Social Determinants of Health and the Nervous System

     Social Determinants of Health (SDoH) are where people spend the majority of their time and include the conditions that they live, work, eat and sleep. It also includes social supports, socioeconomic status, and access to healthcare. Simply it is what makes people sick. However, when you go to the doctor, you don't get asked about your SDoH even though they can be traced back to an illness especially ones affecting you nervous system. For example, if you are having to work 2 jobs to be able to pay for food and rent every month you will be in a constant state of stress. When you are in this constant state of stress, the amount of cortisol being released will negatively affect your entire brain. Cortisol will decrease the number of neural connections in your hippocampus, enlarge your amygdala and even make your PFC completely shut down. If this state of stress become chronic it will lead to your brain not working at full capacity, having more trouble making decisions and controlling behavior.
     As it becomes more difficult to control behavior and make decisions, you will find yourself making impulsive decisions and not using logic. Impulsivity can become dangerous and lead to addiction when alcohol, drugs, and unsafe sexual practices are involved. Addiction causes you not to be able to control your body's decisions despite their negative consequences. Addiction to alcohol may result in cirrhosis of the liver and acute liver failure and even death. Addiction to marijuana may lead to abnormal neural connections that affect reward, cravings and thought control and affect thinking memory and learning. In all cases of addiction, the brain's reward system and regions that control judgment and decision-making are negativity affected.
     In the TedTalk by Rishi Manchanda, it is reported that heart disease was linked to green space. Meaning that the closer you lived to green space like parks and trails for fresh air, the lower your risk of heart disease. These numbers were collected throughout a broad spectrum of neighborhoods, so not matter how rich or poor you were it still held true. Which leads to the conclusion that zip codes matter more than genetic codes. The social determinants that you are made of are the reasons that you are who you are and why you get sick the way you do.
     Being a student in UTHSC's MOT program requires a certain amount of public service and professional development hours to be able to graduate. These hours have helped prepare me to be the best possible practicer by pushing me out of my comfort zone. Many opportunities require meeting people you do not know and who you would normally not be in contact with. This enhances my social skills and being able to adapt to any situation that is thrown my way. It has also help with my advocation of OT and perfecting my elevator speech for numerous different populations. Now I am able and confident in being able to inform members of the community or anyone I am in contact with what OT is and why I have such a passion for it.
   

Locomotion & Adaptive Devices

     Our clients will put their trust in us as OT's to do what is best for them in order to help reach their goals. So, when adaptive devices are needed, it is imperative to make sure that we know how to properly fit them for many reasons. First, each client will have unique body mechanics and measurements and the adaptive device needs to be specific to them to ensure safety at all times. Second, correct measurements will not allow additional pain or injury to prevent conditions such as pressure ulcers. Knowing the client's limitations and capabilities including their physical conditions, age, endurance and psychological condition will allow us to make the safest and most appropriate adaptive device decision.
     If the client is stable on their own but needs occasional assistance with balance, a cane would be appropriate because it provides the least stability of all the ambulation assistive devices. Different variations of canes include standard, with one leg, and wide or narrow base quad canes which provide four prongs for increased balance compared to just the one on a standard cane. To properly fit a client for a cane, the hand grip should be at the level of the ulnar styloid, wrist crease, or greater trochanter. The client's elbow should be relaxed, flexed 20-30 degrees and shoulders should be relaxed and not elevated in order to grip the cane easily and most comfortably.
     Another device that a client could need to provide more stability than a cane are crutches. One of the types of crutches are Axillary crutches and, to properly fit the client, all of the same criteria of the cane are used with addition to the axillary rest being 5 cm below the floor of the axilla when the shoulders are relaxed. This is important to note because contact with the axilla area can result in increased pressure and potential damage to the Brachial Plexus. Another type of crutches are the Loftstrand crutches. These are used for clients that have long term disabilities and need more support than a cane provides, but less support than the previously mentioned axillary crutches. These crutches require the correct fit of the cuff around the proximal forearm along with the correct hand grip fit, which is the same qualifications of the cane and axially crutches.
     As the client's need for stability increases and canes and crutches are no longer provide enough, walkers are the best option. The same criteria is used when fitting walkers as it is used for canes. Walkers provide three or four contacts with the ground and vary in amount of stability based on the different types. One type of a walker is the platform walker which is used for a client that is unable to bear weight though wrist or hand because of a fracture or other injury. It is important to correctly fit where the trough or platform supports the forearm to ensure comfort and no further damage or injury to the forearm. Another type of walker that can be used is the rolling walker. Rolling walkers are the same as standard walkers however, they add wheels.The addition of wheels is ideal for a client who is lacking the UE strength to lift a standard walker but still needs multiple contact points for support.
   

Hierarchy of Mobility Skills

The order for restoring confidence follows the hierarchy of mobility of skills goes as follows: bed mobility, mat transfers, wheelchair transfers, bed transfer, functional ambulation for ADL, toilet & tub transfer, car transfer, functional ambulation for community mobility and finally community mobility and driving. This hierarchy is what I expected because each transfer has an increased activity demand compared to the step before it. This means that each transfer is building on the skills and abilities needed for the previous transfer with the ultimate goal of full community mobility and even driving. You will not be able to perform a bed transfer if you cannot first move, slide and lift your self in the bed so that makes sense why bed mobility is first and bed transfers are later on. In the time I spent shadowing, and with the new information we have gained regarding transfers, I witnessed numerous components of this hierarchy including just the basic bed mobility to slide up in bed or to roll over in order to change the sheets or place a bed pan under the patient. I also saw transfers from the bed to the walker to the toilet to perform ADL'S, but that not past that stage. However, these observations made me agree with this order and how each skill builds upon each other. This course has taught me the importance of body mechanics not only for myself but also for the success of my patients. I am excited to learn more and start to use this new knowledge soon!

Posture & Body Mechanics

As occupational therapists, we have a dual responsibility to our clients. We must teach them the proper principles when lifting, reaching, bending and pulling and pushing and we must provide modifications to tasks to promote good body mechanics and alignment. It is important to teach clients about proper posture and body mechanics because in 2016, the back was the most common body part to be injured. It is also known that 8 out of 10 adults will have low back pain at some point in their life. This back pain, that 80% of people will experience, is caused by poor posture, faulty body mechanics, stressful work habits and a general lack of physical fitness. Once you have injured your back, it has been reported that 90% of back pain is recurrent, so it will continue to bother you. However, it is shown that when using ideal body alignment and posture, there is a muscular and skeletal balance, optimal functioning of the organs and minimizes the risk of progressive deformity.   

To teach clients about the proper body mechanics I would explain the importance of knowing the correct way of lifting objects safety by keeping the objects as close as possible, keeping a straight back, using leg muscles instead of back muscles and taking multiple trips to lighten the load. I would demonstrate how to do this, have them practice and then print a worksheet that they could have to remind them of the steps of proper lifting. I also teach them the slouch-overcorrect technique to demonstrate ideal sitting posture by demonstrating it and then having them practice it as well. This will inform the client on how to get into the ideal sitting posture and how it should feel. Along with the proper sitting posture I would let them know of modifications that can help maintain this posture like pillows, towels or ergonomic chairs. It is also important to educate clients on how important maintaining a healthy body weight is and exercising regality is to decreasing their risk of injury!  

What Commercials do to My Nervous System

     Whenever you sit down to watch a show or game on T.V., it is a known fact that there will be commercials. Commercials about food, cars, phones and games. Some commercials you've never seen before and some you feel like are being played on repeat. But for me, there is always one commercial that I will never forget and always sticks out and that is the ASPCA (American Society for the Prevention of Cruelty to Animals) commercial. These commercials have been the same for as long as I can remember, they play a slow sad song and show you pictures and videos of dogs, cats and other animals that have been mistreated and are looking at you so sad. It breaks my heart every single time. This commercial sticks out to me because I have been raised as an animal lover. I have never lived a day without having some sort of pet living in my house and I wouldn't have it any other way. So in terms of my nervous system, there are numerous things going on when I see this commercial. First in my brain's temporal lobe, which is responsible for my hearing and musical awareness. I hear that song and I automatically recognize it and link it to the sad pictures of animals. Another part of my brain that is affected is my Limbic System, specifically my hippocampus. These brain structures are associated with my long term memory especially those with strong emotional ties. So, every time I see or hear this commercial I will always remember those sad looking faces and the sadness and hurt I feel for those animals.

Do you really need your pinky finger?

     "Man from the South" is a story that follows a bet between an older South American man and a young navel cadet. The bet was that if the young cadet could light his lighter 10 times in a row, the older man would give him a Cadillac. But, if not he would have to cut off his little finger on his left hand. At first the cadet was unsure of this bet, but eventually agreed because he didn't have any use for his little finger. As the story goes on, the tension builds about who would lose this very risky bet but right before light number 10 a women appears and stops the bet. This women is the older man's wife and is very upset with him and apologized to the cadet. She explains that this has happened many times and she has had to make up for his mistakes. She shows her hand which has only one finger and a thumb.
     If the wife never saw this bet and the young cadet would have lost, multiple aspects of his life would have been affected. First, the fact that one of his main occupations is being a cadet which would involve being able to handle all of his gear and firearms. With a missing little finger, the cadet would experience decreased hand mobility and decreased overall hand strength. This would negatively affect how he held a firearm and the control that he had over this equipment and even how he got dressed in his uniform daily. He also would have lost some ability and ease to perform leisure activities with the other cadets like going swimming or having a drink. A strategy that can be used to help this could include an adapted gun that had extra support and made it easy for the cadet to handle and also hand and finger strengthening exercises to help compensate for the missing digit.
     As for the wife, she is missing 3 of 5 digits on one of her hands and therefore is missing significant amounts of strength and ability to perform fine motor and daily tasks! We do not know much about her and her occupations but there are numerous ADL activities that she would need assistance doing. One strategy would be adapting some of her everyday things like her hairbrush, toothbrush and utensils to wrap around her wrist of have grips for her one finger and thumb to fit into so that the hand manipulation and strength would not be needed. Overall, this young cadet got very lucky that someone came and stopped this bet! Even though he did not know it at the time, his little finger is used in just about all hand and finger activities. He would have lost in hand manipulation skills, ROM and strength! This would have changed the way he had learned to live his life and he would have to learn all new strategies and techniques to adapt!

Neurotransmitter Project: Acetylcholine

Implicit Bias

    A bias is defined by dictionary.com as a tendency, inclination or opinion especially one that is preconceived or unreasoned. When our brain does this automatically and unconsciously it is then considered an implicit bias. Implicit bias is your brain's automatic processing and grouping of stereotypes, attitudes and beliefs unconsciously. As humans, we all would describe ourselves as being fair, or at least believing in things that promote fairness. Every person should have an equal and fair shot to get a certain job, to buy a car and to really do anything! With fairness being a characteristic that we as humans strive for, how do we know if we actually are fair? Or if we are letting implicit biases shape our actions and ways of thinking? In order to get answers there are multiple resources and techniques to put implicit bias to the test. This includes things like a self-analysis survey, implicate associations test and understanding when implicit biases are more likely to come through. With self-analysis surveys and association tests, an online test will see how you naturally group things or how you associate certain words and generate specific results. This will help you identify your specific beliefs and feelings and hopefully encourage you to open up and try to break these stereotypes apart. It is also an important tool to realize that implicit biases are more likely to arise in situations when you are stressed and under pressure. It is important to focus on identifying these times and focusing on slowing down and breathing to make the most fair and open-minded decision.

     As OT practitioners and students, it is a very useful and important to learn about implicit bias. We are taught through our education and career that we need to be life-long learners about the field of OT, but it is no different with implicit bias. Teaching yourself to not have these automatic groupings and thoughts is not something that can be learned in an afternoon, it is a life-long process. It is especially important for us as OT's to act in this way because of our strong belief in occupational justice and that every single person has the right to therapy! If we are having implicit bias, we would not be providing the most fair and just services to our clients. The biggest take away I had from learning about this topic is that implicit bias is not something to be ashamed of. It is an automatic unconscious thought of your brain that you need to be aware of and not hide. However, once you are aware of this, it is imperative that you are striving to break the bias and train your brain to not automatically group these beliefs together. 

Scapulohumeral Rhythm

     The scapulohumeral rhythm is important in movement and to obtain  full ROM at the shoulder. This rhythm is present in shoulder elevation, flexion and abduction and really whenever you are reaching to grab something in a tall cabinet at work or for a snack on the top shelf of the pantry. In order to perform this movement the scapula, humerus and glenoid fossa must move and work together. As the scapula moves upward, the glenoid fossa will tilt up to maintain contact with the humerus that is rolling superiorly. It is imperative that they all work together because each part  contributes to total ROM and if one part of this chain is not functioning properly, there will be a decrease in ROM. The scapulohumeral rhythm also helps maintain the subacromial space which will result in impingement and pain if not maintained. This impingement can also lead to rotator cuff muscle weakness and scapulthoracic muscle weakness which will negatively effect the dynamic stabilization of the shoulder. The scapulohumeral rhythm collaborative motion is caused by the shoulder being classified into two joints: scapulothoracic (ST) and the glenohumeral (GH) joints. These joints have a 1:2 ratio for shoulder movement. This means that for every 3° of shoulder movement there will be 1° at the ST joint and 2° at the GH joint. So for a full ROM at the shoulder of 180°, 60° will come from the ST joint and 120° will come from the GH joint. These joints working together will allow for joint congruency which will result in decrease shear forces and will permit optimal length tension relationships for the abductors muscles. Without scapulohumeral rhythm, full shoulder ROM will not be achieved and pain and impingement are likely to occur.

Test Positioning: ROM & MMT

     As an OT, it is imperative that you use bony landmarks and proper positioning when measuring a clients range of motion (ROM). By finding the bony landmarks, it ensures the therapist has the correct placement of the axis, stationary arm and moveable arm on the goniometer to get a precise and accurate reading. The correct placement is also important because with every therapist using the same landmarks and positions the inter-rater reliability will be higher and it will not become an issue if different therapists work with a client. Palpating bony landmarks will also identify any bony or soft tissue irregularities. Along with correct placement of the goniometer, proper positioning of the client is important to ensure that the client is in a comfortable position that allows for full ROM of the joint being measured. This will allow for the most accurate and precise measurements.
     When working with manual muscle testing (MMT), the "test position" is also a very important component. An optimal test position would be in mid-range position of the movement which is where the highest number of cross-bridges are formed and the ideal length-tension relationship is. Another component of MMT is a testing positioned that is gravity eliminated. This is when the client can not resist the force of gravity so the position of the client will be moved so that the movement is done parallel to the ground. With client being in a gravity eliminated position, it allows the therapist to be able to palpate small muscle contractions that may be happening.

Biomechanics AA for Drinking Coffee

     Each morning I wake up and I drink a cup of coffee. My starting position for this is my elbow fully extended, shoulders adducted as my arms are hanging to my side and I am standing at the counter. In order to grab my coffee cup from the counter my major joint will be my elbow joint. My elbow joint will move in the sagittal plane and frontal axis to produce flexion of the elbow to not only grab the cup but also to bring it to my mouth. The digits of my hand will also be in flexion to grasp the cup and my wrist slightly extended. My end position will be my elbow in full flexion or WFL to be able to drink and the digits of the hand in flexion and wrist slightly extended. The osteokinematics of the elbow from extension to flexion is an open kinematic chain because the distal end of the chain, the forearm and hand, are the segments that are moving. In terms of arthokinematics, the moving segment, the ulna, is concave and will roll and glide in the same direction anteriorly on the convex surface of the humerus. The prime mover for elbow flexion is the brachialis which performs a concentric contraction.