Transcript Conceptual Framework For Clinical Practice

Map of Essential Concepts
Model of PT Practice
Model of Disablement
Conceptual Framework
For
Clinical Practice
Hypothesis-Oriented
Clinical Practice
Theory of Motor Control
Fall 2006
DM McKeough
Conceptual Framework
For Clinical Practice
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Model of PT Practice
Model of Disablement
Hypothesis-Oriented Clinical Practice
Theory of Motor Control
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Concept Map
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Models of Disablement
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Nagi and WHO
International Classification of Functioning,
Disability and Health (ICF)
Model Comparisons
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Level of Analysis
Cell / Organ
System
Personal
Society
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Nagi and WHO
Nagi
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WHO
Primary Pathology
Disease
Primary Impairment
Primary Impairment
Functional Limitations
Disability
Disability
Handicap
Disablement Models
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Nagi and WHO
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Nagi Model
ACTIVE
PATHOLOGY 
Interruption or
interference with
normal processes,
and efforts of the
organism to regain
normal state
IMPAIRMENT 
Anatomical,
physiological, mental,
or emotional
abnormalities or loss
FUNCTIONAL
LIMITATION 
DISABILITY
Limitations in
performance at the
level of the whole
organism or
person
Limitations in
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
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Disablement Models
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International Classification of
Functioning, Disability and Health 1/2
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Disablement Models
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ICF
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Contextual
Factors
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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.
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Disablement Models
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Model Comparison
Analysis
LEVEL
NAGI
WHO
1/2
ICF
Cell
Pathology
Disease
Health Condition
System
(Body)
Impairment
Impairment
Body structure &
function
Person
Functional
Limitation
Disability
Activity (Limitation)
Social
Disability
Handicap
Participation
(Restriction)
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Disablement Models
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Model Comparison
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Nagi is a unidimensional (pathologybased) and unidirectional model of
disability whereas ICF is multidimensional
(bio-psycho-social) and multidirectional
model of human health.
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Disablement Models
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Hypothesis Oriented Clinical Practice
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Once an activity (functional) limitation has
been determined by a function test an
hypothesis regarding cause must be
formulated
Hypothetical causes in body function or
structure (impairment) must be evaluated
with an impairment test
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Theories of Motor Control
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Definition and levels of analysis
Reflex theory
Hierarchical theory
Complex systems theory
Neurofacilitation Approaches
Motor Re-learning, Task-Based Rehabilitation
Motor Hierarchy
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Description
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The discipline of Motor Control is the
study of human movement and the
systems that control it under normal and
pathological conditions.
Levels of analysis (study)
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Environmental result of the movement
(Outcome)
Movement pattern
Neuromotor processes underlying movement
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Reflex Theory
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Reflex Theory (Charles Sherrington, early 1900s)
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Complex behavior (movement) is controlled by a
series of chained reflexes (e.g. Frog)
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Hierarchical Theory
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Hierarchical Theory
(Hughlings Jackson 1930s)
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Movement is
controlled by a system
consisting of 3 levels
with a rigid top down
organization
Higher centers control
lower centers via
inhibition
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“Disinhibition”
“Release phenomenon”
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Complex Systems Theory
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Movement emerges
spontaneously from the
interaction of the
individual, the task, and
the performance
environment
Individual
Task
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Motor Control Theories
Movement
Environment
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Factors within the
Individual, Task, and Environment
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Individual
•
•
•
•
Sensorimotor
Psychosocial
Cognitive
Stage of Motor Learning
Environment
Task
• Taxonomy of tasks
• Discrete/ continuous
• Attentional demands
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Motor Control Theories
• Physical
• Socioeconomic
• Cultural
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Factors within the
Individual, Task, and Environment
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Cognition
Perception
Action
I
T
E
Mobility
Stability
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Manipulation
Motor Control Theories
Regulatory
Nonregulatory
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Neurofacilitation Approaches
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Developed during the 1950-1960s in parallel with
increasing knowledge of anatomy and physiology of the
nervous system
Bobath (NDT); Brunnstrom; Kabat, Knott & Voss (PNF);
Ayers (Sensory Integration Therapy) developed the
“Neurofacilitation Approaches” that replaced the muscle
re-education approach used to treat the effects of Polio
during the 1940-1950s
Neurofacilitation approaches were designed to treat the
movement effects of stroke (UMN lesion) by attempting
to affect the CNS directly through the manipulation of
sensory input
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Neurofacilitation Approaches
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Assumptions
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Normal movement
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Results from a chain of reflexes organized
hierarchically within the CNS (Control of movement
is top down – cortex controls brainstem and spinal
cord)
Normal development
Characterized by the emergence of behavior
organized at sequentially higher levels of the
nervous system
 Driven by sensory input
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Neurofacilitation Approaches
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Assumptions
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Abnormal movement
Caused by disruption of normal reflex mechanisms
 Cortical lesions cause the release of abnormal
reflexes organized at lower levels of the central
nervous system
 Release of abnormal reflexes constrains the
patient’s ability to move normally
 Abnormal movement is the direct result of lesion
not secondary or compensatory actions**
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Neurofacilitation Approaches
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Assumptions
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Abnormal movement
In both children and adults, movement is
dominated by primitive reflexes
 In children, cortical lesions interrupt normal
corticalization thus motor control is dominated by
primitive reflexes organized at lower levels of the
CNS (primitive reflexes are never constrained)
 In adults, with acquired motor cortical lesions,
damage to the higher levels of the CNS release
lower levels and movement is dominated by
primitive reflexes (primitive reflexes are
constrained then released)
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Neurofacilitation Approaches
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Assumptions
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Recovery of function
Requires that higher centers once again control
lower centers
 Recapitulates normal development, therefore,
intervention should proceed along a developmental
sequence
 Functional skills will automatically return once
abnormal movement is inhibited**
 Repetition of normal movement patterns will
automatically transfer to functional tasks**
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Neurofacilitation Approaches
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Clinical Implications
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Examination should identify abnormal reflexes
controlling movement
Intervention should modify abnormal reflexes
Intervention modifies the CNS through
sensory input
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Neurofacilitation Approaches
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Current changes to Neurofacilitation
Approaches
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Increased emphasis on directly training
functional tasks as opposed to “normal
movement”
Decreased emphasis on inhibiting abnormal
reflexes
Increased consideration of motor learning
principles (stages of motor learning, feedback,
practice schedules, etc…)
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Motor Re-learning
Task-Based Rehabilitation
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Assumptions
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Normal movement
 Performer + Task + Environment
Abnormal movement results from impairment
in one or more of the systems controlling
movement
 Abnormal movement pattern is the
performer’s best solution to the task given
the systems remaining after damage not
just the result of the lesion itself**
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Motor Re-learning
Task-Based Rehabilitation
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Assumptions
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Recovery of function
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Recovery is produced by plastic reorganization of
undamaged control centers (neural plasticity)
Clinical Implications
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Recovery is best produced by practice of
purposeful, goal-oriented tasks that are
meaningful to pt’s goals (task specificity)
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Motor Hierarchy
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MC system consists of 3 levels
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Highest level: association cortex,
sensory, and motor areas
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Concern: select movement goal
and strategy
Middle level: BG, Cb, and
brainstem motor centers
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S1
Concern: specifying spatial,
temporal, and force parameters of
the motor plan
Lowest level: LMNs, motor plant,
FB about sensory consequences of
the movement
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Concern: producing the movement
pattern and supplying sensory FB
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APTA
Model of Physical Therapy Practice
Diagnosis
Prognosis
Evaluation
Examination
Intervention
Outcomes
Patient Centered Care
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Model of PT Practice
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APTA model of PT practice: defines scope
of PT practice and standardizes practice
activities
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3.
4.
5.
6.
Examination: data collection
Evaluation: data interpretation
Diagnosis: identifies movement limitation
Prognosis: outcome functional level + time
Intervention: treatment plan
Outcomes: treatment results
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Examination
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History
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Systems Review
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Demographics, chief complaint (CC), past medical
history (PMHx), patient goals
Also: medications, living environment/ support
system, employment, activity level (exercise
frequency)
Screening tests
Tests and Measures
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Special tests to rule in/out functional limitations and
impairments
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Evaluation
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Process of making clinical judgments
based on the data gathered during
examination
Hypothesis-oriented clinical practice
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Model of PT Practice
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Diagnosis
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MDs diagnose pathology
PTs diagnose movement dysfunction
PT diagnosis names the primary
dysfunction toward which the PT directs
treatment (Sahrmann 1988)
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Guide Patterns
Politically “correct” terminology
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PT assessment
PT judgment
Clinical impression
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Model of PT Practice
Diagnosis
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Prognosis
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Prognosis and plan of care
Prognosis
Level of functional independence patient is
expected to achieve following treatment and
2. Time required to reach that level
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Plan of care
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Anticipated goals and outcomes
Interventions
Expected duration and frequency
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Intervention
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Purposeful and skilled intervention of the
therapist with the patient
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Coordination, communication, documentation
Patient/ client-related instruction
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Client: consultation
Procedural interventions (PT “treatments”)
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Outcomes
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Treatment goals
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Short-term goals (STG 1-2 wks)
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Impairment level
Long-term goal (LTG - Discharge)
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All goals must be objective and measurable
Functional level
Goals may also include:
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Risk reduction (prevention)
Impact on societal resources ( # of visits)
Patient/ client satisfaction (quality of living)
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APTA Model of
Physical Therapy
Practice
Outcomes
INTERVENTION
Re-examination
Referrals
Coordinate Communicate Document
Patient/client instructions
Procedural interventions
PROGNOSIS & PLAN OF CARE
Projection of optimal level & time frame for improvement
Description of patient/client management
Anticipated goals and expected outcomes
Frequency & duration of interventions & discharge plans
DIAGNOSIS
Identification of dysfunctions that will direct intervention.
Signs & Symptoms Impairments Functional Limitations Disability
EVALUATION
Interpret findings to determine diagnosis, prognosis, & plan of care
EXAMINATION
History Systems Review Tests & Measures
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The End
© DM McKeough 2009
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