a record of active participation or leadership roles in the profession of occupational therapy or relevant organizations. APPLICATION PROCEDURE: Applicants should submit: (1) a cover letter; (2) a curriculum vitae; and (3) the names, addresses, phone numbers, and e-mails of three professional references. Candidates will be notified before references are contacted. Applications will be reviewed immediately and received until the position is filled. Applicants are encouraged to apply by November 30, 2012. For more information and to apply, please contact: Dr. Stephanie Capshaw OT Search Committee Chair University of Texas at El Paso College of Health Sciences Department of Rehabilitiation Sciences Ocupational Therapy Program 500 W. University Ave. El Paso, TX 79968 Tel. 915-747-7269, email: scapshaw@utep.edu The University of Texas at El Paso is an Equal Opportunity/Affirmative Action Employer. The University does not discriminate on the basis of race, color, national origin, sex, religion, age, disability, genetic information, veteran status, or sexual orientation in employment or the provision of services. F-6164

Assistant Professor

Therapy Program The Occupational professional master’shas immediate opportunities to join an established occupational therapy degree

program. The spacious 105-acre, wooded, Downers Grove, IL campus is located just 45 minutes west of downtown Chicago. Applications are invited for a full-time, tenure track faculty position. Successful applicants must possess (1) an earned doctorate (or ABD) in occupational therapy or a related field; (2) eligibility for licensure as an occupational therapist in Illinois; (3) at least 5 years of clinical experience; and (4) instructional experience in a college or university academic program. Experience in pediatrics, geriatrics, or adult rehabilitation is needed. A record of scholarly productivity or potential to develop an active research program and professional service will enhance the candidate’s application. Preference will be given to candidates with a doctoral degree; teaching experience in an academic program; and whose background, experience and interests complement those of current faculty members. A faculty member in the Occupational Therapy Program has responsibilities in teaching, scholarship, and service. Teaching responsibilities include conducting class sessions and designing learning activities that will lead to student mastery and success in their professional and personal development. This role also encompasses the general areas of academic advising and student development. Scholarship responsibilities include pursuing on an ongoing basis the continuance of scholarly growth, engaging in scholarly/creative activity, and disseminating the results through critical peer review. Service responsibilities include participating actively in program, college, and university committees; assisting with the student recruitment and admissions process; professional role-modeling; and participating actively in the professional activities of state and national occupational therapy organizations. Midwestern University is an independent institution of higher education committed to the education of health care professionals. The salary and benefits are competitive. Rank and salary are commensurate with qualifications and experience. Interested applicants should apply online at www.midwestern.edu and send a letter of application, curriculum vitae, and the names and contact information of three professional references to the Chair of the OT Program Faculty Search Committee: Mark Kovic, OTD, OTR/L Chair, OT Program Search Committee, Occupational Therapy Program 555 31st Street, Downers Grove, IL 60515 mkovic@midwestern.edu F-6173

UNIVERSITY OF TEXAS AT EL PASO

OT PRACTICE
Issue: Size:

Faculty

September 24th and October 8th issue - deadline TODAY 4/9 page sq = 4.687 x 5.937” Chair, Department of

Occupational Therapy
The University of Tennessee Health Science Center is conducting a nationwide search for Chair of the Department of Occupational Therapy. The Search Committee invites letters of nomination, applications (letter of interest, resume/CV and references), or , expressions of interest to be submitted to the search firm assisting the University. For a complete position description, refer to Current Opportunities on www.parkersearch. com. Gary L. Daugherty, Senior Vice President | Ryan Crawford, Principal gdaugherty@parkersearch.com | rcrawford@parkersearch.com Phone: 770-804-1996 x 110 Fax: 770-804-1917
The University of Tennessee is an EEO/AA/Title VI/Title IX/Section 504/ADA/ADEA institution.

F-6161

OT PRACTICE • OCTOBER 8, 2012

29

aota SPecialty coNFereNce

adults With Stroke
November 30–December 1, 2012 baltimore, marylaND earn Up to 13 contact Hours (1.3 aota ceUs/13 Nbcot PDUs)

register now at www.aota.org/confandevents/stroke A stroke can take meaning out of life, but occupational therapy can restore it.
An estimated 5.4 million people in America live with the disabling effects of stroke and that number is bound to increase in the years to come. Occupational therapy must take the lead in stroke rehabilitation for survivors, families and caregivers, so join us this fall at Adults With Stroke and take advantage of top-level continuing education!

PR-213

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• Customized Major Medical—Develop an affordable medical package to meet your specific needs. • Group Enhanced Dental Insurance***—Provides coverage for diagnostic, preventive and specialty dental treatments. • Pet Insurance****—Provide affordable health coverage to help you pay the treatment costs of your pet’s accidents, illnesses and routine medical care.

Learn about AOTA-Sponsored Group Insurance Plans for a secure future.

for a free information kit including costs, exclusions, limitations and terms of coverage or visit us at www.aotainsurance.com.
NOTE: Plans may vary and may not be available in all states.
P-6180

Call 1-800-503-9230

* Underwritten by Liberty Insurance Underwriters Inc., a member company of Liberty Mutual Insurance. 55 Water Street, New York, New York 10041. May not be available in all states. Pending underwriter approval. ** Underwritten by Hartford Life and Accident Insurance Company and Hartford Life Insurance Company, Simsbury, CT 06089. *** Underwritten by The United States Life Insurance Company in the City of New York. **** Underwritten by Veterinary Pet Insurance Co. (CA), Brea, CA; National Casualty Co. (Nat’l), Madison, WI. Administered by Marsh U.S. Consumer, a service of Seabury & Smith, Inc.

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CA Ins. Lic. #0633005, AR Ins. Lic. #245544 d/b/a in CA Seabury & Smith Insurance Program Management

AG 9561 55464, 55827, 55991, 55992, 55828 (10/12) ©Seabury & Smith, Inc. 2012