Lesions acquired before the establishment of the normal function of the affected region can be relatively silent medicine disposal buy generic depakote 500mg. If such an extensive lesion is relatively clinically silent treatment emergent adverse event discount depakote 250 mg on line, it has been there a long time and developed slowly medicine xl3 cheap depakote 500mg on line. William Osler Specific questions relevant to particular presentations are dealt with in Chapter 3 medicine you can order online generic depakote 500 mg otc. It may be important to revisit aspects of the history in light of the examination or investigation findings treatment of pneumonia discount 250mg depakote with amex. Hearing your experiences retold as a coherent story can help make sense of the experience symptoms 4 dpo bfp cheap 250mg depakote with amex. If, for some reason, other aspects are important in your assessment you need to explain why. For very long-term pictures, it may be more useful to start with the present situation and fill in backwards. If ability is not demonstrably improving with time, consider whether it may be regressing. The model is undoubtedly somewhat over-simplistic, and more relevant to educational theory than clinical development assessment. Beyond the easily recognized gestalts of Down, Angelman, and other syndromes, it is probably wisest to seek specialist opinions from clinical genetics colleagues. Head circumference measurement See the relevant sections for assessment of abnormal head size (see b p. Conscious level Consciousness infers both arousal (not asleep) and awareness of events. Attention and concentration Two-, three- and four-year-olds should be able to recall immediately 2, 3 and 4 digit sequences (forward), respectively. Frontal lobe function Relatively selective impairment of executive function is common after traumatic brain injury and may be an early indicator of cognitive regression. It is not normally fully established until mid-adolescence, however, so these tests are not useful in younger children. Put your dominant hand down on the table or your thigh repeatedly, first in a fist, then ulnar side down with extended fingers, then palm down. Parietal lobe dysfunction Poor 2-point discrimination, graphaesthesia (interpretation of letters drawn on the hand) or shape discrimination (identification of a coin or paper clip in the contralateral hand particularly in non-dominant lobe disease). It is, however, very language-orientated, with relatively limited testing of memory, visuospatial function, or executive skills (see Box 1. To assess this formally, first check nostril patency (sniff with the other nostril occluded) then use pleasant odours (chocolate, etc. Very irritant odours can be detected somatically by the nasal mucosa (trigeminal nerve). Fields In older children, visual fields can be tested by confrontation with both eyes open. Isolated nasal visual field defects (without temporal field defects) are rare other than in relation to chronic vigabatrin use (see b p. In infants, gross field preservation can be inferred by the refixation reflex: the child refixing on a target as it moves from central into peripheral vision in each direction. Fundoscopy in toddlers requires an assistant to attempt to secure attention, and patience! In neonates get the mother to hold the child against her with head on her shoulder looking to the side, whilst quietly awake. Visual loss is prominent in papillitis and is the usual presenting complaint (only in the mildest cases is it confined to loss of colour vision). Normal red reflex appearances vary in different ethnic groups: if in doubt, check appearances in parents. An abnormal red reflex can be absent (dark pupil), partially obscured (by an opacity in lens or media) or of an abnormal colour or brightness. Rest your thumb on the eyebrow and stabilize the ophthalmoscope on your thumb: this minimizes confusing parallax effects due to movement of the ophthalmoscope relative to the eye. Test for the ipsilateral anhidrosis by sliding a clean metal teaspoon lightly over the forehead and noting the slight drag on crossing to the stickier, normal side. The affected pupil is larger and reacts poorly to light (thus, asymmetry may be more marked in, or on initially moving to , brighter conditions), but contracts briskly on accommodating to a near target. Afferent pupillary defect A non-reactive pupil can arise from a lesion either in the afferent (optic nerve) or the efferent (third nerve) limb of the pupillary light reflex. Due to the bilateral consensual nature of the pupillary light reflex, an eye with an interrupted optic nerve, but intact third nerve will still constrict when the opposite eye is illuminated, but both pupils will dilate when the injured eye is illuminated. Swing onto one pupil for 5s then promptly swing over to the other pupil for another 5s then back, and continue repeatedly until a consistent impression is gained of whether one pupil is dilating as the torch swings onto it. The difference will be that the consensual response will be present: the pupil will constrict when the other eye is illuminated. Duane retraction syndrome: on attempted adduction, limitation or absence of abduction, variable limitation of adduction and palpebral fissure narrowing because of globe retraction. This is very useful in detecting subtle non-alignment of eyes in the neutral position. Diplopia Paralytic eye movement abnormalities, particularly if acute give rise to subjective diplopia. The false image (the most lateral one) will be from the affected eye and will disappear when the affected eye is occluded, although younger children will struggle to report this reliably. Covering one eye with red glass and asking children to consider the red image can help. Only a readily identifiable and rare ocular cause, such as lens dislocation could otherwise give rise to this. Cranial nerve V For an approach to the evaluation of disturbances of facial sensation, see Table 3. Note whether boundaries of any reported area of altered perception correspond to the anatomical boundaries of the divisions of the trigeminal nerve (see Figure 3. Corneal reflex Approach with a wisp of cotton wool from the side to avoid a blink due to visual threat. Note whether a blink is elicited and also ask whether the sensation felt similar on each side. Informally, observing the blink produced by brushing eyelashes elicits similar information. Motor functions of trigeminal nerve Test the ability to resist attempted jaw closure (lateral pterygoid). A readily elicited, exaggerated jaw jerk confirms that an upper motor neuron picture is of cerebral, rather than high cervical spine origin. Ask the child to imitate facial expressions (grimace, frown, smile, forced eye closure). The child should normally be able to bury their eyelashes in forced eye closure: distinguish upper motor neuron involvement of the seventh cranial nerve (minimal effect on eye closure or eyebrow elevation) from lower motor neuron cranial nerve lesions (typically marked effect on eye closure). Rinne tuning fork testing is reliable in children as young as 5 if performed carefully. In the conscious child, it is rarely necessary to elicit a gag reflex formally to assess palatal and bulbar function: this can be inferred from observation of feeding and swallowing behaviour. In the disabled child, demonstration of the presence of a detectable gag reflex is not an adequate demonstration of the safety of oral feeding and a formal feeding and swallowing assessment is required (see b p. Assess power by asking the child to turn their head to the contralateral side and then prevent you pushing back. The integrity of 12th nerve function is assessed by observation of the tongue at rest in the open mouth (fasciculation? The latter forms a very sensitive screening test that will detect all but perhaps the mildest of pyramidal weaknesses, although formal neurological evaluation may be very helpful in identifying the cause of a puzzling gait or postural abnormality. Mild pyramidal weakness (causing perhaps only a subtle tendency to walk on the toes) may be reflected in greater wear at the toe. The two may co-exist, particularly in cerebral palsy and acquired brain injury where the failure to consider extrapyramidal stiffness can result in effective therapies being missed. Dystonia in a limb can sometimes be brought out by passively moving the arm whilst asking the child to perform repeated movements. Formal examination of power in the legs is best performed in supine lying, although seated assessment is possible. Mild pyramidal weakness results in pronator drift: a downward drift and pronation of the affected arm. Dynamic assessment of power by examination of posture, gait, and movement may be more informative. Proximal weakness of shoulder and hip girdle (associated with complaints of difficulty raising head from pillow, combing hair, raising arms above the head, getting up from chair, climbing stairs) usually implies muscle disease and distal weakness (difficulty opening bottles, turning keys, buttoning clothes, writing), generally neuropathic disease. Assessment of fatiguability is important if neuromuscular junction disease is suspected. Fatiguability of eye movements is assessed by the ability to maintain an upward gaze. The successful elicitation of a deep tendon reflex requires the muscle belly to be relaxed yet moderately extended. For both these reasons, examination of reflexes in the upper limb can be helped by your holding the arm, placing a finger or thumb over the tendon and striking your own finger or thumb (while making jokes about what a strange thing that is to do! They can help localize thoracic spinal cord lesions, although they are less reliable than a sensory level to pinprick. Examine the spinothalamic (pain and temperature) and dorsal column (light touch, proprioception, and two-point discrimination) separately in all areas pertinent to the clinical scenario. If a child can discriminate hot and cold, or sharp and blunt, and locate light touch accurately, then function is intact. Tickling (which may be elicited by stroking) is a spinothalamic, not dorsal column, sensation. Other movement disorders (such as tics or myoclonus) will interfere with the intended trajectory, but a child will usually slow down just before reaching the target to ensure an accurate landing (with the help of intact cerebellar function). To psoas Lateral cutaneous of thigh To iliacus L2 L3 L4 Femoral Obturator L5 S1 S2 To gluteal muscles Sciatic S3 Posterior cutaneous of thigh To lateral rotators of hip Common peroneal (common fibular) Tibial. A downward drift and pronation of one arm in this procedure implies mild pyramidal weakness. Tendency to catch a toe on the floor either resulting in leg swing laterally during swing phase or it is compensated by hip flexion. Observe walking and running gaits over a significant distance and repeated requests. In challenging situations it can be helpful to video the gait to permit unhurried evaluation. Complex situations (certainly if surgery is being considered) may require formal gait analysis (see b p. If the pattern suggests peripheral nerve involvement, this needs to be narrowed down further on the basis of Figures 1. In the latter case the pattern of weakness does not correspond to a particular peripheral nerve, but to a root level. It will normally be associated with a corresponding dermatomal sensory loss, although a very focal lesion can selectively involve the ventral or dorsal root only causing isolated weakness or dermatomal sensory loss, respectively. For example, weak ankle dorsiflexion could represent a common peroneal nerve injury (Figure 1. Also, the L5 root pattern of motor weakness involves hip abductors and foot inverters. Avoid examining immediately after a feed (sleepy) or when very hungry and distressed. Opacities in the cornea or media require a formal ophthalmological assessment to exclude cataract. A white retina is a potential sign of retinoblastoma and requires urgent referral. Lower motor neuron facial nerve injury can be seen after forceps delivery due to pressure over the zygoma. This is caused by developmental hypoplasia of the depressor angularis oris muscle resulting in a failure of the lower lip on the affected side to grimace fully. The asymmetric crying facies may be mistaken for facial nerve injury but the face above the mouth (particularly the nasolabial folds) will be normal. Bulbar function In practice, a history of efficient sucking and swallowing is the most useful indicator of bulbar function. As this is slowly lowered, the sternocleidomastoid will become more apparent and palpable. The classic Erb palsy comprises weakness of shoulder abduction, elbow flexion and finger extension (see b p. It can be hard to state confidently that deep tendon reflexes are pathologically exaggerated or depressed: alertness, sedative drugs, systemic illness and many other factors can lead to temporary symmetric changes in reflexes. Neither crossed adductor responses nor a few beats of unsustained clonus are pathological in the neonate. Although thankfully much rarer, be alert to trauma to the cervical spinal cord resulting in a flaccid tetraparesis with variable ventilatory function. To the novice, this picture may be mistaken for a globally suppressed, asphyxiated neonate. Pointers include the clinical context (breech extraction, no biochemical evidence of global hypoxic ischaemic insult) with a combination of preservation of facial alertness but lack of perception of painful stimuli. A limb may still withdraw from pain due to local spinal reflexes, but crying implies central perception of the stimulus. Re-fixation on objects moved peripherally from central vision implies intactness of the visual field in that direction. If not yet sitting unsupported, gently tip to each side to detect lateral righting reflexes and their symmetry. Real world neurological examination of the toddler this is the group par excellence where opportunistic observation forms the backbone of the examination.
The effect of the program on me was more like rain or wind medicine effexor depakote 500mg mastercard, gradually eroding my false beliefs treatment 5th metatarsal fracture purchase 500 mg depakote with amex. I gradually learned that I have an incurable treatment quadriceps pain depakote 250mg on line, lethal disease medicine allergy generic depakote 250mg line, that having it is not my fault medicine 606 cheap 250mg depakote visa, 290 Narcotics Anonymous but that seeking recovery is my responsibility treatment 24 seven generic depakote 500mg overnight delivery. I slowly came to understand that fellowship is toxic to addiction, and that isolation is a prerequisite for relapse. I still need to be reminded that my best information about recovery is heard from others, and not my own loud head. Some days I learn something new, and others I feel like I am making no progress at all. I have problems, fears, frustrations, and a constant struggle with low self-esteem. We both were interested in science, both ended up in pharmacology departments, both used heavily, both thought our knowledge would protect us. For me, this is not only about what I might want, but also about what I have already received. When I think about things this way, it is clear to me why fellowship is the foundation of recovery. Even with over twenty years clean, I still have to fight the urge to distance myself from people at meetings by focusing on differences. We can speak any language, have any politics or ideas about our Higher Power, and come from any upbringing. In this diverse and growing group of people there is someone for everyone, as a sponsor, a confidant, or a trusting newcomer. As the fellowship matured, this member and others like her came to realize "there is no model of the recovering addict. Before I got clean, it seemed that there were hardly any women in Japan who were addicted to drugs. No one in my family knew anything about addiction, and no one around me talked about it. The seven of us from Tokyo would take the bullet train to visit three members in Osaka. When we heard there was an addict in a mental institution far away, we would go there and talk through the bars. We were doing service work with hospitals and institutions and public information on a regular basis, but we had no connections with physicians. My husband would just walk into a mental institution and ask if there were any addicts there. He would go to very small towns in the hills and talk to the addicts in the institutions, even those who had no intention of stopping. It took many years for some of our members to move on from who they used to be, and to understand that being a boss on the street is different from being a sponsor. Once we were able to read the message in our language, the program became much clearer. I was shocked to read that drugs were not the major problem for us, but that the problem is our obsessive thinking and compulsive behavior. Many women shared how drugs were a good thing for them, until their using became unmanageable. People who had nothing to start with were afraid that they really had nothing to recover. As we started to read the new translations, it clarified that women in Japan were sharing the same experience as members around the world. Many Japanese women addicts shared in meetings about their experiences with sexual abuse and domestic violence. All of these women addicts began sharing their stories, and now people talk about domestic violence and sexual abuse as real problems. On a typical day, I would be taking care of my child and answering calls about where the meetings were. Now I know that working the Twelve Steps is the most important thing-as long as I work the Twelve Steps, I can prioritize my life the way that seems right to me. Because of this hardship and the loss of my self-confidence, I started to work Steps Six and Seven. Six months later, I was considering this idea of sharing my story and describing what makes me happy. I have the tools I was taught in this program, and I know I can use them to overcome difficulties. My Higher Power gives me an opportunity to 296 Narcotics Anonymous see clearly what I really believe in: When I think that I know what success looks like in business or in my personal relationships, my Higher Power always gives me a chance to look back and see how small my thinking has been. But now I have deep respect for those people who, no matter how many times they relapse, still come back to the program and try as best they can. In those early years, we had a misconception about what it meant to be happy in the program. Recently, I was talking with a member who has been in and out of the program for many years, in and out of institutions, in and out of marriages. I, on the other hand, kept coming back to meetings for a long time and loved only one man. Thankfully, that way of thinking has completely changed within me through working the program. I thought that I was doomed to continue in an insane drive toward self-destruction that had already sapped me of any determination to fight. I thought that I was unique-that is, until I found the Fellowship of Narcotics Anonymous. I thought that a drug addict was a weak-willed, spineless creature who must have no purpose in life or sense of worth. I would not, or could not, fall into that trap, as I was an achiever, winning at the game of life. Sometime after having started my internship at a prestigious West Coast hospital, I had my first experience with narcotics. Experimentation quickly led to abuse and then addiction, with all the bewildering helplessness and selfcondemnation that only the addict knows. Once I felt better, I convinced my psychiatrist that I was well enough to return to my training program. He was either naive, gullible, or ignorant of addiction, and let me go merrily on my way. With no changes in my thinking or behavior, relapse followed relapse, and I established a pattern that I would maintain for almost ten years. I continued to try psychiatrists and mental institutions, but after each I would relapse again. After having performed many surgical procedures while loaded, I was asked to leave my residency. Besides institutionalization, I tried job changes, geographical relocation, self-help books, methadone programs, only using on weekends, switching to pills, marriage, health spas, diets, exercise, and religion. Based upon my track record, I was told I was incorrigible and that there was no hope for me. After about five years of heavy using, I developed a physical allergy to my drug of choice. By the time I reached my last hospitalization, my immune system was knocked out and I was a physical wreck. Worse yet, I was totally demoralized and suffering from a spiritual bankruptcy of which I was unaware. There, for the first time, I was confronted by physicians who were addicts themselves. They asked me first if I wanted help, and then if I was willing to go to any lengths to recover. They explained that I might have to lose all my 300 Narcotics Anonymous worldly possessions, my practice, my profession, my wife and family, even my arm. I figured there was nothing wrong with me that a little rest and relaxation could not set right. But instead, I made a pact with them: I would listen and take orders without questioning. These people experienced the same feelings, the sense of loss, doom, and degradation, as I did. They too had been helpless, hopeless, and beaten down by the same hideous monster as I had. Yet they could laugh about their past and speak about the future in positive terms. There seemed to be such a balance of seriousness and levity, with an overpowering sense of serenity. I heard about honesty, tolerance, acceptance, joy, freedom, courage, willingness, love, and humility. I had been praying to God the way a child asks Santa Claus for gifts, yet I still held onto my self-will. Without it, I reasoned, I would have no control over my life, and could not survive. Today, I pray only for His will for me and the power to carry it out on a daily basis, and all is well. I have found that His gifts are without number when I consistently turn my will and my life over to His care. And that change, when multiplied through many addicts, will make the world a better place for all, addict and nonaddict alike. Since all that I have gained from my involvement in Narcotics Anonymous has been freely and unconditionally given to me, it is incumbent upon me to freely give to others as well. In order to remind me of my previous xenophobic attitudes, God in his infinite wisdom and humor has arranged for me to sponsor many men of diverse backgrounds. Differences in drugs used, ethnic origin, socioeconomic background, sexual orientation, or spiritual belief system no longer create barriers to loving, fruitful relationships. Each has taught me more than I can relate here, and it seems that the "two-way street" we speak of in relation to sponsorship is heavily weighted toward my personal growth and awareness. I have found my calling in life, and that is to carry the message to the addict who still suffers. My great spiritual awakening has been that I am an ordinary addict-I am not unique. I had to learn to inject the medicine at the kitchen table with the windows open, not shoot it like dope in the bathroom with the door closed. Life was interesting, challenging, and enjoyable- pushing against the intellectual and social boundaries I was used to . My sponsor grew concerned when my meeting attendance dropped off due to the academic workload. My children and my sponsor were at my graduation, and the memory of how proud they were swells my heart. I waited a long time in the plasma center, and it seemed strange they did not call my name. I broke down crying, admitting I was an addict, and was able to get active in Narcotics Anonymous. I recall going to meetings, saying, "I can stay clean," but really wondering if that was possible. Today we both try to help others in recovery who may be going through this situation. I was taken to the emergency room and was eventually transferred to a physical rehabilitation hospital, where I was diagnosed with a nerve disorder. I was unable to attend meetings during this time, and my sponsor helped me so much. I am so blessed to have had the support of my sponsor and Higher Power during this tough time. I was arrested and taken as a suspect until suicide was verified as the cause of death. He showed up, and the next day the fellowship came and wanted to help any way they could. Finally someone shared that the answer was faith and not to give up five minutes before the miracle. I followed the advice to write a letter to her sharing my recovery and the unsaid things I needed to say, and felt released from the burden of grief. The program has taught me that I can recover from addiction, despite my other ailments. When this addict lost a brother and a son to the disease of addiction, his heart was crushed and his faith was challenged. When I returned, I surrendered with the willingness to do whatever it took to stay clean. I took suggestions and made new mistakes, and the emotional peaks and valleys eventually diminished along with my desire to use. I made mistakes, but I also learned to love, protect, and provide for my boys instead of trying to control, dominate, and fill them with fear as I had done most of my life. I did not want my boys to live as I had, with hate, anger, fear, and disregard for life. No matter what message I carry through words, my boys watch how I act and react to situations.
These results helped elucidate the elements of social networking sites that older adult users find beneficial and enjoyable medications with aspirin purchase 250 mg depakote free shipping, as well as the elements that older adult non-users find disadvantageous medications diabetes generic depakote 500 mg overnight delivery. Further research along this line will help provide designers of social engagement technologies the ability to increase their user base and address the needs and preferences of older adults medicine 6 year in us depakote 500 mg low price, an age group that is projected to sharply increase in numbers in the coming decades treatment mononucleosis 500 mg depakote with amex. Other factors that were discussed frequently during the group interviews conducted by Bixter et al treatment notes cheap depakote 500 mg with amex. These results are evidence that a perceived lack of control over content shared online medicine hat college buy discount depakote 250mg on-line, as well as the prevalence of malicious individuals and software, is either a barrier for some older adults adopting a social engagement technology in the first place, or a barrier for current users in enjoying the technology to its fullest extent. As a result, designers of current and future social engagement technologies will need to do more to not only combat security threats, but also ensure that the safety of the technologies is being communicated with users, particularly older adult users, clearly and effectively. The role technology can play in combating barriers to social engagement Social engagement technologies hold the potential to mitigate the barriers to social engagement that many older adults face-namely, physical, cognitive, and financial challenges. The unique role that technology can play in supporting and facilitating social engagement in older adulthood stems from its ability to provide individual older adults a powerful tool to overcome particular barriers they may experience as they age. Physical challenges such as increased immobility can make traveling and participating in social events difficult for many older adults. Social engagement technologies allow individual older adults to remain socially active from the comforts of their own home through the use of the Internet and the various devices geared toward facilitating social interaction. Thus, no matter the distance between an older adult and the people with whom they want to communicate, they may be better able to retain the social connections that they highly value. Furthermore, with the development of televideo technologies such as Skype, the experience of face-to-face social interaction is increasingly being captured through technical means. Moreover, the variety in types of communication that technology allows provides benefits for individual older adults afflicted by a particular physical challenge. For example, due to memory-related impairments that afflict certain older adults, successfully maintaining ongoing interpersonal communication with others can be difficult. For 202 Aging, Technology and Health instance, Slegers, van Boxtel, and Jolles (2012) found that computer use had a protective effect in older adults for cognitive functions such as selective attention and memory. As a result, the adoption and use of social engagement technologies can serve a dual purpose by affording individual older adults the ability to maintain both a cognitively and socially stimulating lifestyle. One of the benefits of technology for older adults relates to the ability for individuals to maintain high levels of social interaction at little-to-no additional financial cost. Many social networking sites and related applications are free to join, essentially eliminating the previously high cost of long-distance communication. Of course, some technologies can be financially expensive, particularly ones at an earlier stage of development or dissemination. However, as technological progress continues, devices and services that support social engagement and communication are rapidly dropping in price. Computers and smartphones that used to be exceedingly expensive and only within the financial reach of a privileged few are now more affordable. This high level of innovation and consequential reduction in costs have led certain technologies to be disseminated and adopted at high rates over the past few years, including by the older adult population. For older adults to continue to benefit from the advancements made in social engagement technologies, their needs and capabilities must be considered during the design and innovation process. Recommendations for social engagement technologies General design guidelines Design of social engagement technologies should proceed similarly to design of any product or system with which people will interact. Follow the fundamental principles of design that have emerged from decades of research in the fields of human factors, human-automation interaction, human-robot interaction, and human-technology interaction (for reviews see Salvendy, 2012). When designing for older adult users, their specific considerations need to be incorporated. Early focus on the user and the tasks the user will be performing, which often requires a task analysis. Empirical measurement using questionnaires and surveys as well as usability testing studies that rely on observations and quantitative or qualitative performance data. Integrated design, wherein all aspects of the usability design process evolve in parallel, and are generally under the coordination of a single person. A further extension of the idea of user-centered design is universal (or inclusive) design (Sanford, 2012), whereby products or environments are designed that are flexible enough to be usable by people with no limitations as well as by people with functional limitations related to disabilities or due to circumstances. In principle, good universal design benefits everyone and thus, would benefit many more people without disabilities than those with disabilities. Designing for older people can, similar to designs intended for accommodating people with functional limitations, also provide insights into designs that benefit all users. Design guidelines specific to social engagement for older adults In addition to following the standard human factors guidance for design, the specific context of social engagement will influence design considerations. Analysis of the barriers to use for older adults and current social engagement technologies can provide guidance as well. For example, Leist (2013) discussed some ways social engagement technologies can be improved to better suit the needs of older adults. However, at the same time, designers should not give in to ageist stereotypes and overly restrict the content available to older adult users. This could lead older adult users to assume a passive role in their engagement with the technology or prevent them from experiencing certain elements of the technology that they may enjoy. Leist (2013) concluded that design solutions will be strengthened through better understanding of the specific elements of social engagement technologies older adults are interested in. Training and instruction Older adults have more limited experience with social engagement technologies (such as social networking sites) compared to younger adults. As research summarized above demonstrated, older adults were more likely to adopt a communication technology the more personally relevant they found the technology or the perceived benefits associated with use of the technology. As a result, training might be more successful with older adults if it first focuses on older adults using either a site or 204 Aging, Technology and Health part of a site that focuses on personally relevant topics. Nimrod (2010) provided some examples of online communities designed specifically for older adults. Once individual older adults become more comfortable with personally relevant applications, they may become better equipped to explore sites or applications which are broader in scope and content. There are resources available for design of training specific to technology use by older adults. Of course, people differ in their preferred levels of engagement (with whom, for how long, engaging in what activities). Nonetheless, measures of social engagement are correlated with various measures of physical health, mental health, life quality, and even mortality-as we have reviewed in this chapter. Technology designers have an opportunity to design products, applications, robots, and other innovations that will enable social engagement-either by being engaging themselves, or by serving as a medium of engagement between people. Older adults are willing and able to use technologies for social engagement, but, as a whole, they are slower to adopt and report some reticence related to usefulness, usability, privacy, and security. Moreover, older adults may not be targeted as potential users during the design process and thus their capabilities, limitations, and preferences may not be considered into the final implementation. Designing technology with consideration of and involvement by older adults will yield more positive outcomes-and ultimately higher life quality. 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In my own stuff treatment 3rd degree burns order 500 mg depakote with mastercard, I write about toes functioning more like antennae than biomechanical units symptoms 6 days after conception order depakote 250 mg visa. Jan Sultan: Well treatment yeast infection home depakote 250 mg discount, one of the things about that homunculus (the map of the distribution of motor and sensory areas in the brain) that I found fascinating was that the thumb has as much motor sensory dedicated hardware as the whole leg treatment west nile virus purchase depakote 500 mg overnight delivery. A lot of what happens in the foot is actually unconscious or below the level of consciousness withdrawal symptoms depakote 250 mg cheap. Imagine a soccer player running down the field and the ball is coming on a diagonal across his path medications help dog sleep night order depakote 500mg with mastercard. As the player gets closer to the ball, he starts shortening the stride and making small adjustment steps so that when he and ball are in the same space he can kick it into the goal, at a dead run. That whole calibration, at a dead run, and the ball moving at a diagonal trajectory, all happens in the motor cortex. The skaters at the Olympics are a perfect example: what looks like perfect coordination is in fact an example of thousands of practice hours unfolding into fine performance. The motor homunculus diagram I was looking at simply showed the thumb bigger than the leg, including the foot. Rolf had an old anatomy book, Plastische Anatomie, from an anatomist named Mollier, illustrating the way that the two arches are structured. The medial arch is layered on the lateral arch, with the calcaneous being the common origin and the first and fifth metatarsals being the anterior projections of the arches. Moreover, there is a third arch that is the hollow sole of the foot, and it lays transverse to the two long arches. Rolf would say that if you want to get around like the Greek messenger Mercury, with wings on your feet, get your lateral arches up. When a cat is going to enter a space, the tension or the pressure of the whiskers tells the cat whether or not it can fit in the space. I took courses in pistol shooting for accuracy from an Olympic coach, and he pointed out that the handle of the gun has got to be long enough for the little finger to grip in order for you to shoot accurately. The little finger is the one that traps the barrel, in a sense, from the other end and really allows you to be accurate. That was the launch point for me to begin thinking about the little toe, and wondering. In contrast, he said, Middle Eastern people are always scanning, and for them to get from point A to point B may take quite a zigzag course. In that perspective, heaven and earth, above and below, form the energetic field that we are in, and as heaven descends and earth rises they mix in the body to form an alloy with your life force. Heaven and earth mix in the cauldron at the abdomen (the dan tien) and strengthen the ancestral energy called jing. You would rightfully assume that it would come down there, and then the earth energy comes up more dorsally, rising up the back of www. That rising earth energy coming up our dorsum, behind us, then goes extra-somatic into the space above us, meeting heaven. Heaven, meanwhile, is pouring down, coming down the front of our face and inside our skull, and the circuit closes where the tongue touches right behind the front teeth. If you want to bring heaven down, you put your tongue there and then that heaven qi comes down. Certain organs are nourished by the heaven side and others are nourished by the rising earth side. To return, it needs the squeezing of the leg muscles, and there are a set of one-way valves in the veins, so that as you walk, you squeeze blood up progressively and that pumps the blood back up across the pelvis. A certain amount of the return blood from the legs, which is oxygen-depleted, goes around the small intestine and becomes the portal circulation loop. Here is where the digested nutrients are picked up from the small intestine and taken to the liver. The return of color vision coincided with mother nature putting out all this big fruit. Obviously certain fruits being brightly colored would be attractive to the eye, and a carnivore would not be looking for that as food, but perhaps as the location to find the prey that feeds on the fruit. If you extend the logic, birds can perceive color, or at least they have a version of it in the ability to perceive certain frequencies. The eyes moved to the front of the head and started backing each other up, kind of like a telescope or whatever, and we also rediscovered how to see in color. As I see it, the foot and the hand, as articulate structures, have a lot to do with living in a world in which we say, "Oh, that fruit is green. I think of it biomechanically in terms of stored energy: I grab a hold of a piece of gravity with my foot when it comes down, and then I throw it away when my foot goes back. How much of this opening and closing is eccentric versus concentric motion of the muscles? When the compression phase of the gait happens, that arch is lengthening earthward, and then just at the point where it passes under you, and the load comes off of it, it also catapults you as stored energy that is appropriated for locomotion. Pilates came online right after World War I and was inspired partly by the ideal bodies that were coming to the first Olympics. Rolf was getting her inspiration), there was this eccentric expression, moving forward into space with the arms extended, the eye focused on a far horizon. Interestingly enough, although I think that Rolf and Joe Pilates did not have an overlap, they both came up with geometry. A typically concentric body gets its strength close to the body, and not at the limit at all. Take short, fast-twitch muscles, those that tend to have a larger percentage of fast-twitch fibers. In our society people tend to train those much more, to the exclusion of slow-twitch fibers that are still there, albeit in smaller percentages. This is as I understand it, so I could be not quite accurate, but the fast-twitch fibers are largely part of the phasic muscular activity. Fast-twitch fibers tend to consume more glucose, and the slow-twitch ones are more proportionally oxygen-burners. I think that certain kinds of yoga and Pilates train slowtwitch fibers, which are fundamentally postural muscles. Schleip said that if you took ten different psoas muscles, you would find quite a wide range of how much red or white fiber was in any given psoas. The tonic becomes a kind of scaffolding, and the phasic is all the ladders and platforms that are built around this tonic scaffold. Gesture has its base in tonic function, and we push the tonic body around with phasic activity and our feet and legs, for example. The support side then takes me to the legs and the whole thing about the return of circulation by contraction, and the veins with their one-way valves and the whole bit. The acetabulum is not the end of the leg, but rather the sacroiliac joint is the end of the leg. You see the heel strike harder, they use more muscular effort to pull themselves along, rather than that beautiful part of walking that looks like falling and recovery, giving a sense of almost floating. I pin that down to the function of the pelvis, and the way that the ilium is both leg on one side and pelvis on the other. The book Born to Run, which is an absolutely revolutionary statement, talks about the Tarahumara people who come up to run the century marathons. What the author of Born to Run points out is that they tend to run on their forefoot. High heels first appear for riding horses, as a way to hook your foot in the stirrup. Many are in their fifties and say, "I was in corporate life for many years and I wore high heels forty hours a week because that was the protocol at the office. Their feet often have bunions, their toes are jammed up, you see a funny development of the forefoot, and the heel cords are short. But if I look at the foot from the side, where the metatarsals and phalanges come together, that is often stuck at a right angle. In order to get a flat foot rehabilitated, you have to get better tonus and circulation in the peroneals, gastrocs, tibialis posterior, the whole bunch. I often actually end up using my fingernails in order to reach and grab that tough stuff. Well, both of them involve nerve work, but one is in the foot and the other is in the lower leg. If you consider the return of fluids against gravity, that sloppy foot is also not working as the second heart to drive the blood back out of the legs. You would perhaps anticipate a boggy leg that goes with that foot, or edema, that sort of thing. I think about the clients that I see with those feet and very often their spines are stuck in kind of a C-curve pattern. The journey that you have taken us on today dovetails with not only the theme of the feet, but I would say with the aesthetics of what we are doing in this particular issue of the Journal. Jan Sultan currently lives in Manhattan Beach, California, and maintains a full-time practice there. He teaches Advanced Rolfing classes and offers continuing education for structural integrators on a regular basis. In the Third Hour, when our concern is with the lateral line, I suggest to the client another experience - to bite down evenly and methodically on a length of rubber surgical tubing. The powerful flexors of the mandible effect an antigravity action throughout the entire body through the lateral line. This compromise, in turn, transfers the task of supporting the body weight to other more proximal joints, which then become overloaded, and subject to strain, excess wear and tear, and lesions. Often, the antigravity muscles exert more force on one side than on the other, which can produce various lateral asymmetries. Following manipulations to address these lateral asymmetries, we are likely to observe greater symmetry and balance in the distribution of weight over the feet. I also use specific chewing exercises to address lateral asymmetries: since the muscles of mastication are key to the antigravity response, balancing the tonus of these muscles tends to carry through to other antigravity muscles. The foot map also demonstrates the importance of the oral functions to the gravity relationship. This connection has a clear evolutionary basis, as the locomotor system developed to facilitate the pursuit and capture of food. I also undertook a program of postgraduate study in psychomotricity, which is the study of the relationship of physical movement to cognitive, affective, and psychosocial behaviors. Making the map is simple, and begins with asking the client to notice in standing which parts of the feet support the weight, and in walking which parts receive weight and which push off. Next, the client stands on a piece of paper while the practitioner draws an outline around each foot. Then the client draws onto the outlines a representation 16 of his or her felt sense of which parts of the feet are active for support, receipt of weight, and propulsion. To facilitate use of the maps to track changes over time, it is helpful to have pencils or pens of various colors. Interventions the Second Hour of a Ten Series is an ideal time to introduce the foot map. Here, I often suggest to the client another oral exercise that acts on the entire medial line, with the goal of increasing the propulsive force of the feet through better use of the psoas. These are exercises to coordinate and strengthen the internal and external musculature of the tongue and lips. They are rhythmic and are executed with tonic musculature, which brings connection and good tone to the deep medial line. As a direct intervention with the feet, I also use exercises for differentiation and integration of various structures. For example, I ask the client to stand with one foot on a slender stick (about one-half inch in diameter), which I place lengthwise under either successive metatarsal interspaces or successive metatarsal bones (see Figure 1), starting at the lateral foot and working medial. This helps to differentiate the rays of the toes, and also to create space between them. Along with these exercises - especially for clients with diminished arches - I like to add another one to differentiate and strengthen the interossei. With legs extended, the seated client is given an elastic band to wrap around one toe at a time (see Figure 2). The client tugs on the band to apply tension to the toe, and then plantarflexes the toe, against resistance from the band, at the metatarso-phalangeal joint. Figure 3 functional balance in both standing and walking: he drew the bold lines on the map after that process. Figure 2: Plantar flexion at the metatarsophalangeal joint, resisted with elastic band. Case Study Discussions Figures 3-10 will be used for brief case studies to show the maps in use. Each map includes various temporal elements, drawn with different lines, as discussed below. On the initial map (the fine lines in the drawing), we can see how the lateral aspect of the left foot is suspended. Sandro (Figure 4) is a runner, and presented with complaints of body pain in many locations. The oral exercises released tension that had been suspending the left lateral line and throwing the arch of the foot medially in walking (Figure 5). This, in turn, amplified his push-off and brought the left transverse arch more lateral. Observe also how a shift in the balance of 17 Figure 1: Stick placed under third metatarsal. By the end of the session, she no longer felt pain in her neck and did not complain of neck pain thereafter. Karol (Figure 7) complained of great pain in her neck, particularly on the right side. After manipulation of the right medial line followed by mastication exercises, the bold areas indicate that her foot found someplace to receive her weight, as well as greater medial 18 Figure 8 Mauricio (Figure 9) presented with low back pain.
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