1. Copyright 2005 Lippincott Williams & Wilkins Foundations of Therapeutic Exercise Chapter 1 Introduction to Therapeutic Exercise and the Modified Disablement Model

2. Copyright 2005 Lippincott Williams & Wilkins Physical Therapy Physical therapy includes diagnosis and management of movement dysfunction and enhancement of physical and functional abilities: restoration, maintenance, and promotion of optimal physical function, optimal fitness and wellness, and optimal quality of life as it relates to movement and health; and prevention of the onset, symptoms, and progression of impairments, functional limitations, and disabilities that may result from diseases, disorders, conditions, or injuries. Guide to Physical Therapy Practice. Phys Ther 2001;81:1

3. Copyright 2005 Lippincott Williams & Wilkins Physical Therapy (PT) Includes  Examining patients with impairments, functional limitations, and disability or other health-related conditions to determine a diagnosis, prognosis, and intervention.  Alleviating impairments and functional limitations by designing, implementing, and modifying therapeutic interventions.  Preventing injury, impairments, functional limitations, and disability.  Engaging in consultation, education, and research.

4. Copyright 2005 Lippincott Williams & Wilkins Impairment Question “What impairments are related to reduced function and disability for this patient and which exercises can improve functional performance and disability by addressing the appropriate impairments?”

5. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention Patients – Persons with diagnosed impairments or functional limitations. Clients – Persons who are not necessarily diagnosed with impairments or functional limitations, but seek services for prevention or promotion of health, wellness, and fitness. Both seek and benefit from Physical Therapy

6. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise = Core Element Enables Patient/Client to:  Remediate or reduce impairments  Enhance function  Reduce risk  Optimize overall health  Enhance fitness and well-being

7. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Individual Goal-Oriented Treatment  Provide comprehensive and personalized patient management.  Rely on clinical decision-making skills.  Implement a variety of therapeutic interventions that are complimentary.  Promote patient independence (when possible) through home treatment, self-management exercise programs, and patient-related instructions.

8. Copyright 2005 Lippincott Williams & Wilkins The Disablement Process Disablement – “Various impact(s) of chronic and acute conditions on the functioning of specific body systems, on basic human performance, and on people’s functioning in necessary, usual, expected, and personally desired roles in society.” Nagi, SZ, Disability and Rehabilitation. Columbus, Ohio: Ohio State University Press, 1969.

9. Copyright 2005 Lippincott Williams & Wilkins Why Define the Process of Disablement?  To understand the complex relationships of pathology and disease, impairments, functional limitations and disability and to provide a conceptual basis for organizing elements of patient/client management that are produced by physical therapists.  To enable the therapist to make sound decisions regarding therapeutic exercise intervention.

10. Copyright 2005 Lippincott Williams & Wilkins Definitions Impairment – Loss or abnormality of anatomic, physiologic, or psychologic structure or function. Secondary Impairment – An impairment that originates from other, preexisting impairments. Primary impairments can create secondary impairments.

11. Copyright 2005 Lippincott Williams & Wilkins Functional Limitation “A restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected or competent manner.”

12. Copyright 2005 Lippincott Williams & Wilkins Disability The inability to perform or limitation in the performance of actions, tasks, and activities usually expected in specific social roles that are customary for the individual or expected for the person’s status or role in a specific sociocultural context and physical environment.

13. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Consider the functional loss and disability of the patient.

14. Copyright 2005 Lippincott Williams & Wilkins Evolution of Disablement Model  World Health Organization (WHO)  International Classification of Impairments, Disabilities, and Handicaps (ICIDH)  Saad Nagi (NAGI)

15. Copyright 2005 Lippincott Williams & Wilkins ICIDH DiseaseImpairment DisabilityHandicap NAGI SCHEME Active Pathology Impairment Functional Limitation Disability

16. Copyright 2005 Lippincott Williams & Wilkins Primary Differences ICIDH – Functional limitation and disability are not differentiated. Handicap – Final element. Limitation – Lacks consideration of cause of limitations in performing societal roles. NAGI – Considers distinction between functional limitation and disability.

17. Copyright 2005 Lippincott Williams & Wilkins Modified Disablement Model

18. Copyright 2005 Lippincott Williams & Wilkins Impairments Physiologic – An alteration in any physiologic function. Anatomic – An abnormality or loss of structure. Psychologic – Any abnormality related to the psychologic system.

19. Copyright 2005 Lippincott Williams & Wilkins Health-Related Quality of Life (HRQL)  Added to the final 2 elements of pathway (Functional Limitations and Disability)  Definition – Generally corresponding to total well being, encompassing 3 major components.

20. Copyright 2005 Lippincott Williams & Wilkins 3 Components of HRQL  Physical Function Component, which includes Basic Activities of Daily Living (BADLs) and Instrumental Activities of Daily Living (IADLs).  Psychological Component, which includes the “various cognitive, perceptual, and personality traits of a person”; and  Social Component, which involves the interaction of the person “within a larger social context or structure.”

21. Copyright 2005 Lippincott Williams & Wilkins Risk Factors  Demographic, social lifestyle, behavioral, psychologic, and environmental factors  Comorbidities  Physiologic impairments  Anatomic impairments  Functional performance factors Risk factors are predisposing in that they exist before the onset of the disablement process.

22. Copyright 2005 Lippincott Williams & Wilkins Prevention and Promotion of Health, Wellness, and Fitness Key Preventions in Physical Therapy Primary – Prevention of disease in a susceptible or potentially susceptible population through specific measures such as general health promotion offers. Secondary – Efforts to decrease duration of illness, severity of disease, and sequelae through early diagnosis and prompt intervention. Tertiary – Efforts to decrease the degree of disability and promote rehabilitation and restoration of function in patients with chronic and irreversible diseases. Promotion of Health, Wellness, and Fitness – Critical Foundation of Therapeutic Exercise Intervention!!

23. Copyright 2005 Lippincott Williams & Wilkins Use Of Disablement Model – Empowers the Physical Therapist to:  Develop comprehensive and efficient examinations and evaluations of impairments and functional limitations relating to the patient’s unique disability profile.  Reach an accurate diagnosis based on logical classification of pathology, impairments, and functional limitations.

24. Copyright 2005 Lippincott Williams & Wilkins Disablement Model (cont.)  Develop a prognosis based on the evaluation and the patient’s goals.  Create and implement effective and efficient interventions.  Reach a desirable functional outcome for the patient as quickly as possible.

25. Copyright 2005 Lippincott Williams & Wilkins Through understanding the Disablement Model, practitioners may develop a plan to satisfy the demands of all involved. Functionally Meaningful Patient Outcomes + Patient Satisfaction Financial and Social Costs of Providing Care Clinical Value =