Confidence and Mobility

Mobility is the constant state of instability. Therefore restoring confidence in mobility to perform occupations is an important factor in life. For an individual to be moved safely and with confidence, involves being comfortable with a small base of support, the line of gravity is outside of the base of support near the limit of stability, and the center of gravity is moving. The hierarchy of mobility skills is a great way to restore a clients confidence, no matter the level of independence they have. Based on this hierarchy the client can start at a level of functioning that is best for them, then as a therapist we can help that client build up from there to reach a state of stability and independence. The hierarchy of mobility starts with bed mobility and increases with --> mat transfers--> wheelchair transfers--> bed transfers--> functional ambulation for ADLs-->  toilet and tub transfers--> car transfer--> functional ambulation for community mobility--> community mobility and driving.

I agree with this hierarchy of mobility. My previous job in an inpatient rehab allowed me this opportunity. I have seen this hierarchy applied to many different clients, not only in occupational therapy, but physical therapy too. This approach to mobility is great for increasing trunk control as their stability becomes more unstable. It is also a great approach for a client that may have problems with orthostatic blood pressure and increase their ability to regulate BP as they increase in mobility. This hierarchy is not only helpful for the client, but also the therapist. It helps reduce fall risk, injury, and help to build confidence. 

I think this approach is very helpful because after SIM labs, it showed that transferring from the bed to the wheelchair vice versa can be very tiring and if the client is not strong enough they may need more help to transfer. Bed mobility allows them the chance to control how they move and increase strength. Even moving from the bed the a mat will allow them the ability to still build strength and confidence that they can transfer safely. Each level will get more challenging, and at each level you can strengthen the client to prepare for transfers. Even if they are not completely independent they can be safe and feel confident in whichever transfer they are performing. 

I personally never knew there was a hierarchy explaining this, I thought it was just what the therapist thought was best. I really love the fact that there is a specific chart to increase a clients stability and strength to reach a state of independence with mobility. 

The Just Right Fit

It is very important that each client be fitted to their assistive devices. An assistive device can be something like a walker, cane, or even crutches. Each client will have different heights, cognition, endurance and stability levels which will determine the effectiveness of each assistive device. If the client does not have very good upper body strength or wrist restrictions  you do not want to fit them with a device that is going to require the majority of upper body strength and make them push weight through their wrist. Another factor that is important when finding the just right fit for assistive devices is the stability and endurance of the client. You want to allow that individual to feel safe at all times and also have a device that correctly matches their endurance levels. An individual that may have really good stability, but tires easily may need a rollator. An individual that has good endurance, but weak stability may need a standard or front wheeled walker. 

To fit a client to a rolling walker the hand grips should either be at the level of the ulnar styloid or wrist crease. The handgrips can also be placed at the same level as the greater trochanter. Make sure that the client also has relaxed shoulders and the elbows flexed about 20-30 degrees.  

For a platform walker the platform should be adjusted so that weightbearing is allow through the forearm when the elbow is flexed at 90 degrees with the scapula relaxed. the proximal surface of the ulna should be positioned 1-2 inches off of the platform to prevent compression of the nerves. The grip on the platform should be slight medial so  there is a comfortable grip when arm is supported on the platform. 

To fit a client for a cane you want to make sure the client is standing straight forward, making sure they are steady and not going to fall. Along with the walker the cane handle should also be at level with the wrist crease, ulnar styloid, or greater trochanter. The cane can be adjusted with the locking mechanism allowing the client to have 20-30 degrees of elbow flexion. If the client needs a quadcane the same rules apply, just remember that the wider legs face away from the patient. If the legs are not facing away you can adjust them. 

When fitting a client for axillary crutches the height should be based on the appropriate  height of the patient. The hand grips should be placed at the level of the greater trochanter, ulnar styloid, or the wrist crease. The axillary rest should be about 5cm below the floor of the axilla with the shoulders relaxed. This is about 2.5 inches or a palm's length distance to fit under the arm. 

To fit a client with lofstrand crutches the arm band should be placed 2/3 of the way up the forearm. An important tip to remember is that the hand grips should always face forward to promote a proper gait.

There are many different types of assistive devices that accommodate for weightbearing status, endurance, stability, and decreasing fall risk of the client. Consider the needs/goals of the client when finding the right fit in assistive devices, and ALWAYS remember to use the gait belt when transferring or walking with a client. 

Body Mechanics

Why is proper body mechanics and posture an important factor? Body mechanics and posture work together to prevent injury and illness. Having poor body mechanics when lifting/moving things increases the risk of back pain. A benefit of having proper posture and body mechanics requires less energy to maintain a state of balance. Proper posture includes keeping your body centered over the base of support in regards to line of gravity when this is disturbed the individual increases risk of falling or injuring ones self. Proper posture and movement helps the body reduce stress applied to the spine and does not strain the body's muscles and ligaments. Posture is also involved in joint function and when the alignment is off it causes stress and the degeneration of different joints. Another factor associated to poor posture is a more difficult time breathing, if the body has proper posture the chest is able to expand. It is important to teach good body mechanics and posture to individuals because they are reducing their risk of injury, illnesses, and joint and muscle damage while increasing the spines stability. 

During an intervention of teaching a client body mechanics and posture the first thing I would do would be to have the client stand against the wall if possible to explain correct body posture. While against the wall the client needs to have their heels to the back of the wall, the shoulders against the wall, with the chin tucked and head down while against the wall as well to demonstrate proper posture. I could even have the client show me what they think correct posture is to them and correct where necessary. Next to assess body mechanics I will get the client to make sure they have their feet placed shoulder width apart or large enough to have a good base of support. Reminding the client that when lowering down to grab something and lift back up to bend at the hips and knees and not at the waist which stresses the back. They also may need to be reminded that when using proper body mechanics the neck pelvis and back should all be aligned remembering not to twist at the waist, which will cause back pain and or injury. Lift with the legs and arm muscles not your back and keep the object close to was it level. The client can practice this while using a stick placed on their back to make sure their alignment is correct or they can perform an activity while the therapist observes and corrects their posture. 

Man From The South

In the story, Man From The South by Roald Dah the soldier made a bet and if he lost this bet he would lose his pinky finger. If the soldier would have lost the bet, his ability to have a strong grip strength in his pinky would not as strong as needed. Upon losing the bet the wife might have to help with taking care of the man. One way that her life may be impacted along with his is going to the restroom. After using the restroom one must be able to wipe and if the grip strength is not present it would be difficult for him to clean himself so his wife may have to help it. They could work on exercises to increase grip strength of the other digits or make adaptions to going to the restroom.  They could also use a type of assistive device to help the man go to the restroom independently. Using a long handle bottom wiper that has a grip that includes only the three jaw-chuck grasp or even the lateral grip could make cleaning the bottom easier. Another way would be to have a device installed on the toilet to clean the soldiers bottom. This type of technology may have been more difficult to come by so using therapeutic exercise along with an assistive device to clean himself may promote more independence  for both the soldier and his spouse. 

Health and Occupational Therapy

Health promotion is the use of discipline specific techniques to assist people in achieving their health related goals. As an occupational therapist it is their job to have a holistic approach to health promotion while giving that client, or population their maximum health and quality of life. There are many different approaches that can have a negative impact on an individuals health like not being able to engage in occupations that can cause health issues known as occupation deprivation along with not being able to participate in occupations due to socioeconomic status, gender etc referred to as occupational apartheid. Therefore helping clients to engage and participate in these activities will increase or hopefully create a healthier lifestyle for them. As healthcare providers its best to think of healthy people 2020 and 2030 which is aimed to helping achieve a long healthy life. Healthy lifestyles are hard to understand to some individuals because they have limited health literacy. This is due to the fact that some individuals reading levels and understanding of healthcare is very low. Therefore its best to simplify health terminology, along with clear explanations, while asking questions to make sure the client understands the best approaches and techniques to live a full, healthy life.
As occupational therapist engage in helping a client live a healthy lifestyle they have the possibility to improve patient satisfaction and quality of care because they are client centered. While helping keep the cost per capita down, OT's are innovative and they think creatively to adapt to clients needs on the spot. Along with adapting they promote advice and the correct referrals so the client can live as independently as possible without returning to the hospital because they were taught and understood health literacy. Overall, it is best to understand that an occupational therapists' role in health promotion is important to not only prevent an injury or disease before it happens but also to limit the struggles of a disease already present. Health promotion not only is beneficial to clients, but also other healthcare providers and even family members.

It's All About The Rhythm

For the shoulder to have the greatest ROM the scapulohumeral rhythm is very important. Scapulohumeral rhythm is the muscle interactions within the scapula and humerus.  For every 3 degrees of shoulder movement, there is 1 degree of scapular movement and 2 degrees of humeral movement. This rhythm and its ratio is very important in the synchronization of the scapula and humerus movements.  The rhythm also helps maintain the subacromial space within the glenohumeral joint. This rhythm also allows for good length tension relationships to prevent active insufficiency. The two joints congruency results in decreased shear forces of the humerus in the glenoid fossa.  When the motion is distributed between the humerus and glenoid fossa it allows for stability, if the ROM is large there is a chance for instability. The scapulohumeral rhythm is important for therapist when looking at the overall muscle and shoulder joint functions. A poor rhythm could also cause shoulder impingements in the rotator cuff like bone spurs, humeral and scapular movement dysfunction, and changes in the acromion shape.

Modifications & Living Life

Many individuals do not think something as simple as an Alexa can help an older person who lives alone. One example in the podcast was that an elderly person had fallen and called 911 with the help of her assistive device, known as an Alexa. Many older individuals want to grow old in their homes or even remain as independent as possible in their homes or assisted living facilities. As occupational therapist strive to make aging in place safer this can be done with the use of assistive devices. An interdisciplinary team works together to make the best recommendations to home modifications and adaptive equipment. Some of the top modifications were putting grab bars into homes, elevated toilets, and even making a shower easier to get in and out of. 

Occupational therapist are not inventors and sometimes clients want something to work for them and no one else, so they have to reach out to other individuals to hopefully find the best product for that client. As a therapist it is their goal to make adaptive equipment as client centered as possible. Assistive devices can be incorporated into an individuals life not only by a therapist, but someone as simple as an employee at a home store. As stated in the Ted talk there needs to be a universal design. Different individuals need different requirements and we as by standers need to think of others needs to make it an easier world for us to all live in. Not only when someone has a disability in a public restaurant and needs help reading the menu but is blind, but also for older adults to grow older in their homes and to be as safe as possible. All individuals deserve to live life to the fullest and adaptive technology is an important part of life now of days.