The Disablement Process

1. What is Physical Therapy Disablement Process What do Physical Therapists do Nagi Model Who Model ICF Model The Disablement Process Model Comparison Patient Cases Intervention Strategies Healthcare Domain Healthcare Professionals Clinical Application Clinical Reasoning Map of Essential Concepts

2. Disablement process What is Physical Therapy What do Physical Therapists do Nagi model of disablement WHO model of disablement ICF model of disablement Comparison of models Patient cases Intervention strategies Healthcare domain Healthcare professionals Clinical application Clinical reasoning Last Viewed Exit Disablement Concept Map

3. Disablement Process • Disablement Model • A conceptual explanation of the process and underlying mechanisms by which disease, injury or birth defect impacts a person’s ability to function (perform their expected role in society). Last Viewed Exit Disablement Concept Map

4. What is Physical Therapy? • Physical Therapy is a group of health care professionals dedicated to: • Alleviating pain • Preventing the onset and progression of impairment, functional limitation, disability, or changes in physical function and health status resulting from injury, disease, of other causes • Restoring, maintaining, and promoting overall fitness, health, and optimal quality of life (Guide to Physical Therapists Practice) Last Viewed Exit Disablement Concept Map

5. What do Physical Therapists Do? • Relieve / resolve disability or functional limitation by • Changing the underlying impairments (Guide to Physical Therapists Practice) • The Goal of Therapeutic Intervention • Maximize function and thereby minimize disability. Last Viewed Exit Disablement Concept Map

6. Nagi Model 1/8 • A conceptual explanation of the process and underlying mechanisms by which disease, injury or birth defect impacts a person’s ability to function (perform their expected role in society). • Nagi experimental hypothesis • Disease Causes Impairment Impairment Causes Functional limitation Functional limitation Causes Disability Last Viewed Exit Disablement Concept Map

7. Primary Pathology Primary Impairment Functional Limitations Disability Nagi Model 2/8 Last Viewed Exit Disablement Concept Map

8. Primary Pathology 3/8 • Pathophysiology due toDisease, Injury, or Congenital Abnormality Last Viewed Exit Disablement Concept Map

9. Primary Impairment(Signs & Symptoms ) 4/8 • Result of primary pathology - physiological or psychological consequences (e.g. in stroke: hemiplegia, loss of selective movement control, sensory loss, perceptual problems, aphasia) • Not usually amenable to intervention by PT Last Viewed Exit Disablement Concept Map

10. Secondary Impairments 5/8 • Due to lack of treatment of primary impairments (e.g. dicubiti, contractures, disuse atrophy) • Usually what PTs treat Last Viewed Exit Disablement Concept Map

11. Functional Limitations(Abilities Lost) 6/8 • Due to impairments (inability to perform ADLs) • Basic ADLs (BADLs): self care: dressing, grooming, hygiene, toileting, bed mobility, transfers, locomotion, speech, reading, writing • Instrumental ADLs (IADLS): higher order skills requiring more psychological processing in addition to motoric functioning (e.g. shopping, paying bills, meal preparation, going to the movies) Last Viewed Exit Disablement Concept Map

12. Disability (Handicap) 7/8 • Social and psychological consequences of functional limitations (inability to fulfill expected social roles, e.g. hold a job) - may be heavily influenced by external factors like: support system or funding Last Viewed Exit Disablement Concept Map

13. Limitations of Nagi Model 8/8 • Nagi is a unidimensional (pathology-based) and unidirectional model of disability only • Does not account for impairments and functional limitations not due to pathology • Functional limitations due to obesity or due to sedentary lifestyle • Dose not consider societal barriers: architectural, attitudinal Last Viewed Exit Disablement Concept Map

14. Disease Primary Impairment Disability Handicap World Health Organization Model (WHO) 1/3 Last Viewed Exit Disablement Concept Map

15. WHO 2/3 Nagi Level of Analysis Primary Pathology Disease Cell / Organ System Primary Impairment Primary Impairment Personal Disability Functional Limitations Society Handicap Disability Last Viewed Exit Disablement Concept Map

16. 3/3 Nagi Model WHO Model (International Classification of Impairments, Disabilities, and Handicaps, ICIDH) Last Viewed Exit Disablement Concept Map

17. Patient Cases • Inversion ankle sprain • Myelomeningocele Last Viewed Exit Disablement Concept Map

18. An example of using the model to determine the level of disability/handicap 1/6 Following a severe inversion ankle sprain, this 35 year old, male, Fed Ex driver is unable to walk or work. Last Viewed Exit Disablement Concept Map

19. An example of using the model to determine the level of disability/handicap 2/6 Following a severe inversion ankle sprain, this 35 year old, male, Fed Ex driver is unable to walk or work. Last Viewed Exit Disablement Concept Map

20. An example of using the model to determine the level of disability/handicap 3/6 Following a severe inversion ankle sprain, this 35 year old, male, Fed Ex driver is unable to walk or work. Last Viewed Exit Disablement Concept Map

21. An example of using the model to determine the level of disability/handicap 4/6 Following a severe inversion ankle sprain, this 35 year old, male, Fed Ex driver is unable to walk or work. Last Viewed Exit Disablement Concept Map

22. An example of using the model to determine the level of disability/handicap 5/6 Following a severe inversion ankle sprain, this 35 year old, male, Fed Ex driver is unable to walk or work. Last Viewed Exit Disablement Concept Map

23. An example of using the model to determine the level of disability/handicap 6/6 Following a severe inversion ankle sprain, this 35 year old, male, Fed Ex driver is unable to walk or work. Last Viewed Exit Disablement Concept Map

24. An example of using the model to determine the level of disability/handicap 1/6A 40 year old woman born with spinal bifida, transports via a wheel chair, practicing lawyer, married with two children. Last Viewed Exit Disablement Concept Map

25. An example of using the model to determine the level of disability/handicap 2/6A 40 year old woman born with spinal bifida, ambulates via a wheel chair, practicing lawyer, married with two children. Last Viewed Exit Disablement Concept Map

26. An example of using the model to determine the level of disability/handicap 3/6A 40 year old woman born with spinal bifida, ambulates via a wheel chair, practicing lawyer, married with two children. Last Viewed Exit Disablement Concept Map

27. An example of using the model to determine the level of disability/handicap 5/6A 40 year old woman born with spinal bifida, ambulates via a wheel chair, practicing lawyer, married with two children. Last Viewed Exit Disablement Concept Map

28. An example of using the model to determine the level of disability/handicap 6/6A 40 year old woman born with spinal bifida, ambulates via a wheel chair, practicing lawyer, married with two children. Last Viewed Exit Disablement Concept Map

29. Medical Aspects Social Aspects Domain of Physical Therapists Practice Disability Functional Limitation Pathology Pathophysiology Impairment Healthcare Domain Health Care Cardiopulmonary Integumentary Musculoskeletal Neuromuscular Physical Psychological Social Last Viewed Exit Disablement Concept Map

30. Levels at Which Health Professionals Function 1/2 Pathology Impairment Functional Limitation Disability Physician Physical Therapist Occupational Therapist Last Viewed Exit Disablement Concept Map

31. Activity Emphasis of Health Professionals 2/2 Functional Activity Health Professional Mobility Transfers Positioning Toileting and Hygiene Dressing Feeding Communication Physical Therapist Occupational Therapist Speech Therapist Last Viewed Exit Disablement Concept Map

32. Clinical Application 1/2 • What is the patient’s functional limitation? • How do you know? • Patient told you during history • Performance on normalized functional assessment, reliable test was > ± 2 SD from mean • What is causing the functional limitation? (What are the impairments?) • How do you know? • Performance on valid and reliable impairment test Last Viewed Exit Disablement Concept Map

33. Clinical Application 2/2 • What practice pattern(s) is most appropriate? • What is you prognosis? • How are you treating the impairments? • How are you documenting progress: (Outcome measures) • Impairments • Functional limitations • Disability Last Viewed Exit Disablement Concept Map

34. Intervention Strategies 1/2 • Requires understanding of the underlying process. • Efforts to prevent or modify disability can be aimed at: • Preventing/ modifying disease • Preventing/ modifying impairments • Preventing/ modifying functional limitations • Preventing/ modifying disability Last Viewed Exit Disablement Concept Map

35. Intervention Strategies 2/2 • Impairment interventions: medical interventions to deal with the impairment, and preventive interventions to avoid activity limitation • Activity limitation interventions: rehabilitative interventions and provision of assistive devices and personal assistance to mitigate the activity limitation, and preventive interventions to avoid participation restrictions • Participation restriction interventions: public education, equalization of opportunities, social reform and legislation, architectural “universal design” applications and other ways of accommodating activity limitations in major life areas Last Viewed Exit Disablement Concept Map

36. Model Comparison Last Viewed Exit Disablement Concept Map

37. 1/11 Clinical Reasoning Use of the Nagi Model In Clinical Decision Making Last Viewed Exit Disablement Concept Map

38. How do you decide what to treat? 2/11 • What is the functional limitation? • How do you know? • What is causing the functional limitation? (What are the impairments?) • How do you know? • How should I treat the impairments? • How should I set S/LTGs? • How should I documenting progress? Last Viewed Exit Disablement Concept Map

39. How do you decide what to treat? 3/11 • What is the functional limitation? • How do you know? • Subjective CC from the evaluation. • Performance of ≤ 2SD below the mean on valid & reliable functional test. Last Viewed Exit Disablement Concept Map

40. How do you decide what to treat? 4/11 • What is causing the functional limitation? (What are the impairments?) • How do you know? • Given the subjective history (and your knowledge of anatomy and physiology), you hypothesize what impairments, in this case, might be causing the functional limitation. • Test your hypothesis: performance of ≤ 2SD below the mean on valid & reliable impairment test. Last Viewed Exit Disablement Concept Map

41. How do you decide what to treat? 5/11 • How should I treat the impairments? • Evidence based practice (EBP) • How should I documenting progress? • By showing progress on function / impairment measures greater than expected by chance. • ≥ 2 SD in the standard error of the measure (SEM). • 2 SD in a population equals the 95% confidence level. Last Viewed Exit Disablement Concept Map

42. How to select and measure a LTG 6/11 • Use the patient’s LTG (Listen to the pt during Hx) • LTGs are set at the disability or functional level • Disability data is collected at the “quality of life” level (SF 36) • Functional limitations are objectively determined by performance of ≤ 2 SD below the mean on a valid, reliable, normalized functional test Last Viewed Exit Disablement Concept Map

43. How to select and measure a LTG 7/11 • Objective goal assessment is set at of ≥ 2 SD in the standard error of the measure (SEM). • 2 SD in a population equals the 95% confidence level. • In reality, we guess at a realistic estimation of an expected % improvement (usually 10-20%) based on experience (previous performance of pts with similar S&S). Last Viewed Exit Disablement Concept Map

44. How to select and measure a STG 8/11 • After the LTG has been identified, hypothesize what impairments are causing the functional limitation. • Test your hypothesis by performing a valid, reliable, normalized impairment test. • Performance of ≤ 2 SD below the mean rules in that variable as an impairment. • STG are objectively assessed by improvement of ≥ 2 SD (change > chance – “clinically meaningful”). Last Viewed Exit Disablement Concept Map

45. Clinical Example 9/11 For the UPS driver: • LTG: return to work following 1 week (Disability level) • The objective measure of goal accomplishment is Yes or No on returning to work in one week. • One week duration was selected on the basis of known tissue repair rates • PT interventions (cryotherapy and ROM exercises) may be able to change the natural rate of tissue recovery (evidence remains unknown) • Orthosis (Air splint) will help support the ankle in a shoe and assist return to work Last Viewed Exit Disablement Concept Map

46. Clinical Example 10/11 For the UPS driver: • One functional limitation is the inability to walk, effectively, on the injured ankle. • A valid and reliable measure of effective ambulation is the 10 meter walk test. • Gait velocity of 1-1.8 mph, 236 feet/min is required to cross a street during a red light (Podsiodlo ’91) • STG: On a 10 meter walk test, walk faster than 236 feet/min carrying a 5 pound box, without an assistive device. Last Viewed Exit Disablement Concept Map

47. Clinical Example 11/11 For the UPS driver: • Impairments causing his functional limitation • Pain: 8/10 • Impaired strength: DF/EV 3-/5 20 pain • Impaired ROM: EV 00-150 (00-350) • STG: EV AROM ≥ 00-200 • SEM for goniometry is ± 2.50 • 2 SD ±50 Last Viewed Exit Disablement Concept Map

48. International Classification of Functioning, Disability and Health 1/9 • The World Health Organization (WHO) authorized the International Classification of Functioning, Disability and Health (ICF) in 2001. • It is accepted by 191 countries as the international standard to describe and measure health and disability. The ICF classifies the health and disability using approximately 1500 items of "body function", "body structure", "activity and participation "and "environmental factors". Last Viewed Exit Disablement Concept Map

49. International Classification of Functioning, Disability and Health (ICF) 2/9 Last Viewed Exit Disablement Concept Map

50. 3/9 Contextual Factors Functioning and disability ("Body Functions and Structures," "Activities," and "Participation") are seen as an interaction between the "Health Condition" ("disorder/disease") and the contextual factors ("Personal Factors" and "Environmental Factors"). ICF is multidimensional (bio-psycho-social) and multidirectional model of human health. Last Viewed Exit Disablement Concept Map