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Archive for category: Brain Health

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A Place Called Vertigo

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

I am not sure what the word “vertigo” refers to in U2’s hit song, but as someone living with vertigo, I can tell you it is not a place you want to be.  Vertigo is highly unpleasant and can be caused by multiple factors including visual or auditory problems, or more commonly, head injury.  I best describe my vertigo as my eyes and ears sending different messages to my brain regarding the position of my body in space.  So, while my eyes tell me I am sitting still in a chair, my ears tell me I am on a boat in the middle of a hurricane.  The result of these mixed messages is spinning, nausea, dizziness, problems walking, and ultimately dysfunction.

For me, my benign positional vertigo (BPV) lives in my right ear.  As a result, I cannot lie on my right side, laterally flex my head to the right, lie flat with my neck extended, or look down into extreme flexion.    While I can tolerate these movements momentarily, I cannot hold these positions for more than a few seconds otherwise I am sent into a spin that can last for days.  I am fortunate to know my triggers and do my best to avoid them (no yoga for me).  I have also learned, after living with this problem for two decades, how to catch my symptoms early to prevent a slight episode of dizziness from turning into days of bed rest.

When my clients experience vertigo and describe this to me, I can fully appreciate where they are coming from.  The story is a book I too could write.   But, like other “hidden” ailments, I get concerned when the medical community does not take this complaint seriously.  This is especially true in my industry where insurers and their assessors often want “proof” of a health problem to support someone’s recovery. While I recognize that people can be dishonest, my experience is that people don’t make this stuff up.  Health professionals need to give people the benefit of the doubt, including insurance situations. To understand, or better yet, support someone with any “invisible” problem like vertigo, health professionals need to be compassionate and should care enough to listen, to research and learn, and ultimately believe.  Empathy, TRUST, and understanding will go a long way to support those that need it. I can only imagine how frustrating, devastating and angering it would be for someone to assume or opine that my “place called vertigo” is not a place at all: because, believe me, I live here.

 

previously posted August 2013

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Being a Life-Long Learner Can Help You Age Well

As we’ve mentioned before when discussing how to support optimal aging, the old cliché is true when we talk of cognition – “use it or lose it”.  Just as we need to exercise our bodies for physical health, we must do so for our brain to support cognitive health.  Learning something new is a great way to flex the muscles in your brain, and the great news is you don’t have to sit in a classroom to do so.  Take a look at the following from the McMaster Optimal Aging Portal which discusses how online learning can support you as you age.

McMaster Optimal Aging Portal:  How online learning can support optimal aging

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Occupational Therapy Approaches for Substance Use in Clients with Brain Injuries

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)
Co-written by Ashley Best, Student Occupational Therapist

In our previous blog post titled “Brain Injury and Substance Use”, we discussed how the cognitive and emotional changes associated with brain injury can overlap with substance use.  But what wasn’t covered was the role of the Occupational Therapist when working with clients who have these challenges.  While our role is complex in cases like these, we have tried to simplify how we use function and meaningful activity in combination with direct treatment to address some common themes as outlined below.

1. Harm Reduction

Arguably the most important strategy of any professional working with someone who uses substances is Harm Reduction. An Occupational Therapist can work with a client to better understand the process of using a substance with the same skill used for analyzing other daily activities. By breaking down what a client’s substance use looks like, from the trigger to being under the influence, the OT can identify areas of potential harm or danger. Some common concerns with substance use, and some OT intervention examples are:

 

 

 

 

 

 

 

 

 

 

It is important to recognize that the above strategies are not meant to encourage substance use but ensure the safety of the client when they are not willing or able to stop.  Sometimes just reducing the harm is all we can offer until the harm can be eliminated.

Clinical Example: A man with previous regular alcohol use prior to an accident, now has seizures when he does not have alcohol in his system. Thus, it is actually more harmful to ask this client to not use alcohol. Instead, monitoring the amount he drinks and ensuring he has regular supports at home are two strategies that can reduce the harm that alcohol may cause.

2. Recognizing Substance Use as a Barrier to Goals

The financial, behavioural, and health effects of substance use often negatively impact a client’s ability to reach their goals. An occupational therapist can help a client to understand and hopefully address the gap between substance use and being able/unable to move forward in other areas of life. An OT may also strategize ways to achieve goals despite substance use by planning use around occupations and this, in turn, may help decrease use over time.

Clinical Example: An individual with a brain injury has a goal to return to work but does not have the insight to recognize how using narcotics would impact their success on the job. Thus, helping the client break down the requirements of a job, recognize poor fits, and then implementing strategies to change substance use behaviour so that it doesn’t impact work (in the case that abstaining from use is not an option) could be an intervention focus.

3. Using Activity to Avoid Triggers

Often, substance use is time-consuming between acquiring, using, and coming down from the influence. This becomes a major challenge when people stop using because there is a lot of free time that may lead to boredom and relapse. This is an important place for occupational therapists to intervene by helping the client identify meaningful activities to engage in when they are feeling an urge to use. This could involve interests and values, or just discussing past activities that the client would like to resume.

In the case of someone with a brain injury, more guidance may be required to identify triggers (if the client has low insight what is triggering). In addition, activities that the client can perform may be different following a brain injury, and thus they may need support in finding new meaningful activities to fill the time that was previously taken up with substance use.

What is the take-home message?

As the above indicates, implementing any of these strategies will require the client to exercise a high level of control over their addiction. Thus, an OT can help support and accommodate each client’s unique situation by providing remedial and compensatory strategies to help clients transition from the occupation of substance use, to other, ideally more meaningful and healthy alternatives.

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Brain Injury and Substance Use

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)
Co-written with Ashley Best, Student Occupational Therapist

As clinicians working in the community with clients who have a brain injury, we all too often see the challenges of recovery impacted by the use of illicit drugs and alcohol.  And while we treat both the brain injury and substance use as they impact function and the ability to participate in life roles, we often wonder, which came first? 

Statistics show that individuals with brain injuries have higher rates of substance use than the general population. However, statistics also show that individuals with brain injuries have higher pre-injury rates of substance use.  While this does not explain a “causal relationship” or answer the “which came first” question, we know the interplay is complicated and that acquiring a brain injury can change the way the brain processes information which may influence substance use behaviours and patterns.

Here are some examples of how this can happen:

  1. Cognitive Changes: Having a brain injury can result in cognitive changes from mild to severe difficulties with memory and concentration, communication, processing speed, problem-solving, and more.
  2. Emotional and Personality Changes: A brain injury can also result in emotional and personality changes such as impulsivity, irritability, and lack of insight.

The changes and symptoms mentioned above occur as a result of injury to the brain’s frontal lobe. The frontal lobe is responsible for more complicated cognitive processes. It helps us to problem solve everyday challenges and consider the positive and negative impacts of our decisions. When a person hits their head or is jolted quickly, the frontal lobe will often impact against the skull – bruising, damaging, and disrupting the connections between the brain cells in this region.

So how does this relate to substance use?

Well, there are reward pathways in the brain which react and process substance use triggers and the associated emotional response. These pathways respond to the positive feelings associated with substance use and strengthen the more the substance is used, telling the brain to seek more. These pathways recognize triggers of substance use and respond by sending the “craving” to the frontal lobe. The frontal lobe determines whether or not the substance will be sought after, and if so, how the substance will be obtained and used.

When we think about individuals with brain injuries and associated cognitive and emotional challenges, we can see how if a person has difficulty with impulsivity, for example, then ignoring a craving may be more difficult than it would be pre-accident. In addition, when a person with a brain injury decides to engage in substance use, challenges such as poor planning and problem-solving may make the use even more unsafe.

Though we may not have evidence to connect brain injury to substance use directly, the cognitive changes in the brain are likely to make managing, using and even recovering from substance use much more difficult.

So now that we have talked about how substance use behaviours and patterns may change after acquiring a brain injury, the question remains, What can be done to help an individual who has both a brain injury and problems with substance use?  This question will be answered in part 2 of our blog post: The Comorbidity of Substances and ABI – the Role of the OT…stay tuned!

 

References:

Bjork, J. M. & Grant, S. J. (2009). Does traumatic brain injury increase risk for substance abuse. Journal of Neurotrauma, 26, 1077 – 1082.

Ilie, G., Adlaf, E. M., Mann, R. E., Ialomiteanu, A., Hamilton, H., Rehm, J.,… Cusimano, M. D. (2015). Associations between a history of traumatic brain injuries and current cigarette smoking, substance use, and elevated psychological distress in a population sample of Canadian adults. Journal of Neurotrauma, 32, 1130 – 1134.

West, S. L. (2011). Substance use among persons with traumatic brain injury: A review. Neurorehabilitation, 29, 1 – 8.

WETA. (2017). Facts about concussion and brain injury. Retrieved from https://www.brainline.org/article/facts-about-concussion-and-brain-injury

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How Anxiety and Depression Can Impact Cognition

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)
Co-written with Ashley Carnegie, Occupational Therapist

As a student working with an Occupational Therapist in the community, I realized early in my placement that many clients struggle with anxiety and depression in combination with cognitive challenges like decreased attention, concentration and focus, difficulties with memory, and slower information processing abilities. This spiked my interest, as I was unaware of the possible impact anxiety and depression could have on cognition and how these symptoms could be related.  I decided to look into this further, and am sharing my findings below.

Occupational Therapists work in a wide variety of settings including the community. As the hospitals become less and less able to accommodate people long-term, community-based occupational therapy services are becoming more and more common. Working in the community allows occupational therapists to reach a wide variety of clients, and therapists utilize a strength-based approach to build on the client’s current strengths to promote wellness and productivity.

Depression and anxiety are the most common types of mental illness throughout the world, including Canada. From my community placement experience as a student Occupational Therapist, I have found that the majority of the clients I have seen are experiencing depression and/or anxiety, often in combination with other primary diagnoses.

Interestingly, depression and anxiety can negatively impact the way the brain thinks, learns, and processes information and thus how it functions.  However, the relationship is complicated as a decrease in cognition may also lead to an increase in depression and/or anxiety which can then perpetuate the cycle.

Research has highlighted how anxiety and depression can negatively impact several aspects of cognition including:

  • Psychomotor speed
  • Attention
  • Executive functioning
  • Problem-solving
  • Attentional switching
  • Cognitive flexibility
  • Visual learning
  • Memory

The result for most people tends to be poor functional outcomes in their daily lives. Additionally, the brain regions believed to be responsible for these functions have been shown to be abnormal in people that also suffer from anxiety and depression  (e.g. hippocampus, amygdala, temporal lobes, and prefrontal cortex). Decreased memory, slowed information processing, and issues with verbal communication can negatively impact multiple areas of people’s lives. This information demonstrates the importance of the need to detect and treat anxiety and depression as early as possible as well as the need for early cognitive interventions for clients with anxiety and depression.

As a student Occupational Therapist, I wanted to further investigate how Occupational Therapists can help. I found evidence that Occupational Therapists can help clients in reducing functional decline, while also reducing the probability of relapse by treating cognitive deficits. Occupational Therapist’s target these areas by teaching client’s cognitive remediation and compensation strategies during their interventions and treatment monitoring.

Examples of remediation interventions may include:

  • Retraining higher-level cognitive skills (e.g. strategy use, self-monitoring, self-correction, problem-solving, self-evaluation)
  • Education
  • Relaxation and stress management techniques to regain control
  • Divided attention training (e.g. learn tasks separately and then combine tasks)
  • Imagery
  • Rehearsal strategies

Examples of compensatory interventions may include:

  • Modifying the environment (e.g. dim lights, reduce distractions)
  • Altering the task, (e.g. use of rest breaks, breaking the task into smaller components, repetition of instructions)
  • Use of both internal and external cueing/reminders (e.g. use of mnemonics, post-it notes, organizers, applications)

With both, often, a cognitive behavioural approach is taken.  Cognitive behavioural therapy (CBT) works to change clients thought structure to allow positive mood change, enhance coping strategies/problem solving, and help challenge faulty beliefs.

Anxiety and depression are common and are known to negatively impact a person’s cognition.  Worsening cognition then can deteriorate anxiety and depression further.  Early intervention is key to break this cycle and to promote function and wellness.   Occupational therapists play a vital role in providing interventions for those with anxiety and/or depression by implementing interventions for these issues, as well as treating the common resulting cognitive deficits.  Both remediation and compensatory techniques are used, often through cognitive behavioral therapy.  If you, or someone you know, is struggling with anxiety or depression this may present as cognitive difficulty, or if cognitive issues are present, anxiety and depression may also surface.  Consider occupational therapy if you would like support and strategies to improve these symptoms and to reduce their effect on your daily life.

 

References:

1. Carrier, A., & Raymond, M. H. Community occupational therapy practice in Canada: A diverse and evolving practice.

2. McRae, L., O’Donnell, S., Loukine, L., Rancourt, N., & Pelletier, C. (2016). Report summary-Mood and Anxiety Disorders in Canada, 2016. Health promotion and chronic disease prevention in Canada: research, policy and practice, 36(12), 314.

3. Statistics Canada (2014) Survey on Living with Chronic Diseases in Canada (SLCDC). Retrieved from http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5160

4. Lee, R. S., Hermens, D. F., Porter, M. A., & Redoblado-Hodge, M. A. (2012). A meta-analysis of cognitive deficits in first-episode major depressive disorder. Journal of affective disorders, 140(2), 113-124.

5. Jaeger, J., Berns, S., Uzelac, S., & Davis-Conway, S. (2006). Neurocognitive deficits and disability in major depressive disorder. Psychiatry research, 145(1), 39-48.

6. Bora, E., Fornito, A., Pantelis, C., & Yücel, M. (2012). Gray matter abnormalities in major depressive disorder: a meta-analysis of voxel based morphometry studies. Journal of affective disorders, 138(1), 9-18.

7. Femenía, T., Gómez-Galán, M., Lindskog, M., & Magara, S. (2012). Dysfunctional hippocampal activity affects emotion and cognition in mood disorders. Brain research, 1476, 58-70.

8. Lorenzetti, V., Allen, N. B., Fornito, A., & Yücel, M. (2009). Structural brain abnormalities in major depressive disorder: a selective review of recent MRI studies. Journal of affective disorders, 117(1), 1-17.

9. Fleming, J. (2017). An occupational approach to cognitive rehabilitation. Workshop presented through the Canadian Association of Occupational Therapists, Toronto, ON.

10. Grieve, J. I., & Gnanasekaran, L. (2008). Intervention for Cognitive Impairments. Grieve, JI, & Gnanasekaran, L.(3rd ed. ed.). Neuropsychology for occupational therapists: cognition in occupational performance. Oxford. Malden, Mass.: Blackwell.

11. Haran, D. (2009). Cognitive-behavioral therapy for depression. The Israel journal of psychiatry and related sciences, 46, 269.

12. Knapp, P., & Beck, A. T. (2008). Cognitive therapy: foundations, conceptual models,  applications and research. Revista Brasileira de Psiquiatria, 30, s54-s64.

 

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The Cognitive Job Demands Analysis: Your Brain at Work

Many employers know that a Physical Job Demands Analysis involves a health professional outlining the physical aspects of a specific job position.  These are common in manufacturing or production industries where jobs can be heavy, repetitive, or require high physical demands.  But these reports are seldom helpful if an employee suffers a brain injury, cognitive or emotional impairment and their return to work issues relate to cognitive or psychological changes and not necessarily physical impairment.

A Cognitive Job Demands Analysis is an objective evaluation of the specific cognitive, emotional and psychological skills required to perform the essential job duties of a given position. As mentioned, traditional Job Demands Analysis typically address only the physical components of the essential job duties.  Yet, jobs are multifaceted and performance at work depends on the interplay of human physical, cognitive, emotional, behavioral and environmental factors.  As such, having a cognitive job demands analysis in conjunction with a physical job demands analysis is ideal, or these can be completed as a standalone assessment if required.

Cognitive job demands analyses can be helpful in providing a baseline measurement tool against which an individual’s cognitive and psychological capacities may be compared, such as when hiring new employees, developing and implementing training programs, or to assist in return to work post injury or illness. These comprehensive and detailed assessments can be utilized when any health condition (cognitive, physical, or emotional) impacts an employee’s thinking, cognition and/or their interpersonal processes and abilities.

Much like with a physical job demands analysis, a cognitive job demands analysis involves an on-site observation of a worker(s) completing the job in question and usually includes objective measurements, and sometimes interviews with employers and co-workers. Some of the more specific aspects examined include:

  • Hearing, vision and perception
  • Reading, writing and speech
  • Memory, attention, and higher level cognitive abilities, like problem solving, insight and judgement
  • Safety awareness
  • Work pace
  • Self-supervision
  • Deadlines and work pressure
  • Interpersonal skills required for the job
  • Self-regulation and the need to work independently, with supervision, or in a group

A comprehensive job demands analysis should include comparisons of the information obtained to standardized classification data related to occupations, such as those outlined by the National Occupational Classification 2011 proposed by Human Resources and Skills Development Canada. After a report is generated, recommendations and interventions for consideration can be developed.

Do you feel that your organization has positions that need to be outlined via a cognitive job demands analysis? Do you have more questions on how a cognitive job demands analysis can be used in the return to work process? If so, seek out the services of an Occupational Therapist, or contact us for a free consultation.

For additional informative posts on workplace health and wellness please refer to our Healthy Workplace page.

Resources

Haruko Ha, D., Page, J.J., Wietlisbach, C.M. (2013). Work evaluations and work programs. In H. McHugh Pendleton and W. Schultz-Krohn (Eds.) Pedretti’s Occupational Therapy Practice Skills for Physical Dysfunction (337-380), St. Louis, Missouri: Elsevier Mosby.

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The A to Z of OT: X is For… AtaXia

Ataxia is characterized by a loss of muscle control and coordination, and can affect the whole body or only specific parts.  Ataxia has a pronounced impact on how people go about the activities in their day. Without adequate muscle control and coordination, tasks like getting dressed, walking, and preparing a meal become more challenging.  Learn more about Ataxia and how Occupational Therapists help individuals with Ataxia find functional solutions in our post, Game… Set… Cerebellum.

 

October is Occupational Therapy Month and to celebrate we will be sharing a new series called the A to Z of OT.  In our attempts to further educate the public about what Occupational Therapists do we will be highlighting twenty-six of the awesome ways OTs provide Solutions for Living.  

We encourage you to follow along and to add to the discussion by highlighting other awesome things OTs help with for each corresponding letter!

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The A to Z of OT: N is for… Neuroplasticity

What is neuroplasticity?  Just as we need to exercise the muscles in our body, we also need to exercise our brain. Our brains are made of billions of neurons, which interact with each other to complete specific tasks. Signals are sent from one neuron to another along neural pathways, and these determine our thoughts, emotions, insights, and so much more. Each task relies on a different neural pathway, so the pathway for reading a book is different than the pathway for putting on our shirt. The more we use a pathway, the stronger the connection becomes.

These neurons have the ability to physically change themselves when faced with new and difficult experiences. This ability is called neuroplasticity.

Learn more about Neuroplasticity, its use in Occupational Therapy, and how we can use this knowledge to help reduce cognitive decline as we age in this previous post, Cognition and Aging, Use it or Lose it.

 

October is Occupational Therapy Month and to celebrate we will be sharing a new series called the A to Z of OT.  In our attempts to further educate the public about what Occupational Therapists do we will be highlighting twenty-six of the awesome ways OTs provide Solutions for Living.  

We encourage you to follow along and to add to the discussion by highlighting other awesome things OTs help with for each corresponding letter!

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The A to Z of OT: B is For… Brain Injury Recovery

It is well known that brain Injury is the leading cause of death and disability worldwide. In fact, in Canada, Traumatic Brain Injury (TBI) is more common than breast cancer, spinal cord injury, HIV/AIDS, and multiple sclerosis (MS) combined.  A brain injury can cause many physical, emotional and cognitive challenges.  Recovery from a brain injury can often be a long and bumpy road.  Occupational Therapists help brain injury survivors with all aspects of living including, physical symptoms, their living environment, cognition and memory and more.  Learn more about Brain Injury, methods of prevention and how OTs assist with recovery in this post from our blog, ABI the Silent Epidemic.

 

October is Occupational Therapy Month and to celebrate we will be sharing a new series called the A to Z of OT.  In our attempts to further educate the public about what Occupational Therapists do we will be highlighting twenty-six of the awesome ways OTs provide Solutions for Living.  

We encourage you to follow along with The A to Z of OT and to add to the discussion by highlighting other awesome things OTs help with for each corresponding letter!

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Game… Set… Cerebellum

Co-authored by Meredyth Bowcott, Student Occupational Therapist

The 2018 Rogers Cup has just wrapped up in Montreal and Toronto, and once again spectators in Canada and around the world were dazzled by the likes of top-ranked tennis players such as Rafael Nadal and Simona Halep. If you’ve ever tried your hand at the sport, you know it requires great speed, agility, endurance, and of course coordination.

So how do these players prepare to return a serve that can clock in at speeds of over 160 km/hour? Well, they do it with a little help from a part of the brain called the cerebellum.

The Mighty Cerebellum

The cerebellum registers the serving player’s movement pattern, along with the speed and trajectory of the tennis ball, and predicts the outcome of these movements. As the returning player makes a split-second decision about how to get into position to hit the ball back, the cerebellum is still hard at work. It receives instructions for how the body should be positioned in order to return the serve, simultaneously comparing the body to the actual position of joints and muscles. The cerebellum sends signals to adjust the position of the body in real time, giving the player the best shot at returning the serve.

We can’t all be tennis superstars, but we do all rely on our cerebellum in our day to day lives. Truly, any intentional movement that you accomplish in a smooth and predictable manner, from watering your plants to drinking a cup of coffee, is brought to you in part by your cerebellum.

Ataxia

So, what happens when this crucial brain structure becomes damaged and isn’t working as it should? One of the symptoms of cerebellar dysfunction is ataxia. Ataxia is characterized by a loss of muscle control and coordination, and can affect the whole body or only specific parts (upper extremity, lower extremity, trunk, etc.). Individuals with ataxia may have difficulty initiating movements, movements may appear jerky and imprecise, and they may have poor sitting or standing balance. Others may have difficulty swallowing or experience rapid back and forth eye-movements.

Ataxia has a pronounced impact on how people go about the activities in their day. Without adequate muscle control and coordination, tasks like getting dressed, walking, and preparing a meal become more challenging.

How Occupational Therapy Helps

It’s important for medical teams to determine the cause of the ataxia and see whether it is due to an underlying issue that can be treated. When symptoms persist, occupational therapists (OTs) focus on ways to help individuals with ataxia compensate for their symptoms. Some of the ways an OT might help someone with ataxia are:

Energy conservation: Fatigue can exacerbate symptoms of ataxia, therefore it’s important to think about how to conserve energy throughout the day.  We do this with the four P’s:

  • Prioritizing: OTs can help establish a list of priority activities, that is which tasks throughout the day are more important for the individual to be able to get done. Focusing attention on what’s most important contributes to a more rewarding day.
  • Pacing: It’s important to take regular breaks – before fatigue sets in – and practice proper pacing technique. OTs can help create a realistic daily schedule that allows time for productivity and rest.
  • Planning: OTs are skilled in task analysis and can help individuals find the most efficient way to accomplish an activity. This reduces unnecessary expenditures of energy, and can reduce frustration.
  • Positioning: OTs consider how the individual interacts with their environment while accomplishing a task. For example, ensuring everything needed to make dinner is within reach limits unnecessary movement.

Joint stabilization: If muscle incoordination occurs in the upper extremity, it can be beneficial to stabilize the arm when accomplishing gross and fine motor movements. For example, stabilizing one’s elbow by leaning it on a table can help create a smoother movement when drinking from a cup.

Adaptive equipment: OTs can recommend equipment to make certain tasks easier. In some cases, the use of weighted utensils may help reduce jerky arm movements. Self leveling spoons can also help minimize spills during mealtime. Lining work surfaces in the kitchen with a non-slip mat such as Dycem © can provide traction to compensate for muscle incoordination.

Every person with ataxia is different, and occupational therapists have the skills to develop individualized plans to help them lead active and fulfilling lives. For more information on these and other ways occupational therapy plays a part in treating ataxia, contact an OT!  In the meantime, if you like sports, watch the cerebellum in action at the upcoming US Open!

 

References:

Anderson Preston, L. (2013). Evaluation of Motor Control. In H. McHugh Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction, 7th Edition. (pp. 461-488). St. Louis, Missouri: Elsevier Mosby.

Foti, D. & Koketsu, J.S. (2013). Activities of Daily Living. In H. McHugh Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction, 7th Edition. (pp. 157-232). St. Louis, Missouri: Elsevier Mosby.

Mayo Clinic. (2018). Ataxia. Retrieved from:

https://www.mayoclinic.org/diseases-conditions/ataxia/symptoms-causes/syc-20355652

Tipton-Burton, M., McLaughlin R, & Englander, J. (2013). Traumatic Brain Injury. In H. McHugh Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction, 7th Edition. (pp. 881-915). St. Louis, Missouri: Elsevier Mosby.

UBC Medicine – Educational Media. (2014, February 18). The Cerebellum – UBC Neuroanatomy – Season 1 – Ep 8 [Video File]. https://www.youtube.com/watch?v=17mxfO9nklQ