What is the difference between Occupational Therapy (OT)
& Physiotherapy (PT). This is a question often asked by parents. What is
Physical Therapy?
Physiotherapy is the same as Physical Therapy (used in the
USA).
Although being 2 different areas of rehabilitation, PT and OT
overlap in every rehabilitation setting, more so in pediatric therapy. In the
USA, there is a scope of practice for each of them, delineated by boards,
organizations, and insurance companies. The PT and OT roles vary state wise,
practice wise, and may slightly change periodically.
Having said this, PT & OT are not watertight
compartments. PT is foundational to improving mobility and function; OT is
foundational to functional occupation of the patient. Broadly speaking, PTs
deal with the lower body, gross motor, mobility, transfers, breathing exercises,
and endurance. OTs work on the upper body, fine motor, writing, dressing and
other activities of daily living (ADL). Addressing cognition and feeding overlaps
between OT and speech therapists.
Speaking about the overlap in adult rehabilitation, PT &
OT both work towards improving transfer mobility of patients i.e. transfers out
of bed, transfers from bed to chair, transfers sit to stand, and transfers from
wheelchair to toilet seat. While working in the USA, I have worked on transfers
on a regular basis, either along with an OT, or each of us has done the same
with an aide (based on staff availability).
When it comes to children, there were many tasks that
overlapped between PT and OT. For eg. rolling, sit-stand transfers, sitting and
standing balance tasks would be done by each therapist during different
sessions. Or during a co-session, PT would address postural control, while the
OT would work on fine motor, cognition, visual skills at the same time. If the
PT sat a child / adult on a therapy ball, the OT would work on eye-hand
coordination at the same time.
While in the USA, as a PT, I would still offer a vision-perception
or a fine motor task (e.g assembling a puzzle, fixing pegs on a foam board) during
PT sessions but working on visual skills would not be my stated goal. An OT
would work on vision-perception tasks.
PTs deal with muscle tone, core stability, and postural
deviations that contribute to other areas such as vision, proprioception, and
ultimately learning. The foundations of core strength and endurance that are
addressed through play can contribute to improved handwriting. When we look
closely at children with ASD, a large majority will have issues with muscle tone,
core strength, balance, and endurance.
Scenario in India While nations like USA can afford to have PT & OT both
due to economics and availability of therapists, the situation differs
significantly in India, where there is a shortage of pediatric PTs as well as
OTs. in proportion to the population. India is a vast country, with many small
cities and towns where PT and OT is just starting to grow in the last decade.
Activ Kaarya Parents of young children are referred to Activ Kaarya with
concerns about their child such as motor, sensory, feeding, behaviors, lack of
sitting tolerance, difficulty with coping in the classroom. I am a pediatric PT, with a long experience of
working in the USA alongside OTs. Because of my training in Sensory Integration, as well
as teaching hand and chewing-swallowing biomechanics as a faculty, my practice
comprises a holistic approach of addressing both – motor & sensory
components in therapy sessions. What I cannot do and if the child needs it, I will
refer out to another professional as per ethical practice, eg. Oral Placement
Therapy.
I would like to convey to all therapists in
India, whether you are a PT or an OT, try to look at the child as a ‘whole’
entity. Consider all domains of development - motor, sensory, feeding, communication, cognitive, and socioemotional.
It can be
quite puzzling to parents when their child of 3-4 years demonstrates issues
with communication, behavior, and may have difficulty settling in nursery
school. There are a number of children who have well developed speech and yet
display impulsiveness or lack of attention or anxiety, that become a barrier to
academic learning.
As a
sensory-motor therapist, I have many questions for parents when I first see a
child of 3-4 years, with a diagnosis of autism or yet no diagnosis at all. There
is a certain pattern of responses that I hear from parents; something that conveys
to me that parents need more explanation about what they see in their child. Most
parents report that their child is walking, all milestones were achieved, and all
motor development is fine. But speech is the only concern; there has been
difficulty with attending a nursery school due to atypical behavior.
I urge parents
to think beyond this superficial knowledge of motor development. It is important to know that achieving
milestones or certain positive behaviors is not adequate. Remember that
development is much more than checking off milestones. The list of milestones
should be used only as a reference that the child is developing appropriately.
Just as you need to ‘read between the lines’ in a paper, a parent should
observe the child in subtle ways regarding their eye contact, comprehension,
and feeding. Besides these, a skilled therapist observes many other components
such as quality of movement, how’ are the motor skills accomplished, behavior, and
cognition. In a nutshell, the therapist is assessing the child’s sensory-motor
development.
My child crawled a lot during
childhood. Although the CDC (Center for Disease
Control and Prevention, USA) has removed crawling as a milestone in 2021-22, it
does not mean that we give up on crawling. Crawling can be done as a form of
meaningful activity, even if the child is little older. Experienced therapists
(including myself) see crucial values of crawling such as better reflex
integration, improving core strength, depth perception, cognition, and hand
arch development that impacts their writing in UKG.
My child can do all movements. Does the child squat, bend, or engage in various movements frequently through the day to pick up objects and toys from the floor? Just
because he squats or bends occasionally to retrieve objects from the floor,
doing the same is not finished. Think about your own life as an adult, each of us has learnt to walk
decades ago, but we still need to continue to walk daily, consistently, and on
different surfaces.
The same
with children. If they have learnt one movement, it is not over. They need to
engage in that movement in various ways, many times a day, over months.
Eye contact is good with mother at
home, but not with people outside of home. Since the mother is with the child
all the time in a safe place called home, this is likely. Although eye contact
can be better in the home environment with parents, it cannot decrease drastically when the child steps outside of home. Also, mother is not going to be with the
child forever and everywhere. More importantly, remember that eye contact is a
reflection of the vestibular-visual systems.
My child will eat by herself if
given snack items. She understands everything, she will climb to the kitchen
counter when she wants juice and biscuits. Snack items cannot be counted as ‘real
food’ because they have poor nutritional value and should not be consumed daily
and frequently. As a clinician, I look into whether the child is touching mushy
foods, using fingers or a spoon, bringing them to the mouth, chewing it or just
gulping down. The Indian cuisine abounds in a large variety of foods that are
cooked consistently in every family. Is the child consuming various food
textures? It gives me an outline of their oromotor area functions, in terms of
tactile sensitivity, proprioception, and vestibular system.
Reaching
out for snacks and juice does not mean the child understands everything. She is
only reaching for the food items that she likes. Human babies and children cry
or display a tantrum when they are hungry. They will look for foods that can be
gulped down easily. This is a need for survival.
My child climbs and is not afraid. Is the climbing meaningful? Do they
climb a ladder in the park? Do they engage in stair climbing at home on a daily
basis? If they are climbing on sofas, furniture, or a parents’ lap constantly –
it is not meaningful. It is a proprioceptive seeking behavior, which means that
their proprioceptive system has not been well developed, and they will
demonstrate decreased body awareness, decreased body spatial awareness, and cannot
gauge the force with which they are holding objects.
My child has good balance, never
falls. Not falling is not a sign of good
balance. The child may not be challenging themselves adequately, which is
required for development. Good balance is when they walk on a balance beam,
walk on uneven surfaces, climb various surfaces at home and in the park.
My child does everything, physical
development is very good but doesn’t speak. Although your child is walking and
major milestones may have been achieved, they may still present with low muscle
tone, poorly integrated reflexes, and decreased balance. They may not readily
bend their body or have a good trunk rotation. These are all suggestive of an
immature nervous system.
If the
child is minimally speaking random words or is nonverbal, the best place to
start is sensory-motor therapy. A good program of sensory motor therapy improves
their understanding / comprehension of the relationship between their body and
the world around them. This comprehension is one of the basic steps of
communication.
My child knows the basic colors and
can fix puzzles. Is the child matching colors to a
board, matching in different games (not just 1)? Is the child matching and
orienting puzzle pieces without too much prompting?
Is the child engaging in different
varieties of puzzles?
All of these reflect vision-perception
and fine motor abilities.
My child is very smart because he
can remember car models and nursery rhymes. These may not necessarily be an
indication of high cognition. Remembering and knowing certain things can be accomplished
by rote learning too.
The child
needs to be looked through a ‘whole’ perspective that involves many components
of development.
My child can write 1 to 100, and do
addition on a tab. In my long years of experience, I
have seen many children with autism who are not able to put 10-20 objects from 1
basket to another, although they write numbers. That means that they have
learnt to write 1-100 when it is done consistently but have not understood the
concept of numbers.
Concept
based learning has to develop. Also, fine motor skills of tearing, cutting,
buttoning have to be developed before schoolwork. Ample research shows that
fine motor skills are related to academic learning.
My child knows everything, so can be
enrolled in regular or inclusive school. There is a difference between
knowing and applying in the real-world situation. Moreover, behavior of the
child matters a lot. Sensory and motor issues at home or clinic may seem mostly
resolved. But the issues become magnified if the child is in a noisy and busy
classroom of 25-30 children, and more academic demands are placed on the child.
This leads to behaviors of throwing objects, crying, roaming around, and tantrums
are observed to resurface.
Therefore,
school enrollment has to be well thought over on a case-to-case basis, and
during different time periods. Presence of a shadow teacher helps but may not
always be the case.
Summary
Most
issues with behavior and communication are rooted in sensory processing
differences (SPD). Lack of adequate sensory development leads to poor motor
abilities.
It is important to know what and how
therapists observe / test and analyze the child’s performance in relation to
sensory-motor systems. And what parents need to understand at their end.
A thoughtful discussion based on
parent’s thoughts and reports combined with therapist observations becomes
imperative in knowing the strengths and weaknesses of the child and becomes a
place to start a good therapy program.
#behavior #sensory #motor #development #speech #communication #child development #cognition
