Partnersin Health

DENTAL DIPLOMACY 6

AT THE HELM 9

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UNIVERSITY OF SOUTHERN CALIFORNIA FALL 2006

DENTAL DIPLOMACY 6

AT THE HELM 9

SEARCH FOR ANSWERS 11

Partnersin Health

In July 2006, the USC School of Dentistry entered into an alignment withUSC’s programs in Occupational Science & Occupational Therapy andBiokinesiology & Physical Therapy, creating a unique partnership. Withthe elimination of Independent Health Professions, the administrativehome for the two departments, the Provost appointed me as the actingdean for the programs last September. Faculty and administrators of thethree programs engaged in a discovery process to determine if such analignment should be made permanent. The answer was a resounding,“Yes,” and I couldn’t be happier.

A shared vision emerged from this exploratory process. Workingtogether, we look forward to providing an interdisciplinary model forpromoting health, preventing disease, addressing health and healthcaredisparities, and providing evidence-based, patient-centered care acrossthe human lifespan. We all agreed that each program would continueto pursue its independent academic agenda, and faculty study groupscame up with eight different opportunities for collaboration based onour collective expertise.

One such opportunity is the prevention of musculoskeletal pain anddisorders in oral health practitioners—a collaboration that is alreadymoving forward. The combined expertise of Jacquelyn Dylla, directorof PT Associates on the University Park Campus, and Jane Forrest, chairof the school’s Division of Health Promotion, Disease Prevention andEpidemiology, created a guide to posture and positioning aimed atpreventing chronic pain and disability that often afflict oral healthprofessionals. Their article appeared in the March 2006 issue of ACCESS,a publication of the American Dental Hygienists’ Association. Workingwith Diane Melrose, the preventive strategies are being translated into our dental hygiene curriculum, utilizing technology fundedby a grant from USC’s Technology Enhanced Learning Incentive Program.

The creation of a USC Institute for Health and Wellness, in underserved and high-risk areas, and a Clinic for Health and Wellnessis another opportunity. We envision the multidisciplinary institute as a site for large-scale research programs focusing on societalneeds. The clinic would serve as a site to test ideasgenerated by the institute’s research. In the clinic,the dental checkup would be a patient’s point ofaccess to a range of preventive services.

This alignment positions us to be more responsive to funding priorities and federal healthcare initiatives. These priorities andinitiatives call for addressing critical societal issues in health and health care, and for redesigning the healthcare delivery systeminto an integrative model that has as its mandate patient-centered, evidence-based care delivered by interdisciplinary teams.

This alignment is still very new. As we work out the details, we are committed to preserving the identity of our three outstandingprograms and, at the same time, providing a model for integrated health care that better serves individuals and society.

—Harold C. Slavkin, D.D.S.G. Donald and Marian James MontgomeryProfessor of Dentistry

There are times in life when opportunity knocks and offers a chance to move forward in a way that

alters our perception and opens doors to new possibilities. This past year was one of those times.

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ALIGNMENT

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Partnersin Health

WeK interdisciplinary relationships for research, education andpractice with units inside and outside USC — locally,nationally and internationally,

K research, graduate programs and professional practicesthat bridge theory and practice,

K learner-centered educational programs for professional,graduate and continuing professional education,

K community health programs that serve the USCneighborhood and provide service-learning opportunitiesfor our students,

K a history of leadership in education, practice andresearch for our respective fields,

K engagement in biomedical sciences, health promotion,health literacy, risk assessment, disease prevention,and quality of life issues,

K impact on health and health care in diverse populationsfrom preconception to senescence.

each have

PTOTOccupation. It is a word that most of usassociate with our work—secretary,dentist, mechanic, homemaker. But, tothose in the field of occupationaltherapy, the meaning is much broader.To occupational therapists, occupationmeans activity—everything from washingdishes to playing the piano or surfing thewaves at Malibu. When you think aboutit, you can’t help but be amazed by thescope of their practice.

By their own definition, occupationaltherapists evaluate, use and adapteveryday activities to improve function,enhance performance, promote health,and prevent illness and disabilities. Theytreat patients and clients of all ages,backgrounds and walks of life, teachingthem occupational skills from rehabilita-tive arts and crafts to positioning thekeyboard at their desks to the correctheight. You’ll find them in hospitals,community centers, skilled nursingand mental health facilities, workplaces,schools, outpatient clinics and inindividuals’ homes.

USC’s occupational therapy program wasestablished in 1942 as a department inthe College of Letters, Arts and Sciences.From its earliest days, it has distinguisheditself as a pioneering program in theprofession thanks to its inquiring andinnovative faculty and the achievementsof its graduates.

USC’s Occupational Therapy programhas ranked #1 in the nation since 1998,when U.S. News and World Reportbegan ranking occupational therapyprograms. It is the only program in thecountry to offer all degrees in the field.The Bachelor of Science in OccupationalTherapy provides the opportunity forundergraduate students interested in thehealth professions to become familiarwith the field and to get a head start onearning a master’s degree. With a majorin occupational therapy from USC,students can earn a Master of Arts atUSC with one year of additional coursesand fieldwork.

The two-year master’s program,established in 1969, was the first suchprogram in the country. Students learnthe theory behind the practice of dealingwith psychosocial and physicaldysfunction. They also studyneurology and kinesiology, whichis the neuromusculo-skeletalfunctioning that allows us toperform our daily activities.

Getting into a shower, a task thatmany of us take for granted, may seemimpossible for those with balance andcoordination problems. Through taskanalysis, students learn to break downan activity into each of its componentsand then to put it back together again ina different way that will enable one to

reclaim this skill. These analytical skillsare also used in evaluating living andwork environments and in developingadaptive equipment that can assistpeople in living normal lives—everythingfrom accessing facilities in your homewhile confined in a wheelchair to usingspecially designed tools that are easierto grasp.

Students also learn how to design livesand living spaces to be maximally healthpromoting to prevent or lessen theimpact of chronic disease or disability.This may entail working with architectsto create smart homes, providingconsultation to Boomers on the optimal-supported living environment for theirparents or helping the Boomers them-selves live each day in a healthier way.

Clinical education is conducted throughfieldwork at over 500 sites throughoutthe country and abroad. Three weeks of

fieldwork are embedded in the first-yearstudents’ coursework. Second-yearstudents have 24 weeks of full-timefieldwork that are typically taken in twodifferent settings. Although no settingis required, disability and mental healthsettings are strongly encouraged

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Headquartered in the Center for Health Professions on USC’s Health Science Campus, the

school’s new divisions are at the top of their game with cutting edge practice, top-ranked

educational programs and research that is generating new knowledge and providing an

evidence base for practice.

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Occupational Science and Occupational Therapy

according to fieldwork coordinatorJaynee Taguchi-Meyer. She works withstudents to ensure their placement insettings that correspond to their interestsand that provide experiences withpatients in different age groupsreflecting a variety of disabilities anddiagnoses. International postings inplaces such as Romania and Ghana areavailable and popular.

For Jennifer Stokely, fieldwork providedthe essential link between a basic under-standing she’d gained and transferringit into practice. This summer shecompleted fieldwork at the Center forDeveloping Kids, a sensory integrationclinic. She had studied sensory integra-tion dysfunction—a neurological disorderthat interferes with typical processing ofsensory information—but hadn’t seenhow it manifests in children. “I walkedin the first day, a little worried, but thesecond I got in there, I was, ‘Oh, I see,

that’s what’s going on,’ and I just madethose connections,” says Stokely, whoearned her master’s this year and is nowenrolled in the clinical doctoral program.

The Doctor of Occupational Therapy(OTD) is designed to produce leaders inthe areas of clinical practice, healthcarepolicy and healthcare management. Aspart of the curriculum, students takecourses in the School of Policy, Planningand Development, which may bereplaced by coursework in other USCschools to better meet their particularinterests. Through the development ofindividual projects that involve need

assessment, program development,execution and evaluation, studentsdemonstrate the requisite skills toearn the degree. In the Ph.D.program, students are trained inthe scientific method and itsapplication to the study of humanoccupation. Rather than a focus ontherapeutic application, studentsare encouraged to contribute tooccupational science theory.

With the addition of the world’sfirst Ph.D. program in 1989, thefield of occupational science wasfounded at USC, providing, ascientific basis for practice and anew name for the department.Occupational science, an interdisciplinarysocial science, focuses on the relation-ship of daily habits, activities andpractices to health and well-being. Today,with federal funding and support fromother sources, faculty are pursuing

answers to someof the pressingquestions inthe field.

One such study,the NIH-fundedBoundaryCrossing studyled by MaryLawlor andCheryl Mattingly,is in its 10thyear and on itsthird project.The researchersare looking athow African

American children with disabilities andtheir families develop and change overtime and how healthcare practiceschange in institutional settings, likehospitals.

“Initially, we were interested inpossibilities of misunderstanding andmiscommunication in the healthcarecontext,” says Lawlor. But they soonrealized that health care was not onlypracticed in doctors offices or therapysessions, but in homes and other places,which led them to immerse themselvesin the families’ lives. Here they foundthat families have considerable

knowledge not only about what is goingon at home, but also about theirchildren’s condition and how best toimplement some aspects of health care.

The researchers began to rethink howthey looked at cultural competency inhealth care. Their conclusion was thatthe medical model in which theprofessionals are the experts can makeit harder to incorporate the family’sknowledge about the child’s condition.“So we are arguing,” says Lawlor,“that we need a model of how peoplelearn in the midst of the healthcareencounters so they have a more effectivecommunication in partnering up.”

In the current project, researchers havebeen struck by how much work familiesdo to understand biomedicine and howmuch they understand the cultural worldof biomedicine. Through collective narra-tives—families sharing their healthcareexperiences with each other—researchersare learning how families learn so muchabout the healthcare system andparticipants are learning how to ask forthings and ways to help the therapist ordoctor understand the family.

“We are going to do more withpractitioner collective narrative groupstoo, so that we understand more abouthow these ideas are getting into practicein ways that will make a difference,”says Lawlor. Some of what researchershave learned has been incorporated inthe curriculum, and they hope that,through their presentations atmeetings, it will impact other programs. O

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Ann Neville-Jan is studying ways to assistchildren with spina bifida in dealing withbowel and bladder issues, and evaluatingthe efficacy of current therapies. Thisinterdisciplinary research, funded by theAssociation of University Centers onDisabilities, includes a team of experts inepidemiology, nursing, occupationaltherapy, pediatrics, psychology andurology from centers in Los Angeles,Portland and Seattle.

At Childrens Hospital Los Angeles,co-principal investigator Neville-Jan andher colleagues use quantitative analysisto track measures of kidney function andthe treatments being used—whether ornot a catheter was used. They are alsousing questionnaires and focus groupswith children, ages five to twelve, andtheir parents to understand how thesetreatments work in real-life settings, aninfrequent practice.

She offers a simple example of the kindof social issues such children face. Kidswho use a catheter typically go to thenurse’s station for assistance when theyneed to use the bathroom and are ques-tioned by other children who wonderwhy they need to go to the nurse. Shesuggests that if children are trained toinsert the catheter themselves, they canavoid the awkward social consequences.

“We are bridging the medical modelwith what is happening out in thecommunity with people with spina bifidaso that those kinds of issues, the socialpart, can affect the change of treatmentsin the medical model.”

In a lab that looks more like a child’sspace ship, Diane Parham measureschildren’s responses to specificstressors—light, motion, sound. Forthe child pretending to control thespace ship, it is a playful experience,a frequently used technique inresearch and therapy with children.For Parham, it is an effectivemethod to gather information thatwill assist her in studying sensoryintegration, which links neuro-science with the activities andexperiences of children.

Her current study focuses on thepart of the autonomic nervoussystem that produces our fight or

flight responses and mediates theresponse by distinguishing between aperceived threat and a real threat.Parham’s research subjects are childrenwho experience physical sensationsdifferently than most of us, typically onesdiagnosed with conditions such asattention deficit disorderand autism.

“Some individuals aremore easily activated inthis way than mostpeople are, and it wasfirst identified in childrenalthough we’ve come toappreciate it’s a lifelongissue for many, manypeople,” says Parham.“The most commonproblems we see, we talkabout them as sensorymodulation problems,having difficulty regulat-ing your reactions toordinary sensory issues.”

A clicking sound for children havingtrouble modulating auditory sensationscan flood the senses and interfere withattention and concentration. This andother sensory sensations, such as touch,can produce a defensive response tosuch things as human touch or thetexture of clothing or food. Severesensitivity around the mouth can resultin serious nutritional problems and otherproblems such as requiring generalanesthesia in order to tolerate dentaltreatment. “A lot of these kids get

labeled as having behavioral problems,”says Parham.

Occupational therapy can help these chil-dren develop coping skills. Parham tells astory of an autistic child with a very highIQ and issues of control and obsession.The sensitivity around his mouth resultedin an eating problem that threatened hislife. The therapist created a game usingJell-O, which he could tolerate, and theywould alternate telling each other whatsize bite they could take. Then therewere games about what kind of food hecould eat. He would be told that, for amonth, he could only eat food that hadholes, allowing him to obsess on foodswith holes in them—donuts, cheerios,bagels—and it worked.

By the age of eight, children aredeveloped and sophisticated enough tolearn strategies to recognize and copewith distressing experience, andoccupational therapists have developeda curriculum to teach them how.

Left page: (top) Faculty member Julie Grayuses the sock-aid to enable patients toperform a daily activity despite conditionsthat restricts their ability to bend over;(bottom) Using games, faculty memberNancy Bagatell helps children developeye-hand coordination and fine motor skills.

This page: (top) Under the direction of a TA,master’s students play the role of therapistand patient while learning to use a transferboard to move a person from a wheelchaironto a shower bench; (bottom) Teachingassistant Elizabeth Cabrera instructs M.A.students on making customized splints tostabilize the thumb joint for patients withconditions such as tendonitis.

In 1997, with the publication of theUSC Well Elderly Study in the Journalof the American Medical Association,the profession began to re-examine itstraditional focus on rehabilitation and tostep into the realm of preventive therapy.The three-year, groundbreaking studyexamined the effect of customizedoccupational therapy sessions on aculturally diverse group of individuals age60 and older. The results demonstratedthat seniors who receivedthe personalized interven-tion showed improvedhealth and well-being thatwere sustained over time,making it cost effective.

With the publication in1999 of Lifestyle Redesign:Implementing the WellElderly Study—one of 13publications that came fromthe study—occupationaltherapists now had a guideto integrating the study’sfindings into practice. AtUSC, faculty were busydoing just that. “We beganto apply the concepts andthe intervention to a varietyof other domains. So weopened up the LifestyleRedesign® weight-lossprogram at USC that ishoused in our facultypractice,” says FlorenceClark, primary author onthe original study and theoriginal practitioner in theweight-loss program.

Many of the programsinitially developed from thestudy now represent most of the therapyprovided through the faculty practice. Inaddition to providing several LifestyleRedesign® group and individual therapysessions, the Motion Picture andTelevision Fund sponsors the weight-lossprogram for those they insure, and USCNetwork covers costs for USC employees.

Among the other practice programs is astudent-support Lifestyle Redesign®

program through the Student HealthCenter. Mary Kay Wolfe, a member ofthe faculty practice, directs this program

that helps students deal with thetransition from family life to college lifeand with college-related stresses. At theUSC’s Executive Heath and ImagingCenter, Katie Salles-Jordon, director ofthe faculty practice, offers LifestyleRedesign® for stress management anddoes lifestyle risk assessments for clients.

The newest Lifestyle Redesign® programis for pressure ulcer prevention in peoplewith spinal cord injuries. When these

painful ulcers develop and are leftuntreated they can lead to surgerycosting up to $60,000. The techniquespatients learn to prevent pressure ulcerdevelopment are effective, but not alwayspracticed regularly. The availability of thisLifestyle Redesign® protocol for pressureulcer prevention will position therapiststo work with clients to establish routinesthat will engage them in preventiveactivities as part of their daily lives.

Clark, working this summer with expertsfrom the USC Marshall School of Business

and others, trained life advisors who willserve guests of the California Well-beingInstitute scheduled to open in fall 2006.The Institute, inspired by the keeninterest in health and well-being of DolePineapple owner Donald Murdock, willinclude a high-end, Four Seasons Hoteland spa with a wealth of sports, workoutfacilities and health-promoting extras.USC-trained life advisors will work withguests to accomplish their individual

goals during their stay and todevelop a personalized lifeplan that will extend beyondtheir stay.

The original and follow-upstudy demonstrated thatthe Lifestyle Redesign®

intervention worked to slowage-associated declines, butresearchers don’t know why.In a new NIH-funded studyof 440 multiethnic eldersreceiving Lifestyle Redesign®

interventions, Clark and hercolleagues are now studyingthe factors that they believeaccounted for the positivechange in physical well-being. They are also lookingto see if Lifestyle Redesign®

also supports bettercognitive outcomes,an area not covered in theoriginal study.

“So, when somebody beginsto live in a way that ismore customized to theirneeds and is more active,what changes? And, is itassociated with the positivehealth outcomes?” saysClark, who is measuring

stress-related biomarkers using cortisolin saliva.

“All of my research is really about lifedesign,” she says. “That’s what I amcalling it now, not so much LifestyleRedesign®, but life design.” WhetherLifestyle Redesign® or life design—it’swhat occupational therapists do.

During her internship in the faculty practice,M.A. student Camille Dieterle teaches yogaas part of the Lifestyle Redesign® programs.

An acute stroke would be a catastrophic event in the life ofanyone, but when that individual is a professional in the prime

of her career and an athletic outdoorswoman, the loss of functionis utterly devastating. Fortunately, this individual was a colleagueof Florence Clark, chair of the Division of Occupational Scienceand Occupational Therapy. And fortunately, Florence Clark is notthe type of person to stand idly by while a friend suffers.

What Clark saw was a woman go from being fiercely engaged inlife—”a kayaker, nature-lover, a real fighter with a tremendoussense of what is fair and just”—to a complete standstill. Sheknew she had to get her moving. “I came up with the idea thatthe key to enabling a person to reclaim their lives was to tap intotheir character, which is shaped by what they have done in theworld up until their injury or illness,” says Clark.

Her approach worked. Working closely with Clark, her colleaguemanaged to reinvent and reinvigorate her life based on pastexperience. She had a new life, and Clark had a new methodology.Dubbed “lifestyle redesign”—a term that is trademarked by Clark,her co-investigators and the university—the new approach wasutilized in 1994’s USC Well Elderly Study.

Clarks says her approach is derived from her training in the artsand humanities. In 1968 she received her Bachelor of Arts inEnglish with a minor in speech drama from the State Universityof New York at Albany. From there, she completed her Master’s inOccupational Therapy at SUNY-Buffalo in 1970.

By 1972 she was working at psychiatric facilities for youth whowere at-risk or suffering from severe mental health problems.Drawing upon her arts background, she utilized acting, puppettraining and other creative activities as therapy. Later, as a thera-pist for developmentally delayed adults and children, she wouldutilize sensory integration techniques that engage patients in thephysical spatial world and are thought to provide a foundation forhigher cognitive functions and assist in the acquisition of language.

This approach intrigued Clark and she decided to study itseffectiveness. USC faculty member A. Jean Ayres, who figurative-ly and literally wrote the book on sensory integration, served asproject consultant. This fortuitous meeting led Clark to accept aposition as assistant professor at USC’s Department ofOccupational Therapy in 1976.

In the 30 years that followed, Clark has worked her way into thevery fabric of the university. In 1982 she received her Ph.D. inEducation from the USC School of Education. Two years later shereceived her first grant, and in 1993 she received one of the veryfirst National Institutes of Health grants that funded occupationaltherapy research. She became chair of the Department ofOccupational Therapy in 1989 and has since led the program toits current number #1 national ranking.

A self-described “connector,” Clark stirs many pots both at USCand abroad. She has served as consultant to numerous govern-ment, professional and private entities including the NationalCouncil on Aging, the NIH’s National Center for Medical

Rehabilitation Research, the U.S. Department of Education and theDepartment of Health and Human Services. She recently learnedthat, through European Union funding, Lifestyle Redesign® is beingadapted to cultures in the UnitedKingdom, Norway, Georgia,Portugal, Belgium and theNetherlands.

At USC, she is not only a familiarface on projects such as the HealthCare Collaborative, but is alsoheavily involved in the AcademicSenate, having served on itsexecutive board and as lead authorof the Community and AcademicLife publication, The EngagedUniversity.

For the past four years, Clark andher husband have made their homeon the University Park campusliving with 268 freshmen at theNorth Residential College, whereshe is faculty master. She alsoserves as academic advisor to thePi Phi sorority. “I love being withyoung students. I really enjoyinteracting with them,” says Clark.

In 2004 the university recognizedher many contributions byawarding Clark the PresidentialMedallion—USC’s top honor.Among her many professionalawards, Clark received the 2001Lifetime Achievement Award fromthe Occupational TherapyAssociation of America, and in1993 she was the Eleanor ClarkeSlagle Lecturer for the AmericanOccupational Therapy Association,the association’s highest honor.

Despite her many accomplish-ments, Clark is by no means restingon her laurels. In addition toseveral current lifestyle redesignprojects and her duties as divisionchair, Clark is enthused about theprospect of collaborative efforts atthe School of Dentistry.

“I think that this is going to lead to incredible intervention inhealth care. People need to be treated holistically, not as a seriesof body parts. My work has always been taking care of themind, body and spirit, and this alliance will build on that focus,”says Clark.

Redesigning Woman by Ben Creighton

A revolutionary force in the field of occupational science, Florence Clark has blended art and scienceto reinvent the role of the occupational therapist.

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Florence ClarkAssociate Dean and Chair,Division of Occupational Scienceand Occupational Therapyat the School of Dentistry

Florence ClarkAssociate Dean and Chair,Division of Occupational Scienceand Occupational Therapyat the School of Dentistry