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Map of Essential Concepts 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
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What is Physical Therapy What do Physical Therapists do
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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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Nagi Model /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 Disablement Concept Map Exit
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Functional Limitations
Nagi Model /8 Functional Limitations Disability Primary Impairment Primary Pathology Last Viewed Disablement Concept Map Exit
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Primary Pathology /8 Pathophysiology due to Disease, Injury, or Congenital Abnormality Last Viewed Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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Secondary Impairments 5/8
Due to lack of treatment of primary impairments (e.g. dicubiti, contractures, disuse atrophy) Usually what PTs treat Last Viewed Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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World Health Organization Model (WHO) 1/3
Primary Impairment Disability Disease Handicap Last Viewed Disablement Concept Map Exit
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WHO Nagi 2/3 Primary Pathology Disease Primary Impairment
Level of Analysis Cell / Organ Primary Pathology Disease System Primary Impairment Primary Impairment Personal Functional Limitations Disability Society Disability Handicap Last Viewed Disablement Concept Map Exit
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3/3 Nagi Model ACTIVE PATHOLOGY IMPAIRMENT FUNCTIONAL LIMITATION DISABILITY Interruption or interference with normal processes, and efforts of the organism to regain normal state Anatomical, physiological, mental, or emotional abnormalities or loss Limitations in performance at the level of the whole organism or person performance of socially defined roles and tasks within a sociocultural and physical environment WHO Model (International Classification of Impairments, Disabilities, and Handicaps, ICIDH) DISEASE IMPAIRMENT DISABILITY HANDICAP The intrinsic pathology or disorder Loss or abnormality of psychological, physiological, or anatomical structure or function at organ level Restriction or lack of ability to perform an activity in normal manner Disadvantage due to impairment or disability that limits or prevents fulfillment of a normal role [depends on age, sex, sociocultural factors] for the person Last Viewed Disablement Concept Map Exit
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Patient Cases Inversion ankle sprain Myelomeningocele Last Viewed
Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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. Pathology Impairment Functional limitation Disability Last Viewed Disablement Concept Map Exit
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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. Pathology Grade II, inversion sprain of the ankle Partial rupture of the anterior talofibular and calcanofibular ligaments Impairment Functional limitation Disability Last Viewed Disablement Concept Map Exit
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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. Pathology Grade II, inversion sprain of the ankle Partial rupture of the anterior talofibular and calcanofibular ligaments Impairment Impaired AROM Impaired strength Pain Functional limitation Disability Last Viewed Disablement Concept Map Exit
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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. Pathology Grade II, inversion sprain of the ankle Partial rupture of the anterior talofibular and calcanofibular ligaments Impairment Impaired AROM Impaired strength Pain Functional limitation Non-weight bearing Ambulates with crutches Disability Last Viewed Disablement Concept Map Exit
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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. Pathology Grade II, inversion sprain of the ankle Partial rupture of the anterior talofibular and calcanofibular ligaments Impairment Impaired AROM Impaired strength Pain Functional limitation Non-weight bearing Ambulates with crutches Disability Unable to work Last Viewed Disablement Concept Map Exit
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An example of using the model to determine the level of disability/handicap 1/6 A 40 year old woman born with spinal bifida, transports via a wheel chair, practicing lawyer, married with two children. Last Viewed Disablement Concept Map Exit
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An example of using the model to determine the level of disability/handicap 2/6 A 40 year old woman born with spinal bifida, ambulates via a wheel chair, practicing lawyer, married with two children. Pathology Failure of neural tube to closure (meningomyelocele) with resultant spinal cord transection (L4-5) Impairment Functional limitation Disability Last Viewed Disablement Concept Map Exit
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An example of using the model to determine the level of disability/handicap 3/6 A 40 year old woman born with spinal bifida, ambulates via a wheel chair, practicing lawyer, married with two children. Pathology Failure of neural tube to closure (meningomyelocele) with resultant spinal cord transection (L4-5) Impairment Bilateral lower extremity paralysis (paraplegia) Incontinence Functional limitation Disability Last Viewed Disablement Concept Map Exit
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An example of using the model to determine the level of disability/handicap 5/6 A 40 year old woman born with spinal bifida, ambulates via a wheel chair, practicing lawyer, married with two children. Pathology Failure of neural tube to closure (meningomyelocele) with resultant spinal cord transection (L4-5) Impairment Bilateral lower extremity paralysis (paraplegia) Incontinence Functional limitation Nonambulatory Independent in w/c for transport Disability Last Viewed Disablement Concept Map Exit
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An example of using the model to determine the level of disability/handicap 6/6 A 40 year old woman born with spinal bifida, ambulates via a wheel chair, practicing lawyer, married with two children. Primary pathology Failure of neural tube to closure (meningomyelocele) with resultant spinal cord transection (L4-5) Primary impairment Bilateral lower extremity paralysis (paraplegia) Incontinence Functional limitation Nonambulatory Independent in w/c for transport Disability None Last Viewed Disablement Concept Map Exit
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Healthcare Domain Health Care Medical Aspects Social Aspects
Domain of Physical Therapists Practice Health Care Pathology Pathophysiology Impairment Functional Limitation Disability Cardiopulmonary Integumentary Musculoskeletal Neuromuscular Physical Psychological Social Last Viewed Disablement Concept Map Exit
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Levels at Which Health Professionals Function 1/2
Pathology Impairment Functional Limitation Disability Physician Physical Therapist Occupational Therapist Last Viewed Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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?) Performance on valid and reliable impairment test Last Viewed Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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Model Comparison Analysis Level NAGI WHO ICF Cell Pathology Disease
Health Condition System (Body) Impairment Body structure & function Person Functional Limitation Disability Activity (Limitation) Social Handicap Participation (Restriction) Last Viewed Disablement Concept Map Exit
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Use of the Nagi Model In Clinical Decision Making
1/11 Clinical Reasoning Use of the Nagi Model In Clinical Decision Making Last Viewed Disablement Concept Map Exit
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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 should I treat the impairments? How should I set S/LTGs? How should I documenting progress? Last Viewed Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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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 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 Disablement Concept Map Exit
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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 (00-350) STG: EV AROM ≥ SEM for goniometry is ± 2.50 2 SD ± 50 Last Viewed Disablement Concept Map Exit
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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 Disablement Concept Map Exit
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International Classification of Functioning, Disability and Health (ICF) 2/9
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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 Disablement Concept Map Exit
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Body Functions 4/9 MENTAL FUNCTIONS SENSORY FUNCTIONS AND PAIN
VOICE AND SPEECH FUNCTIONS FUNCTIONS OF THE CARDIOVASCULAR, HAEMATOLOGICAL, IMMUNOLOGICAL AND RESPIRATORY SYSTEMS FUNCTIONS OF THE DIGESTIVE, METABOLIC AND ENDOCRINE SYSTEMS GENITOURINARY AND REPRODUCTIVE FUNCTIONS NEUROMUSCULO-SKELETAL AND MOVEMENT-RELATED FUNCTIONS FUNCTIONS OF THE SKIN AND RELATED STRUCTURES Last Viewed Disablement Concept Map Exit
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Body Structures 5/9 STRUCTURES OF THE NERVOUS SYSTEM
THE EYE, EAR AND RELATED STRUCTURES STRUCTURES INVOLVED IN VOICE AND SPEECH STRUCTURES OF THE CARDIOVASCULAR, IMMUNOLOGICAL AND RESPIRATORY SYSTEMS STRUCTURES RELATED TO THE DIGESTIVE, METABOLIC AND ENDOCRINE SYSTEMS STRUCTURES RELATED TO THE GENITOURINARY AND REPRODUCTIVE SYSTEMS STRUCTURES RELATED TO MOVEMENT SKIN AND RELATED STRUCTURES Last Viewed Disablement Concept Map Exit
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Activities and Participation 6/9
LEARNING AND APPLYING KNOWLEDG GENERAL TASKS AND DEMANDS COMMUNICATION MOBILITY SELF-CARE DOMESTIC LIFE INTERPERSONAL INTERACTIONS AND RELATIONSHIPS MAJOR LIFE AREAS COMMUNITY, SOCIAL AND CIVIC LIFE Last Viewed Disablement Concept Map Exit
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Environmental Factors 7/9
PRODUCTS AND TECHNOLOGY NATURAL ENVIRONMENT AND HUMAN-MADE CHANGES TO ENVIRONMENT SUPPORT AND RELATIONSHIPS ATTITUDES SERVICES, SYSTEMS AND POLICIES Last Viewed Disablement Concept Map Exit
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ICF Model 8/9 Positive terminology
Multidimensional, bi-directional model (Bio-Psycho-Social) of human health Positive terminology Includes non-pathological causes of impairments and functional limitations Context: potentially has an effect on all levels of model External environmental factors Personal characteristics Participation goes beyond performance of roles and deals with barriers and facilitators to participation in society Last Viewed Disablement Concept Map Exit
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Overview of Dimensions of ICF 9/9
Impairments Activities Participation Contextual Factors Functioning At body level At person level At social level Interaction with environmental factors and personal factors Characteristics Body function Body structure Person's daily activities Involvement in the situation Features of the physical, social attitudinal world Positive Aspect Functional and structural integrity Activity Facilitators Negative Aspect Impairment Activity limitation Participation restriction Barriers Last Viewed Disablement Concept Map Exit
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The End © DM McKeough 2009 Last Viewed Disablement Concept Map Exit
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