Hierarchy of Mobility Skills

In order to increase someone's confidence when it comes to mobility, it is important that the client is educated on the steps it takes to carry out the action, as well as it pertaining to the client's goals, needs, values and that it is relevant. In addition, we want the client to be able to move and function in a safe and correct way, so risks can be minimized. For the body to be mobile, there are some ways to make it easier, which includes making sure the center of gravity is moving, the line of gravity is near the outer edge of the base of support, outside joint motion is controlled, and the base of support is small. As for the order of the hierarchy of mobility skills the first mobility that is done is bed mobility, then mat transfer to wheelchair transfer, bed transfer, functional ambulation for ADL, toilet and tub transfer, car transfer, functional ambulation for community mobility, and last community mobility and driving. It makes sense that it is done in this sequence so it is expected, and I believe it is in this order because the level of cognition needed starts out less complex and easier to understand. As you go up the pyramid, there are more steps and movements to follow and carry out to remember. Also, the base of support is wider and more stable starting with bed mobility, but as you go up the BoS gets smaller, which makes it more difficult. I have observed in the past that it is done in this order, but not with every client depending on their level of independency (level of assistance) along with comprehension and functional body control. I think it depends on the status of the client and what they can do that determines which mobility skill needs to be worked on or started off with. I do agree with this approach because there is not only room for improvement and progress, but it is also putting the client in a safe environment and builds their self-efficacy. 

If the Assistive Device Fits

When fitting a client for assistive devices, it is important that the equipment allows the client to have the most stability and functionality needed depending on their physical condition (ROM, balance/coordination, strength, etc) to be able to carry out ADL's as independent as possible in the safest manner. For example, if a client does not have very much strength in their upper extremities, then a standard walker would not be the best option, because there is lifting needed to be done to maneuver the walker. However, in this case the best option would be a rolling walker because there are wheels and the arms do not have to lift the device. Something else to consider when fitting assistive devices, is the cognitive status of the client. If the client does not understand how to use the device, then this will be difficult for the client to use the device confidently and without problems. Also, if the client does not comprehend how to use the device, like locking the brakes when needed or keeping the device close to the body when in motion, then there can be an increased risk of a fall or something happening that is not in the best interest of the client.

As for actually fitting these devices, for a cane and walker, the hand grip should be placed at the bony landmarks of the ulnar styloid, wrist crease, and greater trochanter. In addition, the elbow should be relaxed and flexed 20-30 degrees, as well as the shoulders not elevated, but relaxed. Furthermore, for a cane, depending on the physical and psychological status of the patient, this will determine if a wide based quad cane or a narrow based quad cane will need to be used. As for a rolling walker, a client with impaired balance or upper extremity weakness, this would be best suited for them. For a platform walker, these are used if the person cannot weight bear through the wrist and hand. The platform needs to support the forearm and that it is in neutral. Fitting for crutches, the bony landmarks are the same as the walker and cane. In addition, the armpit region rest should be about 5 centimeters below the floor of the armpit (axilla) with the shoulders relaxed. In more detail, for Lofstrand crutches the cuffs are wrapped around the proximal arm and are for people with long term disabilities and who are not as stable for use of axillary crutches. Axillary crutches are situated in the client's axillary region and less stable than other types of crutches.

As you can see, it is important that these devices are appropriately fitted to the client and that it meets the needs of the client, so if the assistive device fits, there is likely a higher chance of there being a happily ever after!

Proper Posture and Body Mechanics

Having the proper posture and body mechanics can help prevent and protect the body from resulting in pain and injury. Also, it can help to efficiently and effectively carry out functional tasks in daily activities without having problems. Some things to take into consideration with having good posture and body mechanics is having a good base of support which contributes to stability and balance and allows the body to stay in equilibrium. In addition, if a client has poor posture it can cause tightening and loosening in muscles and cause the spine to become kyphotic or lordotic. Educating a client who has faulty posture and body mechanics can help with restoring or help with injury or pain from reoccurring or happening in the first place. Simply by letting them know the correct way to sit, stand, bend/lift, reach, turning, pushing/pulling and even modifications that could be done.

An intervention example I would use for my client in order for them to have the right body mechanics and posture, is to work on trunk and core exercises to strengthen these areas. Having a strong and stable trunk and core can take a lot of stress and load off the body. Another intervention I would teach is to make sure when the client is performing tasks, especially when repeating a motion, that they are not overworking or fatigued when doing an activity, as this increases the risk of pain and injury. Furthermore, this would include taking rest breaks when needed and not doing an activity that is strenuous to the body.

"Man from the South"

If the soldier were to lose the bet, an occupation that could be impacted is his ability to get dressed and put his uniform and shoes on everyday for duty. This occupation would be greatly affected because the pinky deals a lot with grip, function, power, and opposability, so upper and lower body dressing would be more difficult to perform. Getting dressed requires having to grasp the clothing to put on bilaterally. Also, if there are buttons, zippers, or shoelaces then pinching and gripping could be hard to do. A strategy that I would recommend to help with putting his shirt on in particularly, is for the man to sit down and have the shirt in his lap with the collar facing away from him, then he would thread his bad hand first through the sleeve using his good hand to help and bring it up to his shoulder. Next, he would thread his good hand through the other sleeve and pull it up to his shoulder, then take the opening for the head with his good hand and pull it over his head. If it were a jacket he was wearing, then the same steps would occur except for bringing the head opening over the head, the back of the jacket would go around to the other side and thread that way. In addition, if the jacket had buttons, then the soldier could put an elastic band and loop it through the where the button hole is and then around the button to bring it together. The strategy and modification described would help the soldier be more independent in this specific ADL.

Health Literacy and Health Promotion

After going through and listening to the lecture about health literacy, health promotion, and the social determinants of health, I learned that there is progress still to be made in the United States. As for example, the mission for Healthy People 2020 was to make sure that health was a priority and that it needs to be improved. Also, it said to make sure the public is aware and understands what the social determinants of health are and making progress with them. The social determinants of health are food, education, social justice and equity, stable ecosystem, income, peace, sustainable resources and shelter. However, our country has come in last when it comes to public health and to these determinants. Something else we need to take into consideration is that we are still experiencing occupational alienation, apartheid, and deprivation. All of these can occur simultaneously or can be isolated. It is important as a country and worldwide to make sure that everyone has the same rights, accessibility, engagement and meaning and purposeful activities in life.
What was a huge eye opener to me, were the videos on health literacy and how the medical and healthcare professionals need to do a better job explaining and comprehending medical terminology to clients and patients. It is important that we ask to make sure that the client's understand what they are reading or hearing so health and well-being can be optimized, instead of them feeling incompetent, afraid, insecure, uncertain, etc. We do not need to assume that everyone has the same level of education and be sure to use simple, nontechnical language. When this is achieved, there is a better sense of acceptance, relationship, rapport and support. We need to be better as a country and worldwide to make strides in advocating and educating about health literacy and promotion. We need to improve the patient experience of care, improve the health of populations, and reduce the per capita cost of health care. (IHI Triple AIM)

Scapulohumeral Rhythm

Scapulohumeral rhythm is important and relevant clinically because it shows the joint congruency or the ratio of movement between the scapula and humerus. If there is any dysfunction in the shoulder complex, it can affect the range of motion, function, and there can be pain or impingement. With every 3° of shoulder movement, there is 2° at the glenohumeral joint and 1° at the scapulothoracic joint. Furthermore if the client is properly coordinated (full 180° ROM), there should be 120° of glenohumeral abduction and 60° of upward rotation of the scapula. Knowing this ratio can help with seeing if range of motion has been affected, so if there are any problems with any movements with the scapula or humerus, the ROM of measurements will be different.This scapulohumeral rhythm also needs to have a good length-tension relationship to be able to carry out optimal function. Without optimal function, the ROM will be compromised especially with the osteokinematics and arthrokinematics of the shoulder complex. In detail, if the shoulder cannot elevate, the primary movements, (upward rotation, posterior tilt, and lateral rotation) cannot be carried out with full ROM.

AT & Home Modification/ Living in Place

After reading and going through the instructional online unit about the topic of assistive technology, I learned some things that I did not know before. This included the different categories of assistive technology, which included low, medium and high tech. I always thought that AT was just one whole category, but it makes sense to break it down like that. Also, I learned that there is a process to making a decision for assistive technology. There needs to be consideration of strengths and weaknesses, trials with the different materials, and implementation by issuing and training the AT. It is awesome to know that OT practitioners have the opportunity to specialize in this type of practice, as well as getting to consult, be involved in creating and developing, and have such a huge part in helping clients reach their full potential and to function independently.
As for the home modification and living in place podcast, this is an emerging area of practice and something I have been interested in because I believe home needs to feel like home even if someone has a disability. When living in place, everyone wants to feel safe, have accessibility, and feel comfortable and this is when an OT practitioner along with a team steps in to help. The podcast kept emphasizing the importance of an interdisciplinary team that involves an OT practitioner, construction, interior design, home inspectors, and so on. Also, the people speaking in this podcast were from the Living in Place Institute and discussed how their approach is for all homes and individuals. Also, they want there to be a sense of personal, unique and customized way of setting up a home or discussing certain types of adaptive equipment to the client. Some of the common items that are used within home modification are elevated toilets, grab bars, shower bench, two-hand rails, going away from a standard shower and bath tub, etc. Something else they mentioned that people can do to ensure a better living space is to remove throw rugs, have LED lights, detectors, first aid kit, and even electronic modifications (which is up and rising) like Alexa and Google Echo or Google Home are very beneficial and helpful, as well. It is important as OTs that we stay up-to-date with this emerging area of practice because the medical and health professional world is constantly changing and we want the best for our clients.