Social Determinants of Health

Social determinants of health are the things that can affect a person's health and wellness due to the place where they live or work. Some examples of these things are: education, transportation, employment, housing, access to health care, etc. This is where health begins. Living and working conditions have a huge impact on one's health, though many times these factors are disregarded by practitioners. For one person, his/her social determinants of health could enable him/her to great healthcare, good education, and stable employment, whereas another person living in a different area could not have access to these things simply because of the area he/she lives.

When I think of how social determinants of health can affect your nervous system, I immediately think of stress. Stress has a huge impact on our physical and mental health. Although a little stress is needed to survive and thrive, too much stress can negatively impact our bodies. Living in an area where it is difficult to gain access to transportation, good healthcare, or proper education could cause a lot of stress. With much stress comes increased levels of cortisol. This in turn causes an enlarged amygdala, reduced number of connections in the hippocampus, and shutting down of the prefrontal cortex. With an impaired PFC, a person would have trouble with decision making, self-control, planning, problem solving, and more.

UTHSC's OT program requirements for service/professional development hours facilitates preparedness in us as students because we gain knowledge through hands-on learning and real experiences. In my opinion, that is the best way to learn. Throughout our experiences obtaining these hours, we will come into contact with people from all walks of life who we may not have ever spent time with if not for this requirement. We will see real life examples of these social determinants and their effects, good and bad. I believe this broadens our horizons on interacting with people which will in turn make us more prepared as OT practitioners.

Locomotion and Adaptive Devices

As OTs, we will be fitting clients for assistive devices often. It is important that we make sure these devices fit our clients appropriately because of safety and comfort. In regards to safety, if a device does not fit appropriately, it can be very dangerous for the client and even cause injuries. Next, we want our client to be comfortable in their assistive device. The client could be using the assistive device as much as every day, so it is important it's comfortable for him/her and will not lead to any further injuries.

In order to fit a client for a cane, the hand grip should be at the level of the ulnar styloid, wrist crease, or greater trochanter. The elbow will be relaxed and flexed 20-30 degrees, and the shoulders will be relaxed with no elevation. Canes are the most unstable of assistive devices, so it is important to know if the client is strong and stable enough to only need a cane. This measurement method is also used for walkers.

For fitting axillary crutches, the same method as fitting a cane will be used. In addition to these steps, the axillary rest should be about 5 cm below the floor of the axilla with the shoulders relaxed. Axillary rests that are too high or too low for the client can be painful.

Lofstrand crutches have arm cuffs that wrap around the client's proximal forearms. These type of crutches are commonly used for those with long term disabilities. Lofstrand crutches are more stable than canes but less stable than axillary crutches. Fitting for these crutches will require following the same steps as that of the cane but with an addition of ensuring the arm cuff is situated 2/3 of the way up the forearm.

Platform walkers are for those who cannot bear any weight in their hands or wrists, so they must rely on their forearms for stability. Once again the same fitting method will be used, as canes and walkers have the same method. Also, the client's forearms need to be in a neutral position flexed at 90 degrees in order to get the proper height measurement for the platform attachments.

Lastly, we have the rolling walker. This is for clients with weak upper extremities, so much so that they would not be able lift a standard walker. We would still use the same measurements as the cane and standard walkers. This device offers very little stability as it is extremely mobile. So, we would need to ensure that the patient has good balance and will be able to keep the rolling walker under control. 

Transfers

The order for restoring confidence in mobility based on increasing activity demands (easiest to hardest) is as follows: bed mobility, mat transfer, wheelchair transfer, bed transfer, functional ambulation for ADL, toilet and tub transfer, car transfer, functional ambulation for community mobility, and community mobility and driving. I am not surprised by this hierarchy. I think the hierarchy is in this sequence because with each step, the complexity of the activities increase. For example, the steps involved with driving are going to be a lot more complex than transferring from the bed. It also would not make sense for these steps to be switched around; why learn driving if you cannot get out of bed? This hierarchy shows that mobility skills build upon each other. I witnessed many wheelchair and bed transfers with my time shadowing at assisted living facilities but would've enjoyed getting to see other types of transfers. So, I have really enjoyed learning about all the different transfer techniques and when they should be used. In conclusion, I do agree with this approach. We as occupational therapists should use this as a guide but also remember to adapt when some of our clients are progressing differently than the exact order of this hierarchy.