Today’s disability rehab and insurance world, stuffed with heavy caseloads, time pressures, and all-consuming client needs, often stretches rehab professionals and disability case managers to their breaking point. Some days, getting out of bed to drag yourself into the office or clinic can seem overwhelming. One in five Canadians will experience a mental illness at some point in their lifetime^.¹ The annual cost of loss of productivity due to mental illness in the workplace in Canada was estimated to be over $6.4 billion in 2011.² Let's switch our focus from clients to self, for a moment. We all know there are several things we should be doing for our own health and wellness, such as exercising and eating well, but there are also many small steps we can take to improve our mental health and productivity so we are better able to cope with our stressors and support those clients who need us at our best.

1. Take frequent breaks. A recent study found that people who worked for 52 minutes and then took a 17-minute break were the most productive.³ Set a timer, stretch, go to the bathroom, chat with a co-worker, get a drink of water, or go retrieve something from the printer. This will also help discomfort related to static sitting or standing at your desk.

2. Start drinking peppermint tea. Caffeine consumption is often under-recognized as a contributor to the development of anxiety disorders and panic attacks. Peppermint tea can help you feel more alert and improve your memory, but will not contribute to anxiety as both coffee and black can.

3. Spend time with positive, supportive people. This seems like common sense, but we often end up having lunch with whoever happens to be in the lunchroom. Find people whose company you truly enjoy, and who lift you up. Arrange lunch and coffee dates with them. Having strong social supports is an essential part of resilience, so they will help you be able to weather your workplace and home stressors. 

4. Shut off your screens (T.V., tablet, phone, etc.) at least an hour before bedtime. Sleep deprivation has so many negative effects on our mental health. Often, we feel like we are resting when we do these activities, but our bodies are actually alert. The blue light from the screens makes us more alert and interferes with our ability to fall asleep. We become distracted by what we are doing and end up staying up way too late, which we regret the next morning.

5. Practice mindful relaxation for 2-5 minutes, twice daily. Relaxation techniques can help boost your mood and find a feeling of calmness when everything feels chaotic. You can do them anywhere and anytime, and they do not have to be difficult or time-consuming. Start by sitting comfortably and closing your eyes. Take several deep breaths and pay attention to the feel and sound of the breath coming in and out of your body. Keep doing this for a couple minutes. When thoughts come into your head (and they will!), let them pass through and re-focus on your breath.

6. Surround yourself with pictures of green spaces. We know that spending time in nature helps relieve depression and anxiety and increase productivity, but working in an office or clinic can be about as far away from nature as possible. Ideally, we would all be out walking in a park on our lunch breaks, but having a plant at our desk and/or pictures of green spaces (e.g. as your computer background picture) can help lower our stress levels. 

7. Choose cues to link your habit changes. If you are trying to change a habit, such as exercising more, link it to something you already do. For example, if you want to start meditating, decide to do it when you get your first cup of coffee in the morning (or peppermint tea!), you will be a lot more successful than if you just decide to do it every morning. You can also choose cues to replace an old bad habit with new ones. If you usually use your afternoon break (which is the cue) to go get a donut, you could change that behavior pattern to going for a short walk in a nearby green space with a friend. 

8. Take your vacation. When we get busy, it is easy to feel like we need to keep plowing through the work to get it done. However, vacation time decreases our errors and increases our productivity. Shifting focus from work to fun does the body and mind, good!

9. Choose your environment carefully.  Just as a shade plant will never thrive in the sun, no matter how often you water or fertilize it, there are some work environments you may never thrive in, no matter how much yoga or deep breathing you do. If you are in this situation, think through your options carefully. Can you do a different job with the same employer? Can you do your same job at a different employer? Is there flexibility available to do your job part-time? You are much better to think through your options now when you are not on stress leave, than to wait until you are no longer able to work. It is much harder to find a new job when you are not working.  

10. Do not be afraid to seek help. Talk to your doctor about your mental health. Many employers have an Employee Assistance Plan where you can access free counseling sessions. You do not have to wait to be in a crisis situation to use these. In fact, it is totally fine to do “preventive counseling”. 

Co-authors: 

1.Linda Harrison, Occupational Therapist with Enabling Access Inc. specializes in mental health screenings, activation therapy, cognitive behavioural therapy, is a certified BrainFX 360 cognitive evaluator and leads our Mental Health and Cognitive OT services.

2. Marnie Courage, Occupational Therapist and Director at Enabling Access Inc.

References and Related Reading:

1.http://www.cmha.ca/media/fast-facts-about-mental-illness/#.WQdHRxgZORt

2.http://www.mentalhealthcommission.ca/sites/default/files/2016-06/Investing_in_Mental_Health_FINAL_Version_ENG.pdf

3.https://www.themuse.com/advice/the-rule-of-52-and-17-its-random-but-it-ups-your-productivity

4.http://apt.rcpsych.org/content/11/6/432

5.http://www.scielo.br/scielo.php pid=S1414753X2014000300009&script=sci_arttext&tlng=en

6.http://jap.physiology.org/content/110/5/1432.full

7.http://www.cochrane.org/CD007142/DEPRESSN_relaxation-for-depression

8.https://depts.washington.edu/hhwb/Thm_Mental.html

9.https://www.theatlantic.com/business/archive/2011/08/why-summer-vacations-and-the-internet-make-you-more-productive/244289/

March 13 to 19, 2017 is Brain Awareness Week.

The Canadian Human Rights Act requires that employers ensure that all people are treated equally. This sometimes involves accommodating an employee’s needs, changing the work environment, or duties to enable full participation in their jobs. Duty to Accommodate applies only to needs that are based on one of the grounds of discrimination.

The following are brain function related disabilities:

Neurological Disability - A neurological disability refers to a group of disorders that primarily relate to the central nervous system comprised of the brain and spinal cord. For example, cerebral palsy, epilepsy, acquired brain injury, and multiple sclerosis.

Mental Disorder - A Mental Disorder is a syndrome characterized by a clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. (5th ed.; DSM-5) For example, anxiety disorders, depression, obsessive-compulsive disorder (OCD), and attention-deficit hyperactivity disorder (ADHD).

Mental Illness, like Depression, can cause memory loss and concentration difficulties and anxiety can lead to difficulty with organization of thoughts, concentration, and problem-solving. In fact, 80% of disability costs are related to mental health conditions (Conference Board of Canada 2011).

Learning Disorder -  Disorders which may affect the acquisition, retention, understanding, or use of verbal or nonverbal information (Job Accommodation Network, 2013) For example, dyslexia, dyscalculia, and dysgraphia.

The above differences may be invisible to others, but certainly present real challenges for the individual experiencing the conditions, those working with, and supervising the individual. Cognitive performance areas often affected can include working memory, attention, concentration, judgment, calculation, sequencing, and more. Often, emotional regulation and sensory processing issues co-exist.

Sometimes employers are challenged with finding accommodations for employees without fully understanding (or without being provided with) the medical background related to the disability. When there are questions about an employee’s cognitive abilities, A Cognitive-Functional Capacity Evaluation can answer task-specific employee limitations and strengths. If it is determined the current job is no longer a safe match for the employee, a Psycho-Vocational Assessment can assist in determining appropriate job match criteria, further training and accommodations required. 

Here are some workplace accommodation resources for brain function related disabilities:

Mental Health Accommodations

Cognitive Accommodations

Cognitive Academic Accommodations

Enabling Access Inc. assists employers with job accommodation services,  including the assessments above, as well as, Stay-at-Work and Return-to-Work consultation.

Marnie Courage, OT Reg (MB)

Director of Enabling Access Inc.

Winnipeg, Manitoba, Canada

If you are an occupational therapist, work in human services, or have an adult family member with an intellectual or developmental disability, you know that teaching daily living skills takes patience, repetition and demonstration.  Often we use role playing, workbooks and computer programs to assist us in getting the content across, as learning this stuff can be a challenging experience for many.

Linda Harrison’s “Daily Living Skills Worksheets” is a great teaching aid for content related to Memory/ safety, Leisure/productivity, Communication, Managing Meetings, Problem Solving/reflection and Recording thoughts and feelings. Each worksheet is accompanied by guidelines that include the purpose and directions for use, including helpful tips.

I can see this being a helpful tool when an individual is moving into a new residence, is having difficulty living on their own, lacks initiative for creating structure in their routine, or lacks awareness of personal hygiene and health, which all can be barriers to living independently.  Many worksheets deal with budgeting, home and community management, as well as medication management. There are even a few sheets that deal with social skills.

The importance of first assessing barriers to independence and identifying which occupational performance components to measure, cannot go unmentioned here. The OT, teacher or caregiver should focus on the concepts that require improvement, and not overwhelm the student with working through several concepts  at once by working through these sheets quickly. In my experience, choosing one area of focus for several sessions and allowing the student to absorb the information, practice the skills and apply them to their life, is best, before moving other areas.  Using SMART goals are a great way to know when it is time to move onto the next concept.

It is refreshing to see occupational therapists sharing information and tools, while making them accessible to all, in order to improve our practices and assist new OT’s in their professional development. You can learn more about this resource at www. dailylivingskills.com.

Marnie Courage, OT Reg. (MB)

Managing Director

Enabling Access

Many employees dealing with chronic pain are not ready to return to work following a long absence from injury or illness. Disability Managers and Rehabilitation Professionals have the task of determining barriers to occupational engagement and providing accommodations where needed, to assist employees back to meaningful work.  Occupational Therapists understand that one way we achieve meaning in our lives is through the intrinsic and extrinsic purpose that work can provide us.  Intrinsic purpose or motivation could be to master a task, feel good about the work we do, feel that we are contributing, with no ulterior motive. The extrinsic purpose or motivation may be to earn money, please a boss, or get a promotion.

Through Motivational Interviewing (MI), a counselling approach developed by clinical psychologists Professor William R Miller, Ph.D. and Professor Stephen Rollnick, Ph.D. (Miller and Rollnick, 1991), Rehab Professionals can work with an employee to address the intrinsic values that work provides, and assist them to challenge their fears, and self-imposed barriers to returning to work.  Common fears are that their symptoms will increase, co-workers’ and supervisor’s attitudes about accommodation, there will be new learning requirements, their replacement is doing a better job, etc.

Using MI to align the employee's values and goals with returning to work, Rehab professionals can help take employees who are at "Pre-contemplation" to the “Contemplation Phase” and right through to “Action Phase” of the Motivational Interviewing: Stages of Change, to reduce fears, and replace with an acceptance that returning to work will bring purpose, meaning, and promote engagement in activities that will lead to improved productivity in preparation for returning to work.

Returning to work can be a challenging endeavour for employees and their advocates for other reasons as well, such as having an employer who is not willing to make reasonable accommodations, the wait for physicians to send medical documentation, employee feeling pushed back to work before being ready, and many more. Using MI might just smooth the ride while navigating around these obstacles.

An Australian article review of MI outcomes in Return to Work suggests, “Whilst evidence for the efficacy of MI in clinical settings to motivate health behaviour change is strong, more research is needed to determine whether MI can be usefully applied to improve RTW and other work-related outcomes.”1

1. Kathryn M. Page and Irina Tchernitskaia (2014). Use of Motivational Interviewing to Improve Return-to-work and Work-related Outcomes: A Review . The Australian Journal of Rehabilitation Counselling, 20, pp 38-49. doi:10.1017/jrc.2014.5.

With only the few months of gardening weather we have in the Canadian prairies, it's important to make the most of the time we do have outdoors, which can create the "Binge Gardener" in some of us. Quickly getting our plants, veggies and flowers in after the first sign that frost has retired till fall, is a task most gardeners anticipate all winter and for those living in Manitoba, we often have to wait till June to be certain the frost gremlin will not rear its ugly face again till October sometime.

The trouble with binge gardening is that we try to do all the tasks to ready a garden, plant and nurture our new ground residents in concentrated doses, instead of spreading the tasks out over the growing season. The repetitive physical demands such as bending, squatting, kneeling, reaching, etc., involved in gardening can create musculoskeletal injuries, which can be harder to undo than a overflowing spread of Snow in the Valley that creeps into your lawn!

For folks who have mobility challenges, who are pregnant or are seniors who have energy limitations, this once beloved leisure love can turn out to be a source of pain and aggravation just as gardening  season gets underway. Here are some ergonomic tips and adaptations that might help you are someone you know who loves to garden, but hates the pain it causes.

1. Energy conservation - Break your gardening tasks up into tasks of 30 minutes or less to ensure you have energy to finish what you need to get done without wiping yourself out for the next two days.

2. Engage in Stretch Breaks - The muscles you use in your back, legs and arms are challenged by having to maintain awkward static positions and your hands and wrists are often grasping tools and plants while conducting repetitive tasks. It's important to stretch those muscles to offer relief and prevent stiffness and muscle fatigue

3. Drink plenty of water - While gardening bring out a water bottle of cold water to keep you hydrated and to keep your joints lubricated as you work. Remember if you feel thirsty, you are already dehydrated.

4. Sit on garden stool - For those who have difficulty getting on or off your knees, the tendency is usually to stand and bend from the hips to reach the plants or ground you are working on. This position creates undue forces on your lower spine and can cause low back muscle strain and aggravate the discs between your vertebrae.  Instead purchase a small stool to sit on as you plant or tend to your flowers to prevent low back musculoskeletal injuries.

5. Raise your garden - One of the best ways to prevent the bending and reaching that often causes back pain is to raise your garden bed. This is easily achieved by building a 2-3 foot border with wood or bricks around your garden and filling with the appropriate soil for your gardening zone. Planting in raised beds allows you to sit on your stool or mobility device and reduce the physical demands on your body.

6. Use hose with holes for watering - Gardeners can spend a lot of time watering their plants, especially during a dry season. Instead of lugging watering jugs outside, (which aggravates your shoulders and upper back) use an old hose, lay it alongside your garden and puncture holes along its length to squirt out water, eliminating the need to walk around grasping the spray nozzle and having to wrestle with the knots in the hose as you pull it along.

7. Use proper body mechanics- If you are using wheeled carts for transporting tools or plants, push instead of pull where you can, as pulling a cart behind you can cause injury to your shoulders.  When using standing tools like a rake or hoe or claw, stand with feet shoulder width apart, one in front of the other  and bend your legs while using your upper leg muscles (quadriceps, hamstrings and buttocks) instead of standing with straight legs and bending or twisting at your low back.

8. Hire help for the tough stuff- Although we would like to say we can do it all, doing it all sometimes does us in. Where possible hire someone to do the most physically demanding working like mowing the lawn or turning the garden beds in the spring. Save your energy for the fun tasks like planting, watering, and pruning, which will give you the gratification only fellow gardeners can appreciate, without the aches and pains.

Marnie Courage. OT Reg. (MB)

Managing Director

Enabling Access

marnie@enablingaccess.ca

There is a growing demand for Life Care Planning or "Future Cost of Care Analysis" as we refer to it in Canada.  A life care plan is defined as “a dynamic document based upon published standards of practice, comprehensive assessment, data analysis and research, which provides an organized concise plan for current and future needs, with associated costs, for individuals who have experienced catastrophic injury or have chronic health needs" (International Academy of Life Care Planners, 2002, Standards of Practice. Journal of Life Care Planning.1 (1), 49-57) The cost of these documents varies based on geographic location and the experience of the Life Care Planner. In Canada you can anticipate costs on average to run anywhere from 20-60 hours of billable time for a catastrophic injury at anywhere from $90-150/hr. An even higher rate is typical for court appearances.      

Life Care Plans are prepared by many disciplines including Nurses, Physiotherapists, Occupational Therapists, Kinesiologists, and more. There is now a certification for Life Care Planners, and companies are popping up everywhere dedicated to providing this service exclusively. Typically, these Life Care Plans are required for judicial/forensic use when determining compensatory damages and assisting the court in assessing the disability. They are also prepared for clinical use as a cost effective case management tool to help clients prevent future injuries, and they provide details how the plan can be implemented - a road map of the future for the individual and family. Insurance companies also request these Life Care Plans for making decisions regarding optimal allocations of resources for the client.

The Life Care Plan is usually required for individuals with catastrophic Injury (Brain Injury, Spinal Cord Injury, Amputation, Low Vision, Burns, Multiple Orthopedic Injuries, etc).  When sourcing out professionals to conduct the Life Care Plan, ensure that the approach used by the Life Care Planner is neither Plaintiff Oriented or Defense Oriented, and instead is "Needs based" to ensure a fair and defendable product. All recommendations should maximize the individual's level of independence and ability to participate in society, and prevent functional deterioration and medical complications.

If you, or someone you know has filed a personal injury claim or if you are a case manager or lawyer who deals with catastrophic injury cases, knowing what you get from a Future Cost of Care Report or Life Care Plan is essential in ensuring that the best interests of the client are being addressed. If possible, hiring a Life Care Planner who resides in the same city as the client will save you money as they will have good knowledge of local resources for the client, looking down the road at rehabilitation, housing, personal care supports and more. These reports need to be defendable in court and you don't want to have the Life Care Planner questioned about availability and quality of resources in an unfamiliar community.

Choosing an occupational therapist who provides rehabilitation services to catastrophic injured clients will give you peace of mind, knowing they have the practical knowledge of physical and mental rehabilitative needs for these clients.  Remember, the final product is not just a document, but you are also paying for the author to potentially appear in court, be professional, fair and be able to articulate well the defense of that document regardless of being on the plaintiff or defendant side of the courthouse.

Marnie Courage, OT Reg (MB)

Managing Director

Enabling Access

marnie@enablingaccess.ca 

Work Hardening in the rehabilitation world has widely been used to assist people with regaining physical capabilities in efforts to return them back to work, following injury or illness. We are seeing more and more people suffering from mental health issues, either as a result of having to live with their physical disability or from injuring or ending someone else’s life.

Rehabilitative treatment for clients who are physically injured may involve Work Hardening in a clinic setting to improve strength, coordination, endurance and pain tolerance, with their simulated job tasks. Often clients make good improvements in this type of intensive treatment program. Unfortunately, once they complete the program some folks still have difficulty returning to work, due to their mental health status.

Symptoms of depression, anxiety and anger are common barriers to successful Return to Work experiences. In these cases, clients are usually sent for psychological consult, to determine if regular treatment sessions are warranted. After much time, many beneficial sessions and several attempts of returning to work, we still see these clients struggling to work at the capacity they did prior to their accidents.

Cognitive Work Hardening is like the physical Work Hardening we see in the clinic, but it is conducted by an occupational therapist who works closely with the client in their place of work. The goal of Cognitive Work Hardening is to walk with the client, through their daily tasks, evaluating potential challenges, barriers and triggers that may result in exacerbating their symptoms of depression, anxiety, anger or other emotional distress.

In Cognitive Work Hardening, we can assist our clients by providing strategies for managing work flow, simplifying processes, dealing with coworkers, providing recommendations for clustering  like-energy tasks,  incorporating mental breaks, thought blocking, self-talk, and much more. The common goal is to increase productivity, motivation, confidence and reduce emotional pain and non-productive thinking that stems from emotional distress.

Just because the accident or incident that caused the client to be off work is in the past, doesn’t mean it's not presently running through that client’s mind several times a day. It takes both Body and Mind to heal from injury or loss and we should make sure we are treating both in our rehabilitative programs.

Marnie Courage, OT Reg (MB)

Managing Director

Enabling Access

marnie@enablingaccess.ca

Even after practicing occupational therapy in Canada for 11 years, I still have a hard time defining what I do in one sentence. The profession of Occupational Therapy (OT) has been around since the First World War, as we provided wives of husbands, who were off at war, the skills to make them employable in previously male dominated industries. We also assisted the injured soldiers with relearning their "activities of daily living" (a term adopted by the profession to describe all tasks related to self-care, productivity and leisure).

Since then, the profession, which has grown worldwide, includes rehabilitative therapy for people living with disability throughout the lifespan, from infancy to death. OT's can specialize in a variety of practice areas including the treatment of clients with Mental Health conditions, orthopaedic injuries, spinal cord and brain injuries, the science of Ergonomics and the effects on people, acute hand injury intervention, neonatal care and much more. Through education and skill building we teach injury prevention techniques at work and home, which many companies and groups are benefiting from.

Most Canadian OT's are now graduating from a Master’s Program in schools of Medical Rehabilitation within the faculty of Medicine, along with other allied health professionals, such as physiotherapists. Our academic credibility is supported by the vast amount of research that comes from the profession of many hats, making strong contributions to the medical research community. For more information about the profession, please visit the Canadian Association of Occupational Therapy at http://www.caot.ca

It might seem surprising that most insurance companies do not recognize OT as a basic insurable service, as they do with Massage Therapists, Physiotherapists, Chiropractors and other allied health professionals. Some insurance companies have included OT in their extended health packages, but often these limit coverage to one visit per year or the equivalent in maximum limits. The Canadian Association of Occupational Therapists have been fighting the battle for many years to get the recognition we deserve in the eyes of the insurance companies, with only minimal success.

In speaking with insurance companies locally, it is clear that their members are not asking for the services OT's provide, unless they have a family member with a disability or they themselves have been injured. Unfortunately, like any other insurance coverage, you many only see the value in it following a loss, like house insurance if your house burns down. These insurance companies only include services the majority of their members are requesting they cover.

We need to do a better job, at least in Canada, to educate people about how occupational therapy can help people following an injury, medical diagnoses, or in later life when the physical changes with aging affect mobility and independence. People need to start requesting that their insurance providers cover the services that they or their family member may urgently need one day. We also need to do a better job of marketing the profession. You have seen commercials for Physiotherapy and Chiropractors, but have you ever seen a commercial about Occupational Therapy? Instead of blaming my association for not putting enough resources into marketing and advocating our profession, I am doing my part to spread the word.  OT's are building skills for living, and its time everyone knew what we do and how we can help them.

Here is my best stab at a one sentence definition of what an occupational therapist does: "Helping people to be as healthy and independent as possible in all areas of living, at home, work and play, throughout the lifespan." I would love to hear how you define what OT is or how it has helped you, a friend or family member. I will post a collection of definitions titled "What OT Means to Me" that can be used in our national campaign to have OT recognized by the majority of insurance companies as a basic insurable service.

Marnie Courage, OT Reg (OT)

Managing Director

Enabling Access

marnie@enablingaccess.ca