EBP Midterm

Learning outcome: Conduct a literature search.

Which of the following is a not benefit of completing a literature review?

a.     Decreases credibility by looking at more than one source

b.     Identify gaps in the research

c.      Familiarize yourself with up to date literature on this particular topic

d.     See if a similar study has been done

Neuro Note 5

For my final neuro note, I decided to watch a TedTalk called, “Protecting the brain against concussion” by Kim Gorgens. This is a talk regarding how to better protect our brain against concussions and other head related injuries. Kim Gorgens, a neuropsychologist, gives an informative speech about the significance that brain injuries are occurring in children and teens and makes the argument of the importance of protecting our brains particularly in the use of helmets. Although we cannot always protect our family members from brain trauma, it is important to be aware of brain injuries and take preventative steps. Gorgens states that parents should study up on the signs and symptoms of concussions, speak up to legislative and couches about preventative head wear, and to suit up to prevent a brain injury. In this talk, she says, “The only way to prevent a bad outcome is to prevent the first injury from happening.” To me, that was a very powerful statement that I think should be reinforced more in child rearing. After learning about the different ABIs and the harsh possibilities of coma outcomes, I have been really interested in brain injury and development, which led me to pick this TedTalk for my last neuro note. I think Kim Gorgens shares great points in this video in emphasizing the importance of helmets. We can truly never be careful enough in regards to the safety of our brain. About 4 million kids under the age of 14 are concussed per year and that is only one’s seen in the Emergency Department. It is a common misconception that a concussion refers to the lack of consciousness, however, the definition of a concussion is the change of consciousness which includes feeling foggy, dizzy, ear ringing, or even just a change in a person’s attitude. After listening to this TedTalk, it makes me think more about the safety in kids playing contact sports. I think an advanced protocol needs to be put in place to determine if a child should be able to go back onto the field after a head blow. I think this would prevent brain injuries and side effects later in life. Gorgens also talks about how the proposed law for all people under the age of 18 should wear a helmet when cycling was recently rejected. To me, this is baffling and makes me think that the average person may not have a clear understanding of just how detrimental a head injury could be to person’s life and their future. I think, as OTs spreading awareness about preventative head injuries is important for our scope of practice.

https://www.ted.com/talks/kim_gorgens_protecting_the_brain_against_concussion

Media Project- Virtual

 

Dementia Case Study

Pat Summitt was diagnosed with early onset dementia at age 59. Her symptoms included becoming very forgetful, losing car keys, calling out the wrong terms in basketball games, and wearing inappropriate outwear (ex. shorts when it was snowing). Pat's functioning level soon decreased resulting in her referral to occupational therapy. OT goals include increasing the client's ability to function independently and caregiver education. Pat's occupations include coaching, writing, and playing basketball. Her roles include being a mother, coach, author, spokeswoman. Pat Summitt passed away just 5 years after being diagnosed.  She is most known for coaching the University of Tennessee Lady Vols for 38 seasons with 1,098 wins.

Neuro Note 4

Today, I decided to write my neuro note on a TedTalk called, “Tourette Does the Talking: Thomas White”. This is a talk given by a senior at the University of Notre Dame, Thomas White, whom has Tourette’s syndrome. He speaks about his daily challenges with fighting this neurological battle. This syndrome plays a major role in his daily routines and encounters with other people.  I chose to watch this video because of the little I know about this neurological disorder. Before watching this video, my knowledge of Tourette’s syndrome was very limited. However, now I know that it is a syndrome that is a result from a chemical imbalance in the brain that inhibits involuntary motor or vocal tics. Although the majority of the talk is about Thomas White’s daily struggles, one of the main points he states is that we should all celebrate the beauty of life, not matter what our troubles are. He goes on to talk about that we all have problems, but we’re all in the same boat and can triumph our own “plagues” together. At the point that we all realize this, we can focus on hope and action of who we are and what we can become. He ends his talk with, “We should all embrace the life we live and each word is a celebration and has hope.” To me, this video was so inspiring and really got me thinking about how can occupational therapy be used to help people with Tourette’s syndrome manage their occupations and daily routines. After further research, I have learned that the OT service would vary depending on the individual’s severity and kind of TS. Many OTs work with individuals that are diagnosed with TS using a sensory approach. Some OTs go into further training to learn techniques in CBIT, or Comprehensive Behavioral Intervention for Tics.

https://www.youtube.com/watch?v=0szLOMIt9SQ

https://www.tourette.org/blogs/research-medical/benefits-occupational-therapy-tourette/

MD Case Study

Jonah Marlin was diagnosed with Duchenne Muscular Dystrophy when he was 5 years old when his symptoms became more apparent. DMD is a hereditary disease caused by a defective protein making gene. This is the most common type of MD and occurs primarily is males. Because his parents knew  what to look for, his brother was diagnosed at age 2. Jonah is now 13 and lives with his parents. He is in a wheelchair all day and relies on his parents for all of his ADLs. Jonah has seen OT previously that gave him goals to help with ADLs and social interaction.

Case Study: Trey Gray

Trey Gray was diagnosed with Huntington's Disease in 2003 when he was 32 years old. He became a national spokesperson for Huntington's disease in 2008 and created the Trey Gray fund at Vanderbilt. Since HD is a degenerative disease, OT would focus on his muscle cognition and muscle memory skills to prolong his occupation of drumming. He has symptoms of fatigue, weakness, memory, and mood swings in his early stages. A long term goal for Trey would be to make a daily schedule to better organize his day and keep track of his daily tasks that need to be completed.

Neuro Note 3: Muhammad Ali

When I was looking at some of the options to do my neuro note on, I saw a People Magazine article, "Muhammad Ali's Eldest Daughter Shares Memories of Her Dad and Hope for Those with Parkinson's: 'Attitude Is Everything'". After already learning about Parkinson's Disease, I was excited to read more into the legendary Muhammad Ali's case specifically. I knew that he had PD, but had no idea about his type of care or factors that played into his health status, which is why I chose to write a blog on this topic specifically. This article about Muhammad was given from the perspective of his oldest daughter, Maryum Ali. 

Mayryum, or May May, gave an insightful view of caring for a loved one with Parkinson's. She speaks about how much being engaged in activities that make you happy is important for someone with this disease. She also talks about how attitude strongly affects the patient along with the patient's knowledge of his or her disease.

 After reading her article, I thought to myself, "Patients with PD could really benefit from OT!" OT's could provide this meaningful activities to their clients that in return help give them give positive attitudes. I also thought about the OT's role in educating the client, as well as the caregiver about the disease and what to expect through the different stages of PD. May May stated, "Once my father began to understand the disease and the family did as well, everyone was happier." To me, this just solidifies everything we talked about in class as far needing to inform the caregiver and client. I went to the National Parkinsons Foundation's page and read an article, "Special Challenges of Caring for Someone with PD" to further my curiosity. This site talked about being realistic with the client and caregiver, and I think that is exactly what May Mary and the rest of the Ali family would have appreciated knowing early on.

 http://www.parkinson.org/understanding-parkinsons/caring-for-someone-with-parkinsons/special-challenges-of-caring-for-someone-with-parkinsons

http://people.com/celebrity/muhammad-alis-eldest-daughter-maryum-shares-memories/

Foundations Debrief

As our Foundation course comes to an end, we spent our last class reflecting on what we liked and things we would change in this course. I appreciate that because as a student, it is nice to know that the faculty takes our opinions into consideration when looking at next year's coursework. As a personal reflection of this course, I would say my biggest take away was having a better understanding of the profession of occupational therapy as a whole. I know that no matter what setting I am in that I will use a client-centered, occupation-centered, EBP, and cultural practice approach. I think I sometimes even say the definition in my sleep.  I also have a better perception of the different populations, environments, and setting that involve OTs. My parents are constantly asking me where and who I want to work with in upon graduation, but I can never give them an answer because I am always learning about new and different settings for OTs! Furthermore, I have a better understanding of the basics of OT from learning and studying the OTPF, OT Process, and the Code of Ethics, which I know will help me daily in the 'real world'. I have enjoyed this class and look forward to learning more about OT in other classes and upcoming fieldworks.

Myasthenia Gravis

Kristen Graham had her first Ocular Myasthenia Gravis outbreak when she was 11 years old. After a few years the disease spread to other parts of her body, and is now considered General Myasthenia Gravis. Stress is the primary trigger for her outbreak, so OT would help Kristen balance her lifestyle by making a weekly schedule, conserving energy, and practicing relaxation techniques. 

Emerging Practice: Adults with Autism

When I saw “Adults with Autism” as an emerging practice in occupational therapy, I knew this is what I wanted to write my next blog post on.  People with autism are supported with OT services until they turn 22 within the school system according to the Individuals with Disabilities Act. However, after that they are on their own. Children with autism get older everyday, and have to make the decision of what to do after high school. Adults with autism need to have more opportunities for occupational therapy in community services.  As OTs, we need to have more integration programs from high school into the real world. This could include a wide variety of programs including potentially helping them find a job.

https://www.aota.org/Practice/Rehabilitation-Disability/Emerging-Niche/Autism.aspx

ALS Case Study

Ulla-Carin was a Sweden news anchor whom was diagnosed with ALS at age 49. Her roles and occupations included being a mother, wife, friend, journalist, and athlete. Although she died within a year of being diagnosed, she remained mentally coherent throughout her life with ALS. Fortunately her home was completely renovated and was able to stay at home. The OTs primary goal was energy conservation, so that the client could conserve as much energy as possible throughout the day. She was also able to get an assistive technology device that tracked her nose movement for communication.

Fletcher Cleaves

After hearing Fletcher Cleaves story last week, I have thought a lot about his story and his overall outlook on life. He told us how his doctor was discouraging and how everyone doubted him and his ability to recover, and for me, this was frustrating.  As a future health profession, I think it is so important for us to motivate our clients, so that in the rehabilitation process they will be encouraged to their best. Even though Fletcher had an accident that completely altered his life, he has such a positive outlook on life. For him to have come out of this recovery process, and decided to share his story to others is inspiring. He ended his speech with this statement; “Don’t tell your clients to reach for the stars when there’s footprints on the moon.” I think I will always remember that statement and I am so thankful he came and spoke to our class.

Emerging Area of Practice in OT

In America today, nearly 1 in 3 teens and children are obese or overweight. Since obesity leads to many health issues, such as high blood pressure and diabetes, health professions have been led to try to decrease obesity rates. With that being said, in 2011 AOTA identified childhood obesity as an emerging practice for occupational therapy. When a child is obese, it hinders them to participate in their daily occupations. When limiting a child's occupations, their overall health and well-being is affected. Obesity affects occupational performance, and so it important for OTs to make goals for children with obesity to get more active. In order for the goal to be client-centered, the OT first needs to see what kind of interests the client has in becoming active, whether it being playing at recess or joining a sports team.
I think this new emerging practice correlates appropriately with AOTA's Vision 2025. In order to maximize health, well-being, and quality of life for all people, we need to look at specific health problems that can be partially prevented. I know that obesity often runs in families, but that is something we need to educate the public about. As OTs, we should provide more community activity programs and education about physical fitness and healthy diets.

https://www.aota.org/Practice/Health-Wellness/Emerging-Niche/Obesity.aspx

Case Study: Parkinson's Disease

Muhammad Ali was diagnosed with Parkinson's Disease at age 42. He was referred to occupational therapy to support his occupational performance of being an athlete, motivational speaker, and philanthropist. Being a former boxer, he was use to being very active, so when he should schedule his medicine is very important to his busy lifestyle. It is important for him to remember to take breaks while waiting for the medicine to kick in. Another goal is to educate his caregiver about Parkinson's Disease and how to support Muhammad Ali. After being diagnosed, he wanted to continue his motivational speaking which includes traveling and advocating for PD. With that being said, his short term goals include managing his medication and taking breaks throughout the day. His long term goal is to be able to carry the torch at the next Olympics. 

Activitiy Analysis

After hearing so much about everything that goes into planning therapy sessions with clients, I was looking forward to doing my own. I decided to pick making trail mix as my activity to work with fine motor skills and simple sequencing for cognitive skills. The overall analysis took longer than I had expected. There was a lot to think about when planning an activity! Although my activity went shorter than I expected, I think my group enjoyed it. My other group member’s activities were bow tying, making Rice Krispy treats, and making guacamole. Needless to say, today we ate some yummy snacks! Not only did I learn by creating my activity analysis, but also it was fun to be able to come to class and implement our activities to see the changes we should make for the future. Hands down today has been my favorite day of class thus far!

Memphis Rollin' Grizzlies

After talking about different spinal cord injuries in class I found myself very interested in the different sports that have been altered to include people in wheelchairs. My class was invited to the Memphis Rollin’ Grizzlies practice and I was very excited to say the least. After going to the Memphis Rollin’ Grizzlies practice, I knew exactly what I wanted to write my next neuro note on. I had always heard of adapted sports for people in wheelchairs, but have never experienced it first hand.

            During this practice, I saw the Memphis Rollin’ Grizzlies scrimmage a game of wheelchair basketball. The amount of upper body strength and athleticism that went into this sport was incredible. They had to not only coordinate the sport of basketball, but also play while in a wheelchair. Their drive for the game was so inspiring. These guys did not let their various disabilities keep them from playing basketball.

            I am so glad that I followed up on my interest of the sport and went to practice to further my knowledge. I think my biggest take away from this blog post is to always encourage people to continue doing the activities they enjoy in some form or fashion. Some of these guys started out their adulthood with different goals, when a sudden accident altered their life forever. They didn’t let there knew way of life stop them from playing basketball, but found a different way to play. To be a better occupational therapist I think it is important to know about different community opportunities to better engage and encourage clients. Many people do not know that activities such as wheelchair basketball are available in their communities. As OTs, we should make the public more aware of these kinds of activities and involvement!

Ethics

In class we were given the definition of ethics as, “the study of how judgments are made in terms of right and wrong, the philosophy of human conduct.” Although that seems to be a very direct definition, it still leaves plenty of room for grey area in the clinical setting. As future a practitioner, it is my responsibility to determine what is right and what is ethically wrong in any given situation I come across. Luckily, AOTA has provided a Code of Ethics for practitioners as a guide for OTs. This guide helps provide consistency within the profession along with putting the accountability in the public light to educate the general public on what they should expect from occupational therapist. Having a Code of Ethics within the profession promotes the integrity of the profession as a whole. It also provides protection for practitioners and consumers across the general practice settings.

Lifelong Learner

After being in OT school for just a few short months I have learned that occupational therapist are lifelong learners, but what does that really mean? When I first heard the phrase, I thought it just referred to formal education such as going on to get my doctorate later in life.  Being a lifelong learner does not mean just going to school to get another degree, it’s continuing education voluntarily.  This could be for personal interests or for a specific job. After talking about this topic more in class, I have realized it is pertinent for out professions to continue our education. In order to be the best practitioner I can be, I must be up to date with new therapy techniques and the research behind it to best treat my clients. Not only is it important for our practice setting, it is also outlined in AOTA for OTs to commit to being lifelong learners. I am so excited to be in a profession that puts such emphasis on being successful practitioners in treating our client with the utmost support!

Spinal Cord Injury Case Study: Tyler

Tyler Densfod is a 23 year old in the Air National Guard. On June 11, 2016 Tyler was participating in a drill when a fatal accident resulting spinal cord injury occurred. His T7 and T8 spinal vertebrae were broken resulting in paralysis from the waste down. After time at the Regional One Trauma Center in Memphis, Tyler was transported to the Shepard Center in Atlanta for rehabilitation. During his time there, he received PT and OT 4-5 times a day. During his sessions with the occupational therapist, he worked on ADLs such as: getting dressed and brushing his teeth. Tyler was discharged from the Shepard Center 3 weeks after he was admitted. Upon discharge, Tyler made one of his primary goals to be able to drive again. He has been able to achieve this goal by using the technology of an adapted car. After hearing Tyler's story it makes me realize how important occupational therapy is for individuals with spinal cord injuries. Tyler speaks highly of his time with OT and has stated that if he regains any functioning in his lower limbs he plans to utilize occupational therapy.

Me Before You

As I sat down to write my first Neuro Note, I first skimmed the suggestions that my professor provided for my class when I saw the movie, Me Before You. This was a movie that I had seen when it first came to theatres and had never really thought about the neurological aspect of one of the main character’s paralysis.

Me Before You is a movie about quirky, optimistic woman, Lou, who takes on a new job as a caregiver to Will Traynor to help financially support her family. Will Traynor is a wealthy, cynical man whom became paraplegia after a devastating motorcycle accident. Although he was pessimistic at first, he soon enjoyed Lou’s company and began to look forward to her visits. Before Lou arrived, he did not have any goals or social interactions. She started taking him out in public, planning trips, activities, and learning about his overall interests. It was amazing the affect it had on his mental health. Will desperately needed a motivator and someone to encourage him to still participate in meaningful activities. To me, this movie really portrays just how much social interaction can affect someone’s mental state. Lou’s encouragement and care for his well being really made an impact on his life. Will did not have an occupational therapist, but it makes me wonder how the quality of his life could have been enhanced had he been introduced to OT in an outpatient setting.

After doing some research in occupational therapy for people with paralysis I think it could have impacted his life drastically. An occupational therapist could have helped him make goals, develop routines, and encourage community engagement. An OT could even provide opportunities to educate in peer resources and self-advocacy. Lou had a lot of occupational therapist qualities about her and I think that has a lot to do to the role she played in his life.

After writing this blog, I now realize how important social interaction is and a better understanding of an OT’s role in providing therapy to a person who is paraplegic.

Moyes, J. (2012). Me before you. New York: Pamela Dorman Books.

Occupational Therapy and the Care of Individuals With Spinal Cord Injury. (n.d.). Retrieved April 23, 2017, from http://www.aota.org/About-Occupational-Therapy/Professionals/RDP/spinal-cord-injury.aspx

Universal Design

After numerous courses over the years, I believe I am plenty familiar with the Americans with Disabilities Act and how it gives people with disabilities the right to have equal access to and in public places. However, I never thought why can’t there be a universal design that allows everyone accessibility? Before our class a few weeks ago, I was unaware what universal design truly meant. Universal design is, “The design of products and environments to be usable by all people.” This improves access for all people, with and without disabilities.  After learning about this design, it makes me wonder why here in the US, we don’t go more toward this type of settings in our schools and businesses.  In public places where the entrance is a great big staircase, they meet ADA regulations through a ramp in the back where people who are in a wheelchair have to enter. The majority of the backs of buildings I have been have been gross and typically where the trash goes out. Are these owners implying that in the back with the trash is where people with disabilities belong? I think as a country, we should aim more towards universal designs rather then just meeting ADA standards.

Clinical Reasoning

Today in Foundations class, we started talking about clinical reasoning and the importance of it in occupational therapy. Before today’s class, I had never really thought about just how much goes into clinical reasoning, but now the process of making scientific, ethical, and artistic decisions are much clearer. To determine the scientific element, it is similar to using the scientific method like what I used for my science projects in grade school. We first have to determine what we know, then think of all of the possibilities for that client. To think of the different possibilities and outcomes for a client, OTs must think back to previous cases and academic material, such as textbooks, to help them better understand what could be effective for the client.  The questions we think to ask the client comes from careful assessments and analysis from what we as OTs know. When looking at the ethical element of clinical reasoning, we must weigh things to decide what should be done in that ethical dilemma. We must use our gut instinct to realize the urgency of the client and if it could be detrimental to his or her recovery process or overall health. How you decide what to do when you meet a challenge is determined by the artistic element of clinical reasoning.  You have to be able to read the situation and determine if humor or silliness is appropriate. There is no clear-cut answer for any of these, so to have better clinical reasoning we must embrace the gray area!

What Does "Disability" Really Mean?

After reading “What does ‘disability’ really mean?” for class last week, it got me thinking just how deteriorating that word is. The author, Max Chis, talks about the meaning of the word and how it automatically implies that a person is lesser than ‘normal’. Terms like  “Lack of,” or “not” are the literal definition of the prefix dis. Just by using the word disability already automatically puts a negative connotation on someone just because they may learn or do things differently.  As occupational therapist, we need to look at what a person can do and their strengths to be able to build and work on their weaknesses. Just because someone is different does not make them any less of a person and that should be recognized.

Resources:
Chis, M., Hoff, J., & Firn, G. (2016, December 7). What Does 'Disability' Really Mean? Retrieved April 14, 2017, from https://themighty.com/2016/12/what-does-disability-really-mean/

Person First Language

Although the Person First Respectful Modernizaion Act of 2006 has been put into place nearly 10 years ago, the majority of the population here in the US has yet to recognize respectful language for everyone. When you use "Person First language", this puts the person before the disability. If I broke my arm, I wouldn't expect to be referred to as "broken arm Valerie", and a child with autism should not be referred to as the "autistic child". We should recognize individuals as just what they are- people, not their disability. I think as OTs and OT students is important for us to be examples in using Person First Language and to educate the general public on exactly what it is and how it plays an effect on our society.

Resources:
Person First Language: Guidelines. (2006, July). Retrieved April 14, 2017, from https://odr.dc.gov/page/people-first-language

Health Promotion

The American Occupational Therapy Association’s Vision 25 states, “Occupational therapy maximizes health, well-being and quality of life for all people populations and communities through effective solutions that facilitate participation in every day live.” I think as a future OT it is essential to be aware of the profession’s goal and do my best to try to work towards achieving that purpose. In order to achieve this goal, I think OTs needs to be more involved in community-based settings to be able to reach out to all populations and try to educate people about health. I did not realize the general lack of knowledge about health until I begin leading exercise and health promotion groups. Many people in my groups said that they couldn’t exercise because they could not afford a gym. They were baffled when I showed them different chair exercises and ways to work out in the home. This made me realize how important education in health literacy is and how much it is needed in our society.

4/5 Daily Challenge

Although this is only our second Neurological Aspects class, I am so fascinated with all of the material that has been presented to us this far. Fortunately, I have not personally known anyone with an TBI, but after the past few classes I have realized just how sudden they can drastically change a person's life. The little I do know about TBI's have been primarily about the person with the diagnoses, rather from the family members perspective. After listening to the podcast, "Help me remember", it gave me the point of view of the family's side of the TBI. For me, it was absolutely heart breaking listening to her husband and children's testimony of the everyday struggles and obstacles resulting from the brain injury. I feel like in clinical settings we often just look at the patient's everyday struggles, so hearing the other side was really sad and an eyeopener. I know there is not a cure from TBI's, but it makes me wonder what kind of therapy would an occupational therapist due with Dawn? Would we work more on improving her memory and coping skills? Or, would we work more toward setting reminders and organized calendars? It also makes me wonder what happens to people that do not have such a broad support system like Dawn does.

Resoonse to Aimee Mullins' Ted Talk

After hearing Aimee Mullins' Ted Talk today, I am honestly shocked that our society still puts such a negative emphasis on the word, 'disability'. In a country that seems to be so understanding of differences, it is baffling to me that a person that is considered to have a 'disability' can be looked down upon without knowing an individual's circumstance. Person's with disabilities are more alike then different, and I think it is important that we as OTs are advocates to let that be known. It is not fair that our society can often put people down because they are different when really they have so much potential.

Putting OT theory into Action- Thoughts

Putting OT Theory Into Action: Knowing and Applying Frames of Reference
By: Lynne Oberle

The very first sentence of this article really caught my eye, "It is imperative to understand theory and frames of references to be able to justify why you are implementing any given treatment strategy." After learning about multiple models of framework in the practice of occupational therapy, it is imperative to know why you are going about therapy in order to properly implement it. In order for therapy to be effective, a therapist must look at the research and theories behind it to make sure that the therapy method is right for that specific individual. In the article, the writer talked about how her mother, Anne, was discharged from the hospital without knowing how to properly take care of herself once she got home. Her home is a different environment then the hospital and that is something that the OT's should have focused on during her stay in the hospital. When looking at the Person-Environment- Occupation (PEO) Model, it looks at a person in a holistic way to determine the best therapy for the client. Not only does it look at the person's roles and meaningful activities, but also the environment in which they live in. This model would have been a better approach for Anne in returning to her home so that she and her caregiver would have a better understanding of how to go about her ADLs. A different approach to going about Anne's therapy could have been looking at the Model of Human Occupation. This model looks at an individual's volition, habituation, performance, and environment. Looking at Anne's habituation would allow the therapist to see her roles and daily routines, while looking at her environment would show her physical surroundings that she is returning home to. With that being said, if the MOHO would have been used in this scenario the occupational therapist would have been able to work with Anne's daily routines in the environment she lives in to better her time in therapy and recovery at home. In my opinion both the PEO and the MOHO would have great models to better Anne's transition from the hospital to her home and her overall therapy experience.

How does OTPF influence OT practice?

How does OTPF influence OT practice?
The Occupational Therapy Practice Framework gives occupational therapist guidelines to access and treat clients by using the top-down approach. This type of approach directs occupational therapist to look at the client centered domains and processes. When using the OTPF it drives occupational therapist to look at what is important to the client to set meaningful, realistic goals.