Public Health and Wellness

 In class, we've been learning how to create Occupational Profiles so that we can look at all aspects of a client/patient. However, it hadn't occurred to me that in the field of Occupational Therapy, we don't only work with individual client's/patients, but also populations of people. When looking at a population, OTs still use a holistic approach. They also look at the social determinants of health, which includes looking at the general socioeconomic, cultural, and environmental conditions. Through Professor Flick's lecture, I learned that these factors are extremely important to note because they can prevent people from getting the care that they need. One example is health literacy. If a person or population wasn't able to have the proper education (maybe due to socioeconomic reasons) to read a pamphlet, read the words on a prescription bottle, or know how to fill out paperwork at the doctor's office, they may be in danger of harming themselves by avoiding the doctor or accidentally overdosing on their medicine. Before listening to this lecture, I didn't know how common it was for people to have difficulties like this within the health care system. This reminds me that as a future OT practitioner, it is important to look for signs that a client/patient might be apprehensive about seeing a therapist or doctor because of these barriers and try to educate the population in health literacy. This also reminds me that as a future OT practitioner, it is important to be creative, diverse, and inclusive when thinking about the most effective way to help people.

Scapulohumeral Rhythm

What is the clinical relevance of the scapulohumeral rhythm? How can it affect your ROM measurements of the shoulder? Please give at least 5 reasons in your response

Scapulohumeral Rhythm is defined as a kinematic interaction between the scapula and the humerus. The ratio of movement among the shoulder movement, scapula, and humerus is 3:2:1. For example: if there is full range of motion for shoulder abduction (180 degrees), 120 degrees of movement should happen at the glenohumeral joint and 60 degrees of movement should happen at the Scapulothoracic joint. Because of this, it is important to stabilize the scapula when measuring true glenohumeral abduction or flexion ROM so that the ROM measurements are not skewed. (For example: the seemingly full range of motion measurements may be coming from an unstable scapula that exceeds its 60 degrees of movement while the humerus has less than 120 degrees of movement) 

In order to have full ROM for should abduction, scapulohumeral rhythm has to work to distribute the motion between the two joints and the humerus has to rotate laterally so that the scapula can upwardly rotate and posteriorly tilt. ROM at the shoulder can also be affected by other problems with scapulohumeral rhythm. The scapulohumeral rhythm distributes the motion between two joints, prevents impingement in the subacromial space and tearing of the supraspinatus muscle, permits good length-tension relationship, and helps with the alignment of the humeral head on the glenoid fossa.  It also provides joint congruency, which results in a decrease of shear forces. It is important for clinicians to understand scapulohumeral rhythm because dysfunction in the scapulohumeral rhythm can result in pain, instability, impingement, and decreased range of motion. It is also important to recognize when the client may be compensating due to scapulohumeral dysfunction and therefore may be causing more damage to their body. In addition, it is important to check for compensations when measuring range of motion so that measurements are not skewed.

ROM and MMT-Biomechanics (2)

When measuring Range of Motion (ROM), it is important to palpate bony landmarks and use proper positioning. The bony landmarks serve as a reference point for where the therapist should place the goniometer in order to have good accuracy and reliability. The goniometer has three parts: the stationary arm, the moving arm, and the axis. If the therapist changes the reference point, the values will neither be accurate nor reliable. For example: when measuring ROM for elbow flexion, the axis/fulcrum of the goniometer is placed on the lateral epicondyle, the stationary arm is placed on the lateral midline of the humerus in line with the acromion process, and the moving arm is placed on the lateral midline of the radius in line with the radial styloid process. If the therapist didn't palpate before placing the goniometer the first time measuring ROM for the patient, the measurements would be off. The next time she measured Range of motion, the numbers would not be consistent. This example shows how not palpating bony landmarks affects accuracy and intra-rater reliability.  While intra-rater reliability is higher than interrater reliability for measuring ROM, not using bony landmarks as a point of reference would affect both. In the same way, the proper positioning of the patient's body is needed for the measurements to be consistent and accurate.  In different positions, the ROM will show different measurements due to the relaxing and tightening of different muscle groups in different positions. If the patient is not placed in the proper position, they also may be at a mechanical disadvantage. Inaccurate and unreliable results would affect paperwork, billing, and insurance claims. They could also put the patient in danger if the patient is given the wrong therapy treatments based on the results.



Manual Muscle Testing (MMT)  is used to evaluate a patient's muscle(s) strength/function. When using MMT, it is important that the patient is placed in the proper test position so that the right muscles are activated during the test. It is also important so that the patient is at a mechanical advantage and can produce the most force possible from the specific isolated muscle or muscle groups. Usually, MMT is completed in against gravity position. However, in certain circumstances, the patient may need to be placed in a gravity-eliminated position. This is a resistant-free position and means that the force of gravity is no longer contributing to the resistance placed on that muscle/muscle group.  In this position, the patient's body is placed so that their action is parallel to the ground and the therapist is not applying resistance. The therapist uses a gravity-eliminated position when muscles are weaker and are unable to withstand the resistance of the four second MMT in an against gravity position with or without resistance from the therapist. The scoring for a gravity-eliminated position is less than 2+ according to the MMT grading chart. If there is almost no Range of Motion but the therapist can sense a small contraction from feeling the muscle, the patient score will be a  1 on the MMT grading scale. If there is no palpable or observable muscle contraction, the patient score will be 0.

Picture from: https://www.scranton.edu/faculty/kosmahl/courses/gonio/upper/pages/elbow-flex.shtml

Knowledge Check: Universal Design; Cancer-Related Cognitive Dysfunction

Universal Design-Ted Talk 

"Everyone has a disability to some extent and everyone has to figure out a way to cope around their disability." This was something that stood out to me in Michael Nesmith's Ted Talk. It's true. We do have to find ways around our problems, whether we have a disability like Rheumatoid Arthritis (RA) or something like a sprained wrist. I learned that this is why Universal Design is important. Universal Design is defined by the National Disability Authority as "the design and composition of an environment so that it can be accessed, understood, and used to the greatest extent possible by all people regardless of their age, size, ability, or disability."  This is why things like automatic doors were created. The automatic door allows people with a number of "disabilities" or circumstances to enter a place. This includes (but doesn't limit to) people in wheelchairs, mother's with strollers, people who have difficulty turning a doorknob, etc. The invention of one universal design usually ends up in a snowball effect. It inspires people to either improve on the design or create more designs that help people in various ways. What a great way to serve people in all stages of life and all circumstances!

Link to the Ted Talk -Why We Need Universal Design:
Picture from: https://people.utm.my/azarimy/2016/10/universal-design-for-all/

Cancer-Related Cognitive Dysfunction: 

"Chemo-Fog"–I'd heard of that term before. However, I'd never heard of  Cancer-Related Cognitive Dysfunction. I learned through this podcast that the term "Chemo-Fog" is misleading. When a person hears the words Chemo-fog, they usually think about a patient with cancer who has undergone chemo treatment and has cognitive problems due to the chemo treatment. However, leading research has shown that the chemo treatment isn't the only cause of cognitive dysfunction among cancer patients. The research shows that specifically with breast cancer, cancer itself or other therapies such as radiation can cause cognitive dysfunction even after being cured of cancer. I also learned that Cancer-Related Cognitive Dysfunction can last for many years. It is important for cancer patients and cancer survivors to know that this is a factor so that they are aware of the changes that they can make to their daily lives in order to help their quality of life and their ability to complete daily tasks.

Link to the podcast: Cancer-Related Cognitive Dysfunction 
Picture from: https://www.pacificneuroscienceinstitute.org/blog/brain-tumor/chemobrain-cognitive-dysfunction/

Biomechanics-Everyday Activity-Opening/Closing the Blinds

*quick summary about what is happening at the elbow is posted underneath; main points about the elbow joint are also in bold

When I’m home and it is sunny outside, I open my blinds. When the sun starts to go down, I make sure to close my blinds so people can’t see inside my apartment. In order to open or close the blinds, I start by standing in front of my window.  My knees, elbows, and fingers are extended. My shoulders and forearms are in a neutral position beside me.  When I reach to open or close the blinds, I flex my right shoulder and elbow, extend my right wrist, and flex my fingers at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints to grasp the string.  My forearm remains in a neutral position.  I then go from that position to extending my elbow and shoulder while continuing to extend my wrist and flex my fingers. This enables me to open or close the blinds by pulling the string. This is my ending position. 

Shoulder flexion/extension, elbow flexion/extension, wrist flexion/extension, and finger flexion/extension all occur in the sagittal plane around the mediolateral axis.  All of this happens in an open kinematic chain because the distal segments of my body are free while the more proximal segments of my body are stabilized/ fixed.  The prime movers that flex the elbow are the Biceps Brachi (main agonist), Brachialis, and Brachioradialis. In the scenario given above, flexing my elbow is a concentric movement because the muscles are shortening while producing and a force and the movement is acting against the force of gravity. In the scenario above, the same prime movers are used to extend my elbow. However, the extension is an eccentric movement because the muscles are lengthening while producing a force and the movement is lowering the ulna and radius towards gravity. The antagonist is the Triceps Brachii. 

The elbow joint (humeroulnar joint) is a hinge joint that has 1 degree of freedom and allows for flexion and extension. The joints consist of the concave portion of the ulna (olecranon) coming together with the convex surface of the humerus. When the elbow flexes and extends in this activity, both the concave surface of the ulna and the convex surface of the humerus roll and glide in the same direction.  During elbow flexion, the proximal end of the ulna glides along the distal humerus anteriorly. During elbow extension, the proximal end of the ulna glides along the distal humerus posteriorly. 

Quick summary: 

:

• Task: Opening and closing the blinds by pulling the string 
• Reaching to open the blinds: flexes my elbow 
• To close the blinds: extends my elbow 
• Both are an open kinematic chain 
• Flexion/extension of elbow-sagittal plane/mediolateral axis
• Prime movers in both flexion and extension: Biceps Brachii, Brachialis, and Brachioradialis; main agonist we’ve talked about-Biceps Brachii
• Antagonist-Triceps Brachii 
• Flexing elbow to open blinds-concentric….extending elbow to close blinds-eccentric 
• Elbow (humeroulnar joint): hinge-1 degree of freedom. Flexion/extension 
• Concave ulna (olecranon) comes together with convex humerus
• Elbow flexes-both convex and concave surface of humerus roll and glides in the same direction-ulna glides along distal humerus anteriorly
• Elbow extension-proximal end of ulna glides along distal humerus posteriorly  

Extra information: 

The normal range of motion (ROM) for elbow flexion is 0-145 degrees while normal ROM for extension is 0 degrees. The normal end-feel for flexing the elbow is soft while the normal end-feel of extending the elbow is hard.